**4. Results**

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:

> 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

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

of pain or distress.

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

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

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

**4.** *Design music activities*

438 Update on Dementia

*3.4.5. Analysis*

pants.

Goal: Decrease agitation during morning care

Objectives: Decrease kicking and screaming.

Set a relaxing, musical environment for morning care activities.

care and dressing resident. Music therapist exits when appropriate.

preferences to use with resident during morning care [69].

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

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

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‐

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 The goal of this study was to determine if music therapy could reduce agitation symptoms and if these changes could be sustained by music in aid of caregiving. A repeated measures ANOVA found that Cohen-Mansfield Agitation Inventory scores differed significantly between the various time points. The assumption of sphericity was met according to Mauchly's test of sphericity, *x*<sup>2</sup> (9) = 14.81, *p* = 0.097. Mauchly's test of sphericity demonstrated that the average agitation scores were significantly different between time frames *F* (4, 92) = 7.03, *p* < 0.001, and that these changes can be seen visibly on a graph, **Table 1**, **Figure 3**.


**Table 1.** Bonferroni comparison of agitation scores at various time points.

Post hoc tests were performed using the Bonferroni adjustment for multiple comparisons. The results revealed that between first and second baseline, when participants were receiving care as usual, there were no significant differences in agitation scores (60.87 ± 23.00 vs 57.54 ± 24.17, *p* = 1.0). When post-music therapy scores were compared to baseline 1 scores, there was a significant difference in agitation (60.87 ± 23.00 vs 49.46 ± 21.92, *p* = 0.006) indicating that music therapy significantly contributed to reduced agitation. We measured agitation scores again 2 weeks post music therapy and found that there was a slight, but insignificant increase in agitation (49.46 ± 21.92 vs 51.17 ± 16.33, *p* = 0.189). The agitation scores declined again following CNA-initiated music in aid of caregiving activities (49.46 ± 15.25 vs 44.21 ± 15.25, *p* = 0.605), although these changes were not significant. The participants' agitation after music in aid of caregiving was significantly lower than the initial baseline scores (44.21 ± 15.25 vs 60.87 ± 23.00, *p* = 0.004). These results suggest that routine care did not significantly affect agitation, but music therapy significantly decreased agitation symptoms. The effects of the music therapy inter‐ vention were not sustainable for 2 weeks post music therapy, but agitation declined again after music in aid of caregiving.

**Figure 3.** Changes in Cohen-Mansfield agitation scores over time.

#### **5. Discussion and conclusion**

Music therapy has been recommended as a nonpharmacological intervention to reduce behavioral symptoms related to dementia such as agitation [3, 29], though there is little research documenting the use of music as an interdisciplinary method between music therapists and nursing professionals. In the current study, we hypothesized that music therapy would reduce symptoms of agitation and that music in aid of caregiving facilitated by educated CNAs would sustain those results. We found that when compared to usual care, music therapy reduced agitation significantly, but following music therapy symptoms began to rise again slightly. When nursing home residents were introduced to music in aid of caregiving by the CNAs, agitation began to decline again. This evidence supports the initiative of researchers that nonpharmacological treatments such as music should be used to manage symptoms of agitation in PWD [70]. Because the majority of residents were taking medications to cope with agitation symptoms, our outcomes also suggest that music therapy followed by music in aid of caregiving should be considered as an interdisciplinary, yet complimentary treatment alongside pharmaceutical therapy.

Prior to the intervention, we observed that many of our residents exhibited symptoms of agitation that included spitting on staff members, cursing, and yelling. These behaviors led to CNAs spending much of their time trying to redirect and console residents using techniques that were often ineffective. The reduction of agitation scores that occurred following the music in aid of caregiving indicates that the education for the CNAs and provision of music-based tools were sufficient.

Our study followed the transformational design which presents the theory that nonmusical behaviors can be changed through the introduction of a music therapy treatment plan [69]. For this study, music therapy followed by CNA education and facilitation of music in aid of caregiving activities led to a decrease in agitation for most of our participants. The plan began with specific goals set by the music therapy researchers who used therapeutic techniques to reduce agitation. Next, music in aid of caregiving or "pleasant (musical) diversions from daily routines or struggles" [52] were used to assist in sustaining the goals set by the music therapists. These protocols (e.g., singing and music-assisted bathing) allowed for CNAs to practice skills that may have been effective during music therapy sessions [52]. From our observations, the results positively affected not only the PWD as evidenced by fewer symptoms but also the CNA who was providing care.

#### **5.1. Conclusion**

*p* = 0.004). These results suggest that routine care did not significantly affect agitation, but music therapy significantly decreased agitation symptoms. The effects of the music therapy inter‐ vention were not sustainable for 2 weeks post music therapy, but agitation declined again after

Music therapy has been recommended as a nonpharmacological intervention to reduce behavioral symptoms related to dementia such as agitation [3, 29], though there is little research documenting the use of music as an interdisciplinary method between music therapists and nursing professionals. In the current study, we hypothesized that music therapy would reduce symptoms of agitation and that music in aid of caregiving facilitated by educated CNAs would sustain those results. We found that when compared to usual care, music therapy reduced agitation significantly, but following music therapy symptoms began to rise again slightly. When nursing home residents were introduced to music in aid of caregiving by the CNAs, agitation began to decline again. This evidence supports the initiative of researchers that nonpharmacological treatments such as music should be used to manage symptoms of agitation in PWD [70]. Because the majority of residents were taking medications to cope with agitation symptoms, our outcomes also suggest that music therapy followed by music in aid of caregiving should be considered as an interdisciplinary, yet complimentary treatment

music in aid of caregiving.

440 Update on Dementia

**Figure 3.** Changes in Cohen-Mansfield agitation scores over time.

**5. Discussion and conclusion**

alongside pharmaceutical therapy.

The tremendous need for nonpharmacological treatment in patients with dementia particu‐ larly highlights the importance of making music accessible as a simple and everyday tool that can help in these patients' care. The authors believe that music therapists should challenge this need and that specific training for caregivers at home or in institutions will help ease the burden of care and promote the well-being of both caregivers and people with dementia. Music therapists who work with people with dementia should expand their knowledge and expertise beyond the boundaries of the music therapy room. For that, we must differentiate between music therapy, which is performed by a professional and certified person and the use of music in aid of caregiving done by anyone who cares for people with dementia without the need for any musical background or skill. By promoting training programs in institution settings and at home, we can provide better care for those who need it.

A larger study is needed to test the effects of our intervention and provide evidence of its usefulness. We would like to propose that music in aid of caregiving is not only useful in nursing situations with CNAs but also may be beneficial for all nursing professionals to use to reduce resistance to care while giving medication and for wound care.

Because of the brain's ability to process music even in late stages of dementia [23], it may be beneficial for other healthcare practitioners besides nurses to consider adding music as a tool to aid them in their treatment. Presently, the protocols in this study have been adapted for work with home health aides, family caregivers, occupational and physical therapists, and social workers in multiple types of settings. It is currently being used in the United States, Israel, and Spain. Our future research includes work with a physiotherapist using music to aid with walking. This work will be based on a music therapy technique for patients with neurological problems that make use of rhythm to organize locomotion. Based on previous research with patients with Alzheimer's in which individuals required assistance with walking and inertia, we will test the rhythmic stimulus that may have a physiological effect and help to organize control over walking. This intervention may also reduce the need for multiple caregivers who assist the patient with walking [71].

In conclusion, the limits for the use of music in aid of caregiving are inexhaustible, but larger samples with more stringent designs are needed to confirm its worthiness. Since music is an accessible tool that is part of most people's day-to-day life, it is possible for even those without musical experience, to employ it in their work with a PWD. Minimizing restlessness is significant and contributes to the person with dementia's quality of life, and also improves 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.
