**3. Methods**

*2.5.1. The effect of background music*

432 Update on Dementia

*2.5.2. The effect of singing*

*2.5.3. The effect of rhythm*

moving.

and the number of positive behaviors decreased [51].

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

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].

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

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

#### **3.1. Participants**

#### *3.1.1. Certified nursing assistants (CNAs)*

At MJHS, certified nursing assistants (CNAs) are responsible for providing direct care to nursing home residents. Their duties include but are not limited to dressing, feeding, toileting, bathing, and other activities of daily living. CNAs have the most frequent and most intimate contact with nursing home residents. They report directly to unit nurse supervisors and the director of nursing who oversee their assignments and duties. At the time of the study, two CNAs reported singing with residents but for pleasure instead of with the desire to decrease or alleviate agitation. Only one of the CNAs had a history of formal musical training prior to this study. Previously, she was employed as a school teacher, but had not used music during her caregiving. For this study, there were eight CNAs recruited at the Menorah Center for Nursing and Rehabilitation, six at Metropolitan Jewish Geriatric Center, and 10 at Shorefront Center for Nursing and Rehabilitation. The majority of the CNAs were Black Caribbean American, followed by Latino and Russian. All were female, aged between 35 and 60 and reported to have five or more years of experience working with nursing home residents diagnosed with dementia.

#### *3.1.2. CNA training*

The CNAs participated in a 3-day intensive training course. The purpose of the training was to educate CNAs to facilitate music in aid of caregiving activities appropriate for the partici‐ pants that they provided care. Topics in the training included foundations of music, recog‐ nizing and identifying agitation, working with an iPod for music in aid of caregiving, selecting person-preferred music and music that may influence participant behavior, and preventing agitation through the use of recorded music with six protocols that are described below. CNAs were tested on music in aid of caregiving facilitation and on their ability to use an iPod in a mock-group setting at the end of the training. Video recordings of the CNAs' use of music in aid of caregiving with participants were used for training purposes as a reflective process with the music therapist and to determine if additional education was needed.

CNAs were assigned an iPod mini that was attached to their uniform. The iPod was loaded with personalized playlists created by the research music therapist. The CNAs were also given portable speakers that could be easily stored in their pockets until ready for use. Selections for each song in the playlists were created based on individualized preference and the success of observed reductions of agitation during music therapy groups. The music therapists created other general playlists that were loaded onto the iPod. These were meant to stimulate, relax, or prompt caregiving activities depending on the need of the resident. Some examples of the types of playlists included the following: sing-a-long, Russian classical, music-assisted bathing, energizing, Caribbean, etc., **Figure 1**. As needed, the music therapists created playlists for CNAs to use with residents when they were engaged in activities that triggered agitation such as bath/shower time [42].


**Figure 1.** Sample sing-a-long playlist. Source: Kendra Ray, Michael McGaughy, Scott Stuart, *Music Therapy: Keys to de‐ mentia care* (New York, MJHS) 34. Print [65].

There were six music in aid of caregiving protocols written by the research music therapists and used by the CNAs in this study. A detailed description of each of these protocols can be found online at https://issuu.com/mjhs/docs/2013\_dementia\_workbook\_lr\_fnl\_upt. All protocols used participants' individually preferred music based on a music therapy assess‐ ment and were created specifically for the nursing home residents who participated in this study. The developed protocols were singing, music and movement, music-assisted bath/ shower, music-assisted wound care, music-assisted range of motion, and tonal protocol. A variety were created in order for the CNA to have a selection to choose from that would fit most appropriately when addressing agitation. Each protocol lists the following criteria to be considered before use: staff requirements, objectives, entrance and exit criteria, duration, safety considerations, facility/equipment required, and methods for facilitation.

CNAs were assigned an iPod mini that was attached to their uniform. The iPod was loaded with personalized playlists created by the research music therapist. The CNAs were also given portable speakers that could be easily stored in their pockets until ready for use. Selections for each song in the playlists were created based on individualized preference and the success of observed reductions of agitation during music therapy groups. The music therapists created other general playlists that were loaded onto the iPod. These were meant to stimulate, relax, or prompt caregiving activities depending on the need of the resident. Some examples of the types of playlists included the following: sing-a-long, Russian classical, music-assisted bathing, energizing, Caribbean, etc., **Figure 1**. As needed, the music therapists created playlists for CNAs to use with residents when they were engaged in activities that triggered agitation

**Figure 1.** Sample sing-a-long playlist. Source: Kendra Ray, Michael McGaughy, Scott Stuart, *Music Therapy: Keys to de‐*

There were six music in aid of caregiving protocols written by the research music therapists and used by the CNAs in this study. A detailed description of each of these protocols can be

such as bath/shower time [42].

434 Update on Dementia

*mentia care* (New York, MJHS) 34. Print [65].

Singing protocol uses live and/or recorded background music to facilitate a meaningful opportunity and to prevent or reduce verbal and/or physical agitation during activities of daily living. Music playlists or CNA lead singing should be used while providing care. Communi‐ cation and singing are emphasized in this protocol.

Music and movement uses background music to engage residents to decrease symptoms of agitation, such as unexplained motor activity or verbalizations, until they decrease or are diminished. For this protocol, CNAs are asked to lead movements using sensory-stimulating items such as scarves or ribbons. Pre-recorded playlists were provided that stimulate slow to moderate movement.

**Figure 2.** Abbreviated version of music-assisted wound care provided for CNAs and nursing staff. Source: Kendra Ray, Michael McGaughy, Scott Stuart, *Music Therapy: Keys to dementia care* (New York, MJHS) 70. Print [65].

Music-assisted bath/shower uses background music designed to decrease physical tension and aggressive behaviors often associated with bath time for nursing home residents with demen‐ tia. CNAs are encouraged to begin music during preparation of the bath/shower to reduce agitation and distract from anticipated stress. The selected music was customized with songs that have historically relaxed the resident. Communication, listening, and awareness of sensitivity to noise and temperature and other residents' preferences are emphasized.

For music-assisted wound care, staff are encouraged to play background music during preparation of wound care to distract the resident from anticipated stress or agitated behaviors. The music should continue to be played during and following the procedure to reach desired objectives that may include decreased discomfort, fewer or no aggressive behaviors toward nursing staff and less resistance to wound care. Instructions are demonstrated subsequently (**Figure 2**).

Music-assisted range of motion uses background music to motivate residents' involvement in motion exercises. The objectives are to decrease resistance to movement, and reduce episodes of agitation. CNAs are provided with songs of measured tempos that begin slowly and gradually increase in beats per minute as the playlist develops. Rhythm and movement are emphasized in this activity.

The tonal protocol is a music-based activity with an objective of reducing agitation and increasing socialization. Residents are encouraged to sing familiar songs and play tone bars as led by the CNA. Rhythm and movement are emphasized in this activity.

#### *3.1.3. Residents*

The CNAs and music therapists worked with a total of 28 adults between the ages of 59 and 101 whom assented to participate in this study. Legal representatives were contacted to obtain informed consent and video consent for each individual. This was part of a larger study [10] that was conducted in three Brooklyn-based nursing homes, part of the MJHS system, Menorah Center for Nursing and Rehabilitation, the former Shorefront Center for Nursing and Reha‐ bilitation, and Metropolitan Jewish Geriatric Center. The New York University School of Medicine Institutional Review Board approved the protocol for this study.

Inclusion criteria required for participants to be long-term residents in the nursing home, informed consent from caregiver or legal guardian, mid-stage dementia as measured by Functional Assessment Staging for Alzheimer's Disease (FAST), stabilized comorbidities, auditory recognition with or without an assisted device, and absence of psychiatric disorders other than dementia. Participants were excluded if they declined participation, were being introduced to new medications, were admitted for short-term rehabilitation, had unstable comorbidities, or who had hearing loss that was uncorrectable.

Consented participants were mostly female (*n* = 26, 92.9%). The majority of participants were Caucasian (*n* = 22, 78.6%) followed by African American (*n* = 4, 14.3%). Their country of origins varied, but most were born in America (*n* = 14, 50%). Many of the participants were taking anti-anxiety (*n* = 4, 14.3%), antipsychotic (*n* = 6, 21.4%) medications, but the majority was not taking any psychotropic medications (*n* = 15, 53.6%). Participants had a documented diagnosis of dementia in their medical chart with varying types: mixed (*n* = 12, 42.9%), Alzheimer's disease (*n* = 7, 25%), unspecified/other (*n* = 8, 28.5%).

#### **3.4. Study design**

that have historically relaxed the resident. Communication, listening, and awareness of

For music-assisted wound care, staff are encouraged to play background music during preparation of wound care to distract the resident from anticipated stress or agitated behaviors. The music should continue to be played during and following the procedure to reach desired objectives that may include decreased discomfort, fewer or no aggressive behaviors toward nursing staff and less resistance to wound care. Instructions are demonstrated subsequently

Music-assisted range of motion uses background music to motivate residents' involvement in motion exercises. The objectives are to decrease resistance to movement, and reduce episodes of agitation. CNAs are provided with songs of measured tempos that begin slowly and gradually increase in beats per minute as the playlist develops. Rhythm and movement are

The tonal protocol is a music-based activity with an objective of reducing agitation and increasing socialization. Residents are encouraged to sing familiar songs and play tone bars

The CNAs and music therapists worked with a total of 28 adults between the ages of 59 and 101 whom assented to participate in this study. Legal representatives were contacted to obtain informed consent and video consent for each individual. This was part of a larger study [10] that was conducted in three Brooklyn-based nursing homes, part of the MJHS system, Menorah Center for Nursing and Rehabilitation, the former Shorefront Center for Nursing and Reha‐ bilitation, and Metropolitan Jewish Geriatric Center. The New York University School of

Inclusion criteria required for participants to be long-term residents in the nursing home, informed consent from caregiver or legal guardian, mid-stage dementia as measured by Functional Assessment Staging for Alzheimer's Disease (FAST), stabilized comorbidities, auditory recognition with or without an assisted device, and absence of psychiatric disorders other than dementia. Participants were excluded if they declined participation, were being introduced to new medications, were admitted for short-term rehabilitation, had unstable

Consented participants were mostly female (*n* = 26, 92.9%). The majority of participants were Caucasian (*n* = 22, 78.6%) followed by African American (*n* = 4, 14.3%). Their country of origins varied, but most were born in America (*n* = 14, 50%). Many of the participants were taking anti-anxiety (*n* = 4, 14.3%), antipsychotic (*n* = 6, 21.4%) medications, but the majority was not taking any psychotropic medications (*n* = 15, 53.6%). Participants had a documented diagnosis of dementia in their medical chart with varying types: mixed (*n* = 12, 42.9%), Alzheimer's

as led by the CNA. Rhythm and movement are emphasized in this activity.

Medicine Institutional Review Board approved the protocol for this study.

comorbidities, or who had hearing loss that was uncorrectable.

disease (*n* = 7, 25%), unspecified/other (*n* = 8, 28.5%).

sensitivity to noise and temperature and other residents' preferences are emphasized.

(**Figure 2**).

436 Update on Dementia

*3.1.3. Residents*

emphasized in this activity.

Convenience sampling was used for recruitment. Along with chart review, we received referrals for study participation from therapeutic recreation, social work and nursing depart‐ ments.

#### *3.4.1. Assessment*

The Functional Assessment Staging for Alzheimer's Disease (FAST) was used to measure staging for dementia during screening process [66]. Participants who scored between 5 and 6 on the FAST were considered eligible for participation in this study. To the validity of this study, the tester did not contribute to the intervention and had no prior relationship with study participants.

#### *3.4.2. Outcome measure*

The outcome measure of the study was the Cohen-Mansfield Agitation Inventory [67]. This tool consists of 29 agitated behaviors and the score can range from 34 to 128. The Cohen-Mansfield Agitation Inventory has high inter-rater agreement rates for each behavior for nursing home residents [67]. Other researchers found that the test/retest reliability for this tool was moderate to good in nursing home residents (*n* = 105) who were evaluated for agitation [68].

#### *3.4.3. Music therapy intervention*

Participants in this study took part in music therapy three times a week for 2 weeks. The intervention was facilitated by two nationally board-certified music therapists who conducted music therapy assessments prior to the intervention to obtain historical, musical preferences. This information was gathered from the nursing home resident, his/her family member, recreation, or nursing staff members. Music selections for the music therapy sessions were tailored according to participants' individual preferences.

Music therapy was conducted in small groups of four to six participants in a private lounge in the nursing home where the participant lived. Each session lasted from 15 min to an hour depending on the tolerance of the participant. Musical expression was demonstrated through singing, music and movement, and tonal activities. The music therapists encouraged the residents to play a variety of rhythm instruments, djembe drums, and ocean drums. Movement was encouraged through the use of colorful scarves and ribbons. The music therapists used live music for the sessions and were self-accompanied by guitar and electronic keyboard. An in-depth description of the music therapy intervention including the songs chosen and common themes that occurred is described in our previous publication [10].

#### *3.4.4. CNA music programming*

Following the music therapy intervention, the music therapists trained CNAs to integrate music in aid of caregiving during their daily routine. The transformation design model was used to guide the training created for the CNAs [69]. The transformation design model is a framework specifically for music therapy treatment. The treatment design was created to make available scientific outcomes in clinical practice immediately [69]. The treatment design is directed by nonmusical outcomes with consideration for the nursing home residents' music and music activity preference. Steps to this model are illustrated in the following example:

**1.** *Gather information on nonmusical behavior*

CNA reports that resident gets agitated especially during morning care. The CNA informs the music therapist that the resident becomes agitated as soon as it is time to get dressed. The resident kicks and screams as the CNA attempts to dress her. The resident has been checked for signs and symptoms of pain or distress.

**2.** *Develop treatment goals and objectives*

Goal: Decrease agitation during morning care

Objectives: Decrease kicking and screaming.

**3.** *Design functional nonmusical activities*

Set a relaxing, musical environment for morning care activities.

**4.** *Design music activities*

Music therapist visits resident's room prior to morning care and sings resident's favorite songs with her. CNA joins in singing and initiates morning care and dressing resident. Music therapist exits when appropriate.

**5.** *Transfer outcomes to everyday setting*

Therapist creates a protocol for CNA to use that includes playing familiar music and singing lyrics of resident's favorite songs while dressing during morning care. Music therapist creates playlist on an iPod or a CD player of resident's preferred music based on positive outcomes observed during music therapy. Music therapist instructs CNA with resident's musical preferences to use with resident during morning care [69].

#### *3.4.5. Analysis*

IBM Statistical Package for Social Science (SPSS) Statistics software (version 21) was used to obtain frequencies, percentages, means and standard error, and confidence intervals for demographic information and repeated measures ANOVA analysis related to study partici‐ pants.

A repeated measures ANOVA was conducted to analyze changes in Cohen-Mansfield Agitation Inventory scores for multiple data points. IBM SPSS Statistics software was used to perform the analysis. This method of analysis was chosen since each participant served as her/ his own control and it enabled us to compare changes in agitation between multiple data points over time including the following: baseline 1 and baseline 2; baseline 1 and immediately following music therapy; after music therapy and 2 weeks post music therapy; immediately following music therapy and CNA facilitated music in aid of caregiving. This procedure helped to determine any changes in agitation that occurred during care as usual (between baseline 1 and baseline 2), following the music therapy intervention and following the CNA-initiated music activities.
