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The Effect of a Personalized Music Playlist on a Patient With Dementia and Evening Agitation
Patients with dementia in long-term care facilities often experience agitation, which may be worsened in the evening hours. Personalized music playlists can be an effective intervention to improve verbal communication and decipher the cause of the agitation. This case report discusses the effect of a personalized music playlist on a patient with dementia with significant evening agitation. The patient experienced increased communication and verbalization about her past history, which allowed the facility and providers to tailor specific interventions which decreased the evening agitation. Personalized music playlists can be an alternative to the use of antipsychotics and, possibly, help to completely eliminate the use of them.
Key words: agitation, dementia, personalized music, antipsychotics
Thirty-one percent of Medicare beneficiaries with dementia live in a long-term care setting. Agitation, psychosis, or disordered mood is estimated to affect between 80% to 90% of patients with dementia.1 The irritability, agitation, isolation, and limited communication often associated with a dementia diagnosis in these patients can make daily care and overall well-being difficult to monitor and regulate.
In order to manage these difficult symptoms, over 25% of Medicare beneficiaries with dementia are prescribed an antipsychotic medication. Antipsychotic use is correlated with significant morbidity. As early as 2005, the US Food and Drug Administration (FDA) began warning health care providers of the dangers of atypical antipsychotics, including death. In 2008, they extended the warning to conventional and atypical antispychotics.1 There is a reported increase in cerebrovascular events including stroke, orthostatic hypotension, and thromboembolic events. An increased frequency of pneumonia has also been reported with the use of antipsychotics. Metabolic complications including increased blood sugar and cholesterol levels and weight gain have been well documented in the literature. Sedation and decreased cognition are both associated with the use of antipsychotics. Side effects such as drowsiness, orthostatic changes, and blurred vision also increase patient risk for injuries, such as falls, with their use.2-5 Recently, the FDA issued warnings regarding some antipsychotics and drug reaction eosinophilia and systemic symptoms which may result in injury to organs and death.6
In addition to the quality-of-life and physical issues associated with antipsychotic use, there is significant financial impact. In 2011, Medicare Part D spending on antipsychotic drugs totaled $7.6 billion, which was the second highest class of drugs, accounting for 8.4% of Part D spending.2
Currently, there is a national initiative to reduce antipsychotic use in long-term care.2 Researchers have begun focusing their efforts on alternative strategies and treatments to reduce agitation in patients with dementia. Programs utilizing a personalized music playlist, such as the work of Dan Cohen, MSW, with the Music and MemorySM Organization are consistently demonstrating improved outcomes such as decreased agitation and decreased use of antipsychotics in patients with dementia. Studies suggest that, in persons with mild to moderate dementia, a personalized music list can evoke memories and may enhance social communication and behavior.3,7
Case Report
Ms D was an 82-year-old female admitted to the long-term care facility (LTCF) with Alzheimer’s disease. She was a long-term patient who had resided in the facility since 2013. She had no family or responsible party who visited available to share information about her preferences or past. During the day, she would wander about the facility. She was not communicative verbally with other patients or staff. Each evening after dinner she would become agitated and was verbally offensive to other patients and staff.
As time progressed, she became physically aggressive with staff and other patients. She was deemed a danger to herself and other patients. The provider was contacted to evaluate the patient, and she was placed on quetiapine fumarate 50 mg every evening as well as haloperidol 0.5 mg every 8 hours as needed for severe agitation. Attempts to wean her from the Seroquel over a 2-year period were unsuccessful.
In August of 2015, the resident was placed on a music and memory program at the facility. A nursing student was assigned to the patient and visited with her weekly for 10 weeks. The equipment used in this intervention included an iPod® shuffle, a set of over the ears headphones, a splitter—so the resident and student could listen together—and iTunes music cards to download the music. This equipment and certification through the Music and MemorySM Organization was provided by a grant from the Texas Department of Aging and Disability.
During the first 3 to 4 weeks, the resident would only interact with the student for a few minutes per visit and then would tell her that she had to leave. The student started her interactions with the resident using a questionnaire that inquired about the resident’s history with music. Examples of some of the questions include: “Did you listen to music when you were young?” “What is your favorite song?” “Did you sing in church when you were younger” and “What song did you dance to at your wedding?”. The student shared some personal information about herself including that she was a nursing student who enjoyed listening to music.
The patient was unable to communicate her music tastes or any songs that had meaning. The student reported that she often answered in only two word sentences, if she answered at all. When asked about what music she liked, she would not answer or she would state, “I don’t know.” Words used to describe her were grumpy and annoyed in the initial visits. After 3 weeks of visits, the student developed a personalized music list and put it on the iPod shuffle. The student researched the top-selling songs from the resident’s 16-30 age period including genres from country, gospel, blues, and rock. She reported playing the music for the resident and looking for a positive response.
Initially, the patient was hesitant to listen to the music. When she did listen to the music, it was for a short time, and there was no visible change in her mood or reaction. The student continued to develop the music list and added songs and genres each week in hopes of getting a positive reaction from the patient. The genres or artists which illictied a postive response in the resident, such as listening longer, smiling, or tapping her fingers to the music, were investigated further, and songs were added to the list based on the positive responses. The third week in the intervention, the student noted in her journaling:
I first explained to her what the iPod was, and that I had music to play for her. The idea that all the records she liked could be stored in that tiny little square thing mystified her, and about five other residents had gathered around to listen to me and visit. At first she was a little bit wary of me and anything I had for her. However, I asked if she would just try it for me, and she relented. I placed the headphones on her and turned the iPod on. The first few songs were the Supremes, and she lit up like a Christmas tree! She was humming, tapping her toes, and periodically nodding at me. The one song that I had the most response was “Ain’t No Mountain High Enough” by The Soul Sensation, that I got from the Remember the Titans soundtrack. She was humming, singing, dancing in her seat, with arm movements, and grinning from ear to ear!
The seventh week into the intervention, when the student placed the headphones on the resident, she listened to the music for 35 minutes without interruption. During this week, the resident was listening to the Supremes, Aretha Franklin, and a church choir. When the student removed the headphones, the patient began talking in complete sentences. She shared with the student where she had been born and grown up. She spoke of picking cotton and taking it to a farmer’s barn. She then began to tell the student that she had worked in cafes waiting on people. After the customers left, she would clean the tables and then do the dishes before she could go home to her children. The student reported this encounter was 2 hours long.
In subsequent visits, the patient continued to speak to the student about things from her past such as details about her house and her street name. She remembered the number of siblings she had and stated her younger brother was spoiled because “he did not get enough whippins.”
The significant encounter and increased verbalization were reported to the staff and provider. They found that if the patient was allowed to clean a table each evening, her agitation greatly decreased. She began a dose reduction of quetiapine fumarate; ultimately, both the quetiapine fumarate and the as-needed haloperidol were discontinued. Currently, she has received no antipsychotic medication in the last 9 months.
Discussion
The nonspecific symptoms occurring with recurrent agitation, not caused by a known physical cause in a patient with dementia, makes care challenging. Agitation may manifest itself as demands for attention, pacing, wandering, going through other patients’ things, and/or refusal to participate in activities. Repeated vocalizations or questions and requests can be disruptive to patients and staff. Physical agitation may include hitting, biting, or yelling, which increases the risk of injury to patients and staff.
In this case report, the evening agitation was reduced by allowing the patient to wipe tables and “leave work.” The patient did not begin significant communication until the student was able to locate music that had meaning for the patient. There appeared to be a correlation with increased communication and specific music which had meaning to the patient. Prior attempts with genres such as jazz and country were unsuccessful in illiciting a positive response from the patient. Not all songs from the Supremes brought such a positive response from the patient. This particular patient did not have any close contacts to consults with, so the student relied on visual and verbal cues to choose appropriate music. Potential ways to identify a positive response include an increase in conversation, smiling, head movement, or foot/hand-tapping to the music; patients who are restless may become still. No response or taking the headphones off signaled to the student that the music was not impacting the patient positively. The presented case study demonstrates the potential power of the use of a personalized music playlist in patients with cognitive disorders and specifically with agitated behaviors.
Although the student is no longer working with the resident, the resident continues to have an improved mood and remains off of antipsychotics; the playlist has not been altered from when the student visited with her. The resident also communicates more but continues to wander around the facility. Prior to the intervention, there had been no music therapy or similar intervention in the facility. Music was occasionally played over a speaker or when a visiting group would sing or play instruments. This resdient did not participate in any of these activities at the facility prior to the intervention. Now, she will occasionally stay in the activity area during an activity.
Music therapy has repeatedly shown benefits to individuals in a variety of health care settings and is considered an effective and ethical approach in the care of patients with dementia. Numerous studies have shown the potential benefits of music therapy for patients, including improved mood, decreased agitation, and increased awareness of self and the environment. Increased socialization and improved cooperation during personal care have also been documented as benefits to music therapy, which can assist with caregiver burden8-10
Conclusion
Personalized music can evoke memories from the past and increase communication. This communication may help to explain current behaviors. Personalized playlists can be a cost-effective intervention to reduce agitation in patients with cognitive issues. Providers can consider ordering a personalized music playlist in lieu of antipsychotic medications or in an effort to reduce or discontinue antipsychotic medications. This intervention may have widespread application to other cognitive disorders, such as anxiety or depression, and merits further research.
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2. Center for Medicaid and Medicare Services. National partnership to improve dementia care in nursing homes. CMS website. https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/National-Partnership-to-Improve-Dementia-Care-in-Nursing-Homes.html. Accessed October 12, 2016.
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9. Blackburn R, Bradshaw T. Music therapy for service users with dementia: a critical review of the literature. J Psychiatr Ment Health Nurs. 2014;21(10):879-898.
10. Music & Memory. Alzheimer Society of Toronto’s iPod project study finds personalized music benefits caregivers, too. Music & Memory website. http://musicandmemory.org/blog/2014/06/30/alzheimer-society-of-torontos-ipod-project-study-finds-personalized-music-benefits-caregivers-too/. June 30, 2014. Accessed November 28, 2016.
