**2. Literature review**

#### **2.1. Music therapy and neurological disorders**

The use of music therapy in treating mental and neurological disorders is on the rise. Over the past 60 years, music therapy has developed as a clinically applied treatment in various healthcare settings administered by trained professionals who have completed an approved music therapy program.

Bonde et al. [11] explained that the process of defining music therapy both as a profession and as a discipline can vary depending on the orientation and perspective of a particular group of practitioners, or different cultures. However, the process of defining music therapy can be reflected in the way the profession itself has emerged in different countries and through various traditions. In this way, one has to take into consideration three main factors: profes‐ sional background of practitioners, needs of the clients, and approach used in treatment. Music therapy can be defined as a three-dimensional therapeutic interaction between a trained music therapist, the music, and a patient who meet to reach defined goals and objectives.

Alzheimer's disease and other types of dementia are among the disorders most commonly treated with music therapy [12]. Music therapy for individuals with dementia focuses on improved communication, memory, behavioral management, and facilitating interactive relationships with therapists and carers. Music is seen as a tool to achieve those goals, and the outcomes of music sessions are measured either quantitatively [13, 14] or qualitatively [15, 16]. Hence, in both the neuroscience and music therapy models, music is used instrumentally as an isolated material for impacting change.

The research on music therapy with PWD focuses on two main topics. One examines the effect of music therapy on an increase in desirable behaviors such as concentration span and degree of participation in an activity, and the other examines how music therapy affects the reduction of unwanted behaviors such as restlessness, anxiety, and depression [17].

Music has the power to unlock memories, to be a safe place, and offer solace for people with dementia [18]. The greatest challenge, arguably, in unraveling the myriad effects of music on the brain is the sheer complexity and interactivity of neural network stimulation observed in response to music. As early as 1984, case studies and anecdotal reports described people with dementia with severe cognitive deficits who could still play and/or sing with surprising skill [13, 19–21]. This led to the development of the preservation theory—that areas of the brain involved in the recall of music memories may be preserved from the progression of the disease. Using functional magnetic resonance imagings (fMRIs) in 2009, Janata [22] suggested a role of the dorsal medial prefrontal cortex, which is slower to atrophy in Alzheimer's disease, in connection with emotionally salient long-term memories. In a more recent study, researchers used fMRIs to identify specific brain regions where musical long-term memories seemed to be stored (in the caudal anterior cingulate and the ventral pre-supplemental motor area) in healthy adults. They then contrasted scans of these same regions of healthy older adult controls with people with mild-moderate Alzheimer's disease. The results strongly support the preservation of these regions in people with Alzheimer's disease [23]. This access allows music therapists to connect with PWD where other potential treatments may fail.

#### **2.2. Using music therapy to address agitation with PWD**

**1. Introduction**

428 Update on Dementia

musical skills or background.

**2. Literature review**

music therapy program.

**2.1. Music therapy and neurological disorders**

Caring for people with dementia (PWD) has become a focal point of policy makers, researchers, and healthcare providers. With over 30 million people globally and five million people in the USA diagnosed with Alzheimer's disease and other types of dementia, the need for capable and effective caregiving is necessary [1]. Music therapy has been shown to decrease neuro‐ psychiatric symptoms of dementia [2]. It is well known that music serves as a positive nonpharmacological intervention, and when used therapeutically has the effect to reduce

Caregiver burden in nursing professionals who work in long-term care facilities is often associated with compassion fatigue, burnout, moral, and psychological distress [4–6]. Music therapists are equipped with therapeutic tools that may assist in making caregiving tasks easier. Research has shown that both music therapy and caregiver-initiated music-based interventions can reduce agitation in people with dementia [7–10]. Singing and rhythm-based interventions are two examples of therapeutic techniques that may be initiated to aid in triggering a memory, changing a mood, or moving toward a desired behavior. Paid caregivers, such as nursing professionals, may be able to assist people with dementia even without any

The aims of this chapter are to provide evidence of the effectiveness of a music therapy intervention used to lower agitation symptoms in nursing home residents with moderate to severe dementia. We give examples of music in aid of caregiving that may help sustain or further reduce symptoms of agitation. We hope that this chapter may be used as a resource for practitioners and paid caregivers to broaden the scope of how music may be used collab‐

The use of music therapy in treating mental and neurological disorders is on the rise. Over the past 60 years, music therapy has developed as a clinically applied treatment in various healthcare settings administered by trained professionals who have completed an approved

Bonde et al. [11] explained that the process of defining music therapy both as a profession and as a discipline can vary depending on the orientation and perspective of a particular group of practitioners, or different cultures. However, the process of defining music therapy can be reflected in the way the profession itself has emerged in different countries and through various traditions. In this way, one has to take into consideration three main factors: profes‐ sional background of practitioners, needs of the clients, and approach used in treatment. Music therapy can be defined as a three-dimensional therapeutic interaction between a trained music

therapist, the music, and a patient who meet to reach defined goals and objectives.

oratively in institutional settings such as nursing homes, hospitals, and hospices.

agitation in people who are diagnosed with dementia [3].

Neuropsychiatric symptoms, such as agitation, in dementia have been estimated to be between 80 and 90%, and more than 80% of these symptoms persist for at least 18 months [24]. In nursing homes, agitation may be prevalent in up to 20% of individuals diagnosed with dementia [25]. Agitation may interfere with the nursing staff's ability to provide care as it is one of the most difficult symptoms to manage [26].

Many studies have shown that music therapy should be considered as treatment for individ‐ uals with dementia who exhibit signs and symptoms of agitation [10, 27–29]. In a systematic review, Livingston et al. (2014) analyzed 33 randomized controlled trials and found that music therapy along with other types of nonpharmacological interventions decreases overall agitation [30]. In their randomized controlled trial, Ridder et al.'s [31] results showed that after 6 weeks of music therapy, agitation in individuals with dementia was significantly reduced, while in the control group agitation increased. Other authors [32] found similar results for nursing home residents with dementia who received music therapy for 6 weeks. In comparison with the control group, agitation was significantly reduced following music therapy and results were sustained for 1 month after the music therapy intervention.

#### **2.3. Daily care for PWD**

With the rising number of individuals diagnosed with dementia accompanied by neuro‐ psychiatric symptoms such as agitation, the need for capable care staff is imminent. Nursing professionals are challenged with the difficulty of tasks associated with caregiving and the behaviors that often accompany a diagnosis of dementia. PWD experience problems with activities of daily living including bathing, dressing, and eventually decision making, which for over 60% of people with dementia leads to institutionalization for assistance with care [33].

Caregiver burden in nursing home staff who work in long-term care facilities is often associ‐ ated with compassion fatigue, burnout, moral, and psychological distress. These caregivers may be at risk of burnout between 5 and 37% of the time. Outcomes from a focus group performed concluded that nurses who care for people with dementia want to alleviate their suffering and improve their quality of life and may feel strained due to inadequate resources for caregiving [34]. Two other studies indicated an increasing prevalence in psychological distress in care staff who work in nursing homes for people with dementia [5, 6].

#### **2.4. The use of music by care staff**

Music medicine involves passive listening of music (usually recorded) that is provided by a medical practitioner or a paid caregiver. The music used during the interaction may or may not be selected based either on the subject's musical preference. Music medicine or music in aid of caregiving (as referred to in this chapter) is different from music therapy in that there is no attempt to develop a therapeutic relationship and the interaction does not involve psycho‐ logical processes [35].

A review of nonpharmacological interventions among PWD over the past two decades found that music can decrease resistance to treatment and care [3, 29]. Music helps to reduce symptoms of anxiety during activities that pose difficulties. Several studies have documented the effectiveness of the use of music by care staff for people with dementia. One study found that nursing personnel who used singing had a positive effect on the individuals with dementia, including improved posture, increased awareness of self and surroundings, motivation, and skills to perform daily tasks. The care staff who sang with residents benefited by developing mutuality and increased interactions more than those who only played background music [36, 37]. PWD showed better cooperation and fewer behaviors exhibiting resistance to care when singing and recorded music were used, compared to these activities without the use of music [36]. Other benefits that caregiver singing appeared to influence was communication, decreased levels of aggression, and disruptive screaming [36]. Gerdner [38] has created evidence-based guidelines for paid caregivers to use individualized music for people with dementia. Her techniques are often used by professional caregivers to lessen symptoms of agitation in people with dementia. Hammar et al. (2011) performed a study using a technique called Music Therapeutic Caregiving (MTC). The author compared patterns of behavior in participants whose caregiver used the MTC with patterns of behavior of partici‐ pants whose caregiver performed care as usual [39]. She found that the caregivers who did not use the MTC experienced more episodes of aggression and resistance from their care recipients than those who did not. In other studies using MTC, this author reported that caregivers described a feeling of well-being, happy, and positive interactions with the person who they were caring for. The individuals with dementia demonstrated increased positive emotions and expressed pleasure and appeared more alert due to the MTC [39].

Nursing professionals who sing and play background music can have positive effects on people with dementia. Results from a randomized controlled trial found that regularly listening to music and singing familiar songs can benefit people with dementia cognitively, emotionally, and socially. In this study, researchers found that these musical activities led by the nurses, family caregivers, choral leaders, and music therapists helped to reduce psycho‐ logical burden and that singing and listening to music can have positive effects for up to 6 months for people with early dementia [40].

Other researchers have described qualitatively and quantitatively how music can help to reduce agitation during caregiving [37, 41–43]. A review article found that carers for people with dementia played a significant role in decreasing agitation and in the work of music therapy for elders with dementia in nursing homes [44]. Choi et al. [45] found that music therapy was useful in not only reducing agitation in residents with dementia but also reducing irritability, distress, and anxiety in their caregivers. Numerous studies reported that caregivers who used a tape player or a CD player were effective in reducing agitation in clients diagnosed with dementia [46–48]. Using music during caregiving taps into memories, stimulates emotions, inspires, rewards engagement, and has an effect on individuals with dementia like no other treatment [49].

#### *2.4.1. Training program for care staff: utilizing music in daily care*

with the control group, agitation was significantly reduced following music therapy and

With the rising number of individuals diagnosed with dementia accompanied by neuro‐ psychiatric symptoms such as agitation, the need for capable care staff is imminent. Nursing professionals are challenged with the difficulty of tasks associated with caregiving and the behaviors that often accompany a diagnosis of dementia. PWD experience problems with activities of daily living including bathing, dressing, and eventually decision making, which for over 60% of people with dementia leads to institutionalization for assistance with care [33].

Caregiver burden in nursing home staff who work in long-term care facilities is often associ‐ ated with compassion fatigue, burnout, moral, and psychological distress. These caregivers may be at risk of burnout between 5 and 37% of the time. Outcomes from a focus group performed concluded that nurses who care for people with dementia want to alleviate their suffering and improve their quality of life and may feel strained due to inadequate resources for caregiving [34]. Two other studies indicated an increasing prevalence in psychological

Music medicine involves passive listening of music (usually recorded) that is provided by a medical practitioner or a paid caregiver. The music used during the interaction may or may not be selected based either on the subject's musical preference. Music medicine or music in aid of caregiving (as referred to in this chapter) is different from music therapy in that there is no attempt to develop a therapeutic relationship and the interaction does not involve psycho‐

A review of nonpharmacological interventions among PWD over the past two decades found that music can decrease resistance to treatment and care [3, 29]. Music helps to reduce symptoms of anxiety during activities that pose difficulties. Several studies have documented the effectiveness of the use of music by care staff for people with dementia. One study found that nursing personnel who used singing had a positive effect on the individuals with dementia, including improved posture, increased awareness of self and surroundings, motivation, and skills to perform daily tasks. The care staff who sang with residents benefited by developing mutuality and increased interactions more than those who only played background music [36, 37]. PWD showed better cooperation and fewer behaviors exhibiting resistance to care when singing and recorded music were used, compared to these activities without the use of music [36]. Other benefits that caregiver singing appeared to influence was communication, decreased levels of aggression, and disruptive screaming [36]. Gerdner [38] has created evidence-based guidelines for paid caregivers to use individualized music for people with dementia. Her techniques are often used by professional caregivers to lessen symptoms of agitation in people with dementia. Hammar et al. (2011) performed a study using a technique called Music Therapeutic Caregiving (MTC). The author compared patterns of

distress in care staff who work in nursing homes for people with dementia [5, 6].

results were sustained for 1 month after the music therapy intervention.

**2.3. Daily care for PWD**

430 Update on Dementia

**2.4. The use of music by care staff**

logical processes [35].

Since music is an accessible tool that is a part of most people's day-to-day life, main elements (recorded music, singing, and rhythm) can be used by music therapists to instruct and make it possible for care staff, even those without any musical experience, to employ it in their work with PWD. Minimizing restlessness is significant and contributes to the person with demen‐ tia's quality of life, and also improves the caregiver's ability to give optimal and safe care. Music's positive effect renders it useful for relaxation and for softening resistance, and thus alleviating the day-to-day life of the caregiver and the person with dementia.

#### **2.5. Elements of music: Background music, singing, and rhythm**

The various musical activities that can be used in a training program for caregivers serve as a therapeutic tool with an optimum impact. Following is a review of the literature addressing each of these musical tools in working with people with dementia.

#### *2.5.1. The effect of background music*

Studies examining musical interventions among PWD indicate that individually or culturally matched music significantly increases the music's positive effect on the person. Individually matched music was found to be the best and most effective way to reduce restlessness among Alzheimer's patients [48, 50]. The effect of culturally matched background music on the degree of the patients' restlessness was examined among the residents of a retirement home [51]. While listening to music, a marked reduction in restlessness characteristics was observed, such as less shouting, repetitive requests for attention, and so forth. Also, positive behaviors such as singing, drumming/tapping to the rhythm of the music, smiling, and others were observed. On the other hand, when music was not heard, the number of problematic behaviors increased and the number of positive behaviors decreased [51].

#### *2.5.2. The effect of singing*

Singing has a central place in music therapy with PWD. The literature shows that despite their memory loss, these patients continue to sing old songs, which remain intact in their memory for longer than songs learned at a later stage in their lives. Episodic/explicit memory for songs is not only for the melody and lyrics but also for the world of associations and personal memories that the songs evoke. In practice, the songs work like a stimulus to evoke multitude memories associated with the song [22, 52–54]. The songs stimulate and encourage conversa‐ tion associated with the topic of the song. Music therapy groups that focus on singing have led to an improvement in the patients' conversational capabilities and to a lively discussion about the experience of singing in the group [55]. Singing thus provides PWD with a feeling of social belonging. Singing is comforting in that it is a familiar activity, whereas cognitive activity arouses difficulty and frustration. Singing provides respites of stimulation, awareness, a pleasant feeling, and an experience of success [52]. The feeling of success is important among PWD encountering difficulty and poor functioning, which generally lead to a damaged sense of self-worth and depression. A music therapy group that focuses on singing and evoking memories can alleviate the symptoms of depression among PWD [56]. Singing can also reduce the degree of restlessness among PWD. A decrease in problematic behavior stemming from restlessness is evident during participation in a singing-focused music therapy group [57].

#### *2.5.3. The effect of rhythm*

Rhythm has an effect on the movement system. The body reacts automatically to rhythmic musical stimulus. Even when the listener is not moving, rhythm stimulates activity in the premotor cortex as if priming the body for movement [2, 58–60]. Movement to music is a common phenomenon across cultures, and moving in time with the beat (entrainment) appears to be pleasurable [61–64]. Toe tapping, head nodding, and dance involve perception of rhythm and the beat, which can enable synchrony among individuals, whether playing, singing, or moving.

Music helps to boost physical activity and it also has a calming effect. A group of 18 participants with dementia who took part in exercise sessions with background music showed a reduction in restlessness signs after 4 weeks of activity (twice a week), compared to a group of 18 patients who did not receive the intervention, but only "regular treatment"[50].

Even though many studies have investigated the effectiveness of using music therapy and music-based activities for people with dementia, there lacks evidence of a study that describes collaborative efforts between music therapy and nursing for nursing home residents with dementia. This study was intended to examine whether music therapy could reduce agitation in nursing home residents with moderate to severe dementia and if the reduction in agitation could be sustained or further reduced through the facilitation of music to aid in caregiving by Certified Nursing Assistants (CNAs).
