Imagine a woman with Alzheimer’s disease who’s so cognitively impaired that she can no longer feed herself. She stares into space, her eyes blank. When her daughter visits, she doesn’t recognize her. Now imagine that a therapist brings a CD player with music — an operatic aria the patient enjoyed when she was young. When the woman hears the music, her eyes light up; she hums the tune and waves her arms in time to the music. Her daughter is amazed and thrilled, and for a few precious minutes, her mother seems to know her.

Down the hall, another patient with Alzheimer’s disease has begun the rocking motion that signals the beginning of agitation. At this point psychotropic medication is usually given, but today she brings a CD player. 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. Touch and exercise can also calm cognitively impaired patients, reduce their need for chemical and physical restraints, heighten their awareness, and put the “sparkle” back in their eyes.

About 5.3 million Americans have Alzheimer's disease (AD), with one in eight people age 65 and older (13%) being affected by the disease.¹ By the year 2050, the number of afflicted age 65 and older could range from 11 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

Anyone 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. Stressors can include fatigue; changes in routine, caregiver, or room; as well as illness, pain, and adverse effects of medications.² Noise is also a stressor that can lead to the persistent elevation of stress hormones.³ When the stress threshold is exceeded, the patient can become agitated,² repeating words and becoming restless and aggressive as stress builds.  This disruptive behavior can be a problem for caregivers during routine care, as well as cause strain for other patients and staff.²

In the past, staff at nursing facilities 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, therapists 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, exercise, and the presence of animals 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. 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.⁴ 

Music has the ability to reduce muscle tension, regulate stress-related hormones, stimulate long-term memory, and strengthen the immune system.⁵ According to the American Music Therapy Association, 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.⁶

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. What makes certain music able to elicit thrills is associated with an event in the person’s past.⁵

People listening to relaxing music also show a decline in stress hormones, such as adrenocorticotropic, prolactic, and human growth hormones, as listening to music has been shown to activate a cascade of brain regions that culminates in the transmission of opioids and the production of dopamine associated with positive mood.⁵ Music appears to mimic some of the features of language, and conveys some of the same emotions. But more than language, music taps into primitive brain structures involved with motivation, reward, and emotion.⁶

Music listening also activates a network of brain regions related to attention, memory, and motor functioning. A study of 54 patients with middle cerebral artery stroke showed that those who listened daily for two months to self-selected music had significantly improved verbal memory and focused attention. They also experienced less depression and confusion.^{7 (Level A)}

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.⁸ In another study, elderly persons with dementia who listened to music three times a week for eight weeks had significantly improved next-morning cognitive functioning.⁹

Music can decrease eating issues and weight loss problems that so often plague patients with dementia. A study of the effect of a music program during lunchtime on problem behavior showed that playing background music when residents had their lunch also significantly reduced physical and verbal aggressive behavior among older residents with dementia.¹⁰

Staff can introduce soothing music at mealtimes in a nursing facility by bringing a CD player and several CDs of soft, melodious music into the dining room.  Music that can create feelings of peace includes J.S. Bach, Largo, from Concerto for Two Violins in D Minor, and Ralph Vaughan Williams, Symphony No. 3, Pastoral. Music that can evoke feelings of nurturing includes Brahms, Symphony No. 2, first movement, and Beethoven’s Symphony No. 2, second movement. Music that can help focusing includes Beethoven’s Violin Concerto in D, flute quartets by Hayden, and Mozart’s Sonata for Two Pianos in D Major.¹¹

To make music at mealtimes in the nursing facility part of the patients’ daily experience, it’s important to gain the cooperation of the aides and other multidisciplinary staff. Therapists 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 therapists can follow the same process with family caregivers by explaining the value of soothing music at mealtime and suggesting appropriate CDs.

Preferred music — music based on the patient’s individual preference — has an especially calming effect on agitation. One study showed that individualized music significantly reduced the frequency of agitated behaviors in cognitively impaired elders during and following playing of the individualized music compared to classical “relaxation” music.¹² And when individualized music was administered daily and as-needed to eight elderly persons with dementia, a significant reduction in agitation was found on the day and evening shifts. Music also promoted meaningful interaction between the residents and staff.¹³ Playing preferred recorded music during caregiving routines, such as bathing, has been shown to decrease the frequency and volatility of patients’ aggressive behaviors.⁴ Music therapy can also help improve cognitive functioning among dementia patients.^{9 (Level A)}

The term music therapy means the use of musical or rhythmic interventions specifically selected by a music therapist to accomplish the restoration, maintenance, or improvement of social or emotional functioning, mental processing or physical health of an older individual.4 Music therapy, as a healthcare discipline like physical or occupational therapy, involves 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 (Level B)}

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 isn’t possible, ask family members. Relatives are often grateful when the 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 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 CD player and CDs of the patient’s preferred music. You can ask family members to bring in CDs they believe are especially meaningful to the patient. Allow the patient a minimum of 30 minutes to listen to music in the location where he or she spends the most time. 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 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.

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

Therapists 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. Therapists 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. Gentle touch in addition to verbal encouragement helped residents in one study increase their nutritional intake and avoid weight loss.¹⁴

Massage has many benefits including general relaxation and increased circulation, as well as creating a positive mood, reducing heart rate, lowering blood pressure, and providing pain relief. Studies show that massage can also help alleviate depression and pain by lessening cortisol and increasing serotonin and dopamine. Cortisol is a steroid hormone produced by the adrenal gland in response to stress. Serotonin and dopamine are neurotransmitters that contribute to feelings of well-being and enjoyment.¹⁵

Therapists and families can learn to provide touch therapy to patients with varying stages of dementia.¹⁶ When certified nursing assistants were taught to provide gentle massage in a one-year project to assess the effects of gentle massage on elderly nursing home residents, pain scores and anxiety scores declined. Eighty-four percent of the nursing attendants reported that the residents enjoyed receiving tender touch, and 71% thought this type of massage improved their ability to communicate with the residents.¹⁷

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 multidisciplinary staff, and family members how to use the type of touch that’s 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 has many benefits. Regular physical activity can help prevent depression, manage high blood pressure and cholesterol, and boost high-density lipoprotein (HDL), or "good" cholesterol, while decreasing triglycerides. This keeps blood flowing smoothly by lowering the buildup of plaques in arteries. Physical activity also stimulates brain chemicals that can leave you feeling happier and more relaxed.¹⁸ These brain chemicals, brain-derived neurotrophic factors, protect the brain by inducing the survival and function of neurons, increasing resistance to brain insult, and improving learning and mental performance.¹⁹

For people with mild Alzheimer's disease or mild cognitive impairment, exercising several times a week for 30 to 60 minutes may improve memory, reasoning, judgment and cognitive function; such exercise may delay the start of Alzheimer's for people at risk of developing the disease.20

Exercise can also help improve physical functioning. Older adults who participate in 20 to 30 minutes of moderate-intensity exercise on most days of the week have better physical function than older persons who are active throughout the day or who are inactive. Any type of physical activity is better than no activity for protection against functional limitations, but exercise confers greater benefit for physical capacity.²¹

Moderate exercise twice a week can also significantly slow deterioration in the ability of people with AD to care for themselves. In one study, 134 ambulatory patients with mild to severe AD in five nursing homes participated in either a collective exercise program (one hour, twice weekly of walk, strength, balance, and flexibility training) or a program of routine medical care for 12 months. This simple exercise program one hour twice a week led to a significantly slower decline in activities of daily living (ADL) scores in patients with AD.²²

Exercise also helps cognitively impaired persons improve their sleep, 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.

Adding music to exercise can provide benefits. A group of patients with moderate to severe dementia who attended 30-minute sessions of daily physical exercises supported by music for three months showed a significant improvement in cognition.²³ Another study found that group music with movement significantly reduced the agitated behavior of institutionalized elders with dementia.²⁴

Animal Presence

Today, it’s not unusual to find nursing homes that have a resident cat or dog, and/or a few residents who have a pet in their room. In 1991, physician William H. Thomas envisioned a program that came to be known as the Eden Alternative, which includes the permanent presence of companion animals in long-term care facilities.²⁵ In 2006, the Centers for Medicare and Medicaid Services (CMS) published a document entitled Development of the Artifacts of Cultural Change Tool, a data collection instrument that uses a point structure to help nursing homes measure their progress in improving resident quality of life. The tool gives points to facilities that have an in-house dog or a cat, and/or that permit residents to bring their own dog and/or cat with them into the facility. The tool cites a quality of life study showing that nursing homes with a high quality of life had the most house pets.²⁶

The Centers for Disease Control and Prevention lists the health benefits of pets as the ability to decrease a person’s blood pressure, cholesterol and triglyceride levels; decrease feelings of loneliness; and increase opportunities for exercise, outdoor activities and socialization.²⁷ Owning a pet also helps manage stress. Hypertensive individuals who added a dog or cat to their treatment regimen had cardiovascular measures that remained significantly more stable during stressful situations than hypertensive individuals without a pet.²⁸

The ability to handle stress is important for cognitively impaired individuals in nursing homes. Studies show that short-term exposure to a dog on an Alzheimer’s care unit can cause a significant reduction in agitation for persons with AD. Participants on the day shift exhibited significantly fewer problem behaviors across the four-week study.²⁹ In another study, the presence of a therapy dog for 30 minutes on two occasions during sundown hours reduced the number of agitated behaviors in 28 older adults with AD. Socialization also improved. These changes were unrelated to the severity of dementia, indicating that the presence of a therapy dog may be beneficial in all stages of dementia.³⁰

In addition to having companion animals, residents in facilities can also benefit from animal visits from outside the facility. Animal assisted activities and therapy use trained animals to encourage patient well-being, socialization, and mental and sensory stimulation. In one program, 12 frail older adults (average age 87) showed significant increases in cognitive, physical, social and emotional areas after 70-minute sessions with volunteer pet handlers and therapy animals.³¹

The Delta Society is a national non-profit organization that trains Pet Partners program teams to provide animal-assisted activities/therapy. Animal-assisted activities (AAA) are casual activities that involve pets and their handlers visiting people. Animal-assisted therapy (AAT) is a goal-directed intervention directed and/or delivered by a health/human service professional with specialized expertise, and within the scope of practice of his/her profession. AAT is tailored to a particular person or medical condition to promote improvement in human physical, social, emotional, and/or cognitive functioning, and the result of each session is recorded in the patient’s record.³²

Integrating Music, Touch, Exercise and Animal Presence

To make music, touch, exercise and animal presence 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 CD 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.

Using music, touch, exercise and animal presence with cognitively impaired patients, can calm them, heighten their awareness, prevent excess disability, and put sparkle back in their eyes. This can’t help but give members of the treatment team 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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