Use of preferred music to decrease agitated behaviours in older people with dementia: a review of the literature

Aims and objectives. This paper reviews study findings of preferred music on agitated behaviours for older people with dementia and provides implications for future research and practice. Background. Music has been suggested as a feasible and less costly intervention to manage agitated behaviours in older people with dementia. However, no review of the literature focusing on study findings of preferred music on agitated behaviours in older people with dementia had been reported. Methods. A review was undertaken using electronic databases with specified search terms for the period of 1993–2005. The references listed in the publications selected were also searched for additional studies. Results. Eight research‐based articles met the inclusion criteria and were included in the review. The preferred music intervention demonstrated positive outcomes in reducing the occurrence of some types of agitated behaviours in older people with dementia. The findings from these studies were relatively consistent in finding improvement in agitated behaviours although the findings in one study did not reach statistical significance. The small sample sizes and some variations in the application of the preferred music intervention mean that caution is needed in drawing conclusions from these studies. Conclusions. This review highlights that preferred music has positive effects on decreasing agitated behaviours in older people with dementia; however, the methodological limitations indicate the need for further research. Relevance to clinical practice. Findings from the review highlight the beneficial outcomes of preferred music in reducing agitated behaviours for older people with dementia. The incorporation of preferred music has the potential to provide a therapeutic approach to the care of older people with dementia.     

Caregiver self‐efficacy for managing behavioural problems of older people with dementia in Taiwan correlates with care receivers’ behavioural problems

Aims and objective. To investigate the relationship between family caregivers’ self‐efficacy for managing behavioural problems of older people with dementia and their behavioural problems in Taiwan. Background. Older people with dementia commonly have at least one behavioural problem, which caregivers complain is difficult to handle. To provide interventions that can help caregivers more effectively manage the behavioural problems of care receivers with dementia, caregivers’ self‐efficacy on managing behavioural problems must be assessed. However, it is not clear yet how these behavioural problems of older people with dementia may influence caregivers’ self‐efficacy for managing behavioural problems. Design. A prospective, correlational study. Method. Eighty dyads of older people with dementia and their family caregivers were recruited from neurological clinics of a medical centre in Taiwan. Care receivers were assessed for behavioural problems using the Chinese version of Cohen‐Mansfield Agitation Inventory, community form. Caregivers’ self‐efficacy for managing care receivers’ agitation was measured by the research team‐developed Agitation Management Self‐Efficacy Scale. Results. Caregiver self‐efficacy for managing behavioural problems was significantly and positively associated with more caregiver education, greater duration of caregiving and with care receivers’ less physically non‐aggressive behaviours. When caregiver characteristics were controlled for in hierarchical regression analysis, physically non‐aggressive behaviours explained 6% of the variance in caregiver self‐efficacy. Conclusions. Results of this study contradict the general belief that physically aggressive behaviours of elders with dementia are more difficult for family caregivers to handle than other behavioural problems. Clinicians need to address physically non‐aggressive problem behaviours. Relevance to clinical practice. Nurses could assess older patients with dementia for physically non‐aggressive behaviours and train less educated caregivers to improve their self‐efficacy for managing problem behaviours, thus enhancing the quality of life for both caregivers and care receivers.     

Single ability among activities of daily living as a predictor of agitation

Aims. The aims of this study were to investigate whether the interaction effect between restraint and functional ability, and single ability during activities of daily living can predict agitation among residents with dementia. Background. Agitated behaviour is one of the most common symptoms of dementia and might endanger the patients themselves, caregivers and institutions. However, the prevalence of problem behaviours and its associated factors at long‐term care facilities in Taiwan are less understood. Design. A direct observation was used to observe the agitated behaviours of residents with dementia in special care units. Methods. Residents of dementia special care units who were diagnosed with dementia in eight long‐term care facilities were recruited. Measurements included: demographic data, the Barthel Index, the Mini‐Mental State Examination and the Cohen‐Mansfield Agitation Inventory. Results. The number of subjects who were identified with problem behaviours was 163 (43·5%). Significant differences in sex, being restrained, restrained time, age, family visits, functional status and mental status were found between the agitated and non‐agitated groups. However, mental status, family visits, walking ability, being restrained and getting in and off toilet were five independent factors associated with agitated behaviours after controlling for all other factors. Conclusions. It is recommended that strategies be constructed to encourage the family to periodically visit older residents and to develop restraint‐free environments in long‐term care facilities. Relevance to clinical practice. Residents with dementia require significant daily living support and behaviour management as their illness progress.     

Effects of non-facilitated meaningful activities for people with dementia in long-term care facilities: A systematic review

This systematic review sought to evaluate the effectiveness of non-facilitated meaningful activities for older people with dementia in long-term care facilities. Searches were conducted in PubMed; CINAHL; EMBASE; Web of science; PsycINFO; Cochrane; ProQuest; and ClinicalTrials.gov to identify articles published between January 2004 and October 2019. A total of six studies were included. Results implied that current randomised controlled trials or controlled trials about non-facilitated meaningful activities for people with living dementia in long-term care facilitates are limited, but those included in this review were of adequate methodological quality. Meaningful non-facilitated activities, such as music, stimulated family presence, animal-like social robot PARO/plush toy and lifelike dolls, may have beneficial effects on agitation, emotional well-being, feelings of pleasure, engagement, and sleep quality. However, there remains a lack of conclusive and robust evidence to support these psychological and physiological effects of non-facilitated meaningful activities for older people with dementia living in long-term care facilities by care staff.     

Sexual behaviour of institutionalised residents with dementia – a qualitative study

Aims. The purpose of this study was to explore the characteristics of and the contexts related to sexual behaviours among institutionalised residents with dementia. Background. Institutionalised residents with dementia are frequently unable to manage their sexual needs properly resulting in caregivers having a more conservative and passive attitude toward residents with dementia than those with higher cognitive status. Design. A grounded theory study. Methods. The participants in this study were institutionalised older people with dementia and their formal caregivers. Data were collected using in‐depth, face‐to‐face interviews of 12 formal caregivers and by observing 12 institutional older people with dementia for three days. All observations were recorded and interview data were tape recorded and transcribed verbatim. Results. The results indicated that the predisposing factors included having opportunity, presence of a cooperative target and personal space without privacy. The sexual expressions of institutionalised older people with dementia included: physically intimate touch, sexual expression without touching others and sexual talk. Responses by individuals to sexual behaviour from another resident included neutral response, negative response and positive response. Conclusion. To provide better care, it is recommended that an inventory regarding sexual expression for clinical and research usage be constructed from the research results. Relevance to clinical practice. The findings of this study can provide the basis to develop on‐the‐job training programmes for sexual education of residents with dementia in institutions. Regular seminars on sexual care for the residents with dementia might be beneficial for managing sexual issues among residents and to decrease caregivers’ burden.     

Music and Other Strategies to Improve the Care of Agitated Patients with Dementia

Many patients with dementia symptoms display forms of agitation such as the repeating of words, restlessness and aggression. These forms of behaviour may inflict strain on the co-patients and the caregivers. In this study, 17 experienced formal caregivers from nursing homes and collective residential units were interviewed about their experiences of agitated patients with dementia and strategies to improve their care. The questions were open except for specific questions about sound, music, and opinions about pharmacological treatment. A calm atmosphere and a slow pace emerged as important strategies to control agitation. Fixed routines could develop this. The mixing of lucid and agitated dementia patients appeared as a major problem, because some lucid patients became angry when patients with dementia displayed agitation. Irritability in one patient could trigger agitation in other patients but was possible to stop at an early stage. Several responders had successfully used music to calm individual agitated patients. Music seemed to be an underestimated nursing intervention to control agitation in daily life, but uncontrolled sound could cause agitation in the patients and stress in the nursing staff.     

The effects of group music with movement intervention on agitated behaviours of institutionalized elders with dementia in Taiwan

BACKGROUND: Agitated behaviours are identified by caregivers as the most challenging in dementia care. Alternative approaches reducing occurrence of agitated behaviours and the need for chemical or physical restraints become valuable for institutionalized elders with dementia. OBJECTIVE AND SETTING: This study was to evaluate the effects of group music with movement intervention on occurrence of agitated behaviours of institutionalized elders with dementia in Taiwan. METHODS: A randomized controlled trial was used. Thirty-six institutionalized elders with dementia completed the study, with 18 in the experimental group receiving group music with movement intervention twice a week for 4 weeks and 18 in the control group receiving usual care without intervention. Modified Cohen-Mansfield Agitation Inventory was used to assess agitated behaviours at baseline, weeks 2 and 4. RESULTS: Agitated behaviours were significantly reduced in the experimental group following 4 weeks of group music with movement intervention compared to that of the control group (p<0.001). CONCLUSIONS: Group music with movement intervention can be beneficial in managing agitated behaviours of those with dementia and should be incorporated into care routines in residential facilities.     

Postoperative pain in older people: a review of the literature

Aims and objectives. The literature review was conducted to explore those factors which complicate pain management in older people to inform future research, education and nursing practice in this area. Background. Acute pain management in hospitalized older people is complex because of the physiological changes of ageing, pharmacological factors and under‐representation of this patient group in reported research about assessing acute pain. Methods. A review of the literature was undertaken using electronic databases and specified search terms, some hand searching was also used and included the grey literature, textbooks and conference proceedings. A computerized literature search was carried out using CINAHL, Bandolier, Cochrane, Medline, the British Nursing Index and the International Association for the Study of Pain website for the period 1992–2004. The search terms were acute pain, older people, elder care, pain assessment and acute pain services. Thirty‐seven research‐based reviews and published studies and 17 policy documents were included. Conclusions. Managing acute pain well in older adults involves understanding the influence of a series of integrated factors: attitudes and beliefs, physiological ageing processes, pharmacological factors and the social construction of the older person in healthcare contexts. Relevance to clinical practice. This review offers new insight into those factors which, taken together, add complexity to managing acute pain in older people well. Moreover, nurses are the professional group mainly responsible for assessing pain, administering and now prescribing analgesia and evaluating the quality of pain relief in older people. On this basis, they are also the group most likely to effect improved patient outcomes.     

Special observation and older persons with dementia/delirium: a disappointing literature review

Background. In gerontological practice, special observation is a known nursing activity across different settings. The group that possibly are most effected by this intervention are older persons with dementia and/or delirium. The research literature about special observations in the mental health field is small, more disappointingly there appears to be little published literature about special observations in regard to older persons with dementia and/or delirium. Aims. The aims of this study are to (i) establish the state of current published research on special observations in regard to older persons with dementia and/or delirium and (ii) make recommendations for research and practice. Design and method. A literature review. Results. Most literature pertains to adult mental health practice and services. Themes were generated and discussed in relation to gerontological practice. Conclusion. This review has established there is variance in the usage of the terms ‘special observation’ and ‘constant observation’. It concludes that there is no published research on special or constant observations in relation to older people with dementia/delirium or the purpose of this activity. There is therefore a clear need to establish a research base in the topic. Implications for practice. Given the limited evidence, practitioners and managers need to be cautious when writing and implementing policies about special observation. However, until gerontological research is improved, research from mental health nursing will need to be drawn on with caution and the purpose of special observation determined locally. To be of therapeutic value and to be cost effective, special observation should be seen as a skilled nursing intervention and not a passive ‘watching’ or ‘sitter’ activity.     

Application of light therapy in older adults with cognitive impairment: A systematic review

This systematic review aims to assess the efficacy of light therapy on behavioural and psychological symptoms of dementia (BPSD), cognition, functional status, and quality of life in older adults with cognitive impairment; and secondarily, to identify the optimal characteristics of light therapy to establish an adequate protocol for its clinical application. We searched Web of Science and Medline databases through December 2019, resulting in 36 included articles: 3 evaluated the effects on BPSD, 25 on sleep, 12 on agitation, 10 on mood, 4 on neuropsychiatric symptoms, 4 on cognition, 2 on quality of life and 2 on functional status. Literature has shown potential evidence for positive effects of light therapy on managing sleep, behavioural and mood disturbances in people with cognitive impairment, but a limited effect on cognition, quality of life and functional status. This review provides guidelines for intervention protocols with light therapy in older people with cognitive impairment.     

The effectiveness of chemical restraint in managing acute agitation and aggression: A systematic review of randomized controlled trials

One approach to manage people with behaviours of concern including agitated or aggressive behaviours in health care settings is through the use of fast‐acting medication, called chemical restraint. Such management often needs to be delivered in crisis situations to patients who are at risk of harm to themselves or others. This paper summarizes the available evidence on the effectiveness and safety of chemical restraint from 21 randomized controlled trials (RCTs) involving 3788 patients. The RCTs were of moderate to high quality and were conducted in pre‐hospital, hospital emergency department, or ward settings. Drugs used in chemical restraint included olanzapine, haloperidol, droperidol, risperidol, flunitrazepam, midazolam, promethazine, ziprasidone, sodium valproate, or lorazepam. There was limited comparability between studies in drug choice, combination, dose, method of administration (oral, intramuscular, or intravenous drip), or timing of repeat administrations. There were 31 outcome measures, which were inconsistently reported. They included subjective measures of behaviours, direct measures of treatment effect (time to calm; time to sleep), indirect measures of agitation (staff or patient injuries, duration of agitative or aggressive episodes, subsequent violent episodes), and adverse events. The most common were time to calm and adverse events. There was little clarity about the superiority of any chemical method of managing behaviours of concern exhibited by patients in Emergency Departments or acute mental health settings. Not only is more targeted research essential, but best practice recommendations for such situations requires integrating expert input into the current evidence base.     

Calming music and hand massage with agitated elderly

BACKGROUND: Agitated behavior is a widespread problem that adversely affects the health of nursing home residents and increases the cost of their care. OBJECTIVE: To examine whether modifying environmental stimuli by the use of calming music and hand massage affects agitated behavior in persons with dementia. METHOD: A four group, repeated measures experimental design was used to test the effect of a 10-minute exposure to either calming music, hand massage, or calming music and hand massage simultaneously, or no intervention (control) on the frequency and type of agitated behaviors in nursing home residents with dementia (N = 68). A modified version of the Cohen-Mansfield Agitation Inventory was used to record agitated behaviors. RESULTS: Each of the experimental interventions reduced agitation more than no intervention. The benefit was sustained and increased up to one hour following the intervention (F = 6.47, p<.01). The increase in benefit over time was similar for each intervention group. When types of agitated behaviors were examined separately, none of the interventions significantly reduced physically aggressive behaviors (F = 1.93, p=.09), while physically nonaggressive behaviors decreased during each of the interventions (F = 3.78, p< 01). No additive benefit resulted from simultaneous exposure to calming music and hand massage. At one hour following any intervention, verbally agitated behavior decreased more than no intervention. CONCLUSION: Calming music and hand massage alter the immediate environment of agitated nursing home residents to a calm structured surrounding, offsetting disturbing stimuli, but no additive benefit was found by combining interventions simultaneously.     

Do sound levels and space contribute to agitation in nursing home residents with dementia?

Individuals with dementia living in nursing homes may be exposed to non-therapeutic levels of sound. There is insufficient research examining the relationship between sound levels, personal space, and agitation in people with dementia. Using an observational designed study, 53 participants from four southeastern Wisconsin nursing homes were observed; data on sound levels, space, and agitation levels were obtained. Sound was a significant predictor of agitation. The accumulation of sound predicted agitated behavior and explained 16% of the variance, F(5, 47) = 4.520, p < 0.002, and adjusted R(2) = 0.253. The findings suggest agitation may be a clue that sound in the environment is causing stress for residents with dementia.     

Foot massage versus quiet presence on agitation and mood in people with dementia: A randomised controlled trial

Background

There is increasing interest in using complementary and alternative treatments to manage behavioural and psychological symptoms of dementia such as agitation, aggression and depressed mood.

Objective

To compare the effect of foot massage (intervention) and quiet presence (control) on agitation and mood in people with dementia.

Design

A randomised controlled trial using a within-subjects, crossover design.

Settings

Five long-term care facilities in Brisbane, Australia. The primary outcome was the Cohen-Mansfield Agitation Inventory (CMAI) and the secondary outcome was the Observed Emotion Rating Scale (OERS). The screening and data collection research assistants, families, and care staff were blinded to participant allocation.

Participants

Participants of the study were 55 long-term care residents aged 74–103 years (mean age 86.5), with moderate to severe dementia and a history of agitated behaviour according to the Pittsburgh Agitation Scale. A computer-program randomised participants to 10-min foot massage (intervention) or quiet presence (control), every weekday for 3 weeks.

Results

A carry-over effect was identified in the data, and so the data was treated as a parallel groups RCT. The mean total CMAI increased in both groups (reflecting an increase in agitation) with this increase greater in the quiet presence group than the foot massage group (p = 0.03). There was a trend towards a difference on OERS General Alertness, with a positive change in alertness for participants in the foot massage group (indicating reduced alertness) and a negative change for participants in the quiet presence group (indicating increased alertness) (F₍₁,₅₁₎ = 3.88, p = 0.05, partial ?² = 0.07).

Conclusions

The findings highlight the need for further research on the specific conditions under which massage might promote relaxation and improve mood for people with dementia. The unfamiliar research assistants and variations in usual activity may have contributed to the increase in agitation and this needs further research.

Trial registration

ACTRN12612000658819.     

A randomised controlled trial of Lavender (Lavandula Angustifolia) and Lemon Balm (Melissa Officinalis) essential oils for the treatment of agitated behaviour in older people with and without dementia

ObjectiveLavender and Lemon Balm essential oils are popular in the management of older person agitation due to their ease of application, minimal side effects and low interaction with concurrent medications. This study addressed limitations in the literature to evaluate and compare effectiveness of Lavender and Lemon Balm essential oils on the agitated behaviour of older people with and without dementia living in residential aged care facilities [RACFs].MethodsForty-nine nursing home residents with dementia (n=39) and without dementia (n=10) exhibiting agitation participated in this study. Participants were randomised to a counterbalanced, repeated measures design experiment that tests the treatments Lavender, Lemon Balm, and Placebo (Sunflower oil). Treatments were administered once daily for two-weeks followed by a two-week washout period before commencing the subsequent treatment. All participants trialed all three treatments over a 10-week period. Data were collected on the Neuropsychiatric Inventory (NPI) and Cohen-Mansfield Agitation Inventory (CMAI).ResultsA significant difference was shown when essential oils effect were compared between the cognitive groups. Post hoc analysis reports Lemon Balm more effective in reducing NPI agitation (p = .04) and CMAI physical non-aggressive behaviour (PNAB) (p = .02) in residents without dementia. Lemon Balm less effective in reducing NPI irritability (p = 0.01) and Lavender more effective in reducing CMAI PNAB (p = 0.04) in dementia.ConclusionThe findings support an opposing effect of Lemon Balm and Lavender in reducing agitated behaviour between the participant cognitive groups. There was no reduction in agitation with treatments when compared to placebo independent of cognitive groups.     

Application of music therapy for managing agitated behavior in older people with dementia

Older people with dementia may display negative emotions, memory problems, sleep disturbance, and agitated behavior. Among these symptoms, agitated behavior has been identified by families and nursing staff as the care problem that presents the greatest challenge. Several studies have found that music therapy reduced agitated behaviors in those with dementia and recommended use of music as an effective strategy in managing this behavioral problem. Music therapy represents a lower cost, effective care approach that nursing staff can easily learn and apply to those with dementia. Furthermore, reductions in agitated behavior in dementia patients that result from music therapy can also alleviate caregiver stress and burden of care, leading to improvements in the health and quality of life of both dementia patients and their caregivers. This paper aims to introduce the principles and application of music therapy in the management of agitated behavior in those with dementia.     

The efficacy of acupressure for decreasing agitated behaviour in dementia: a pilot study

Aims and objectives. To investigate the efficacy of acupressure in decreasing agitated behaviours associated with dementia. Background. Agitated behaviour is found in nearly half of all patients who have dementia. The presence of these behaviours increases the likelihood of injury, weakness, dehydration and lack of sleep and contributes to caregiver frustration and fatigue. Design. This pilot study was designed with subjects receiving both acupressure and the control treatment. Each subject served as his or her own control. Subjects received four weeks of acupressure protocols; to avoid a carry‐over effect there was a treatment‐free period of one week. Subjects then were visited by one of the investigators for a six‐week period. Methods. Participants were recruited from a nursing home caring specifically for patients with dementia. Twenty of the 31 subjects (64·5%) completed the study, while 11 were discharged or hospitalized. All the subjects were assigned to an experimental protocol and had a six‐week acupressure treatment program. Baseline data were collected in the first week. Individual treatment sessions began at the second week of the study and lasted 15 minutes, twice a day, five days a week for four weeks. After a treatment‐free period of one week, all the subjects served as controls undergoing a four‐week control protocol consisting of companionship and conversation. Results. Comparison between the control and experimental phases indicated significant differences between the two groups on all outcome measures (Cohen–Mansfield Agitation Inventory, daily agitation records about physical attack, verbal and non‐verbal attack and non‐physical attack) with better results found during the acupressure phase. Conclusions. Acupressure is recommended as an efficacious and non‐intrusive method for decreasing the agitation behaviours in patients with dementia. Relevance to clinical practice. Conducting the acupressure treatment takes 15 minutes. It could provide caregivers with a viable alternative to deal with patients with dementia.