1. Single-Subject Design Project:
Using Music Therapy as an Alternative
Method to Treat and Address Agitation
Among Persons with Dementia
By Emily Rumrill

2. Outline
 Dementia: A Growing Problem
 Music: An Alternative Method
 SSD Overview
 Research Question
 Intervention: Target & Qualifications
 Intervention: Overview
 Intervention: Detailed Description
 Design & Intervention Length
 Design: ABA Single-Subject Design
 Measures & Procedures
 Goal
 Results
 Discussion
 Conclusion
 References

3. Dementia: A Growing Problem
Definition
– A general term for a decline in mental ability severe enough to
interfere with daily life (e.g. memory loss). The most common type of
dementia is Alzheimer’s Disease (DAT), which accounts for 60 to 80
percent of cases, followed by Vascular dementia (VD) at 10 percent
(Types of Dementia, 2015).
Characteristics
– Apathy, depression, impaired communication, poor judgment,
disorientation, confusion, behavior changes, and difficulty speaking,
swallowing and walking (What is Alzheimer’s?, 2015).
Primary Treatment
– Psychopharmacological medications (chemical restraints) and physical
restraint methods (H-.c. Sung et al., 2006).

4. Dementia: A Growing Problem
✜ Agitation is the most challenging and stressful characteristics
reported by family members, caregivers and staff within care
facilities. Research indicates that primary treatment methods can
cause harmful side effects and lead to further decline, increase
incidence of injuries and often leads to more agitation.
Furthermore, the effectiveness of chemical and physical restraint
methods are relatively weak for managing agitated behavior (H.-c.
Sung et al., 2006).
Prevalence of Dementia
– Currently affects an estimated 47.5 million people worldwide
and is projected to increase to 75.6 million by 2030 and triple by
2050 (10 Facts on Dementia, 2015).
Prevalence of Agitation among Dementia Patients
– Over 50% in community dwelling and up to 70% of nursing
home residents (Latest Alzheimer's Facts and Figures, 2013).

5. ♫ Music: An Alternative Method ♫
Music provokes psychological and physiological responses, as
well as emotional integration in persons receiving treatment
for an illness or disability (H.-c. Sung et al., 2006).
 Reduces agitation, temper aggression, anxiety, depression
and stress.
 Elicits positive feelings and promotes relaxation.
 Triggers memory.
 Self-awareness, social relatedness, and arousal and mood
regulation is achieved through listening to music (Schafer,
Sedlmeier, Stadtler & Huron, 2013).
 Increase mental, physical and emotional health by boosting
the immune system, energy levels and self-esteem.
 Increases tolerance to pain (H.-c. Sung et al., 2006).
♪
♬
♭
♩
♫
♮

6. SSD Overview
Research Goal
 Search for alternative methods to address and treat
agitation among persons with dementia, rather than the
traditional methods (chemical and physical restraints)
that can cause many harmful side effects (Yu Lin et al.,
2010).
Research Target
 Agitated behavior accompanied by dementia; specifically
dementia of Alzheimer’s type (DAT) and vascular
dementia (VD) (M. Suzuki et al., 2004).
Research Purpose
 The effectiveness of music intervention therapy against
agitated behavior in elderly persons with dementia.

7. Research Question
If persons with
dementia receive
music therapy as an
intervention will
that reflect a
decrease in the
occurrence of
agitated behavior?

8. Intervention: Target & Qualifications
Target
– Agitation experienced by a person suffering from DAT who
attends an adult day care (ADHS) program throughout the
day, while residing at home with his wife, was targeted
through the implementation of music therapy given
throughout the week.
Qualification
– Diagnosed with dementia (DAT) by the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IV) and is
currently being treated for agitation by at least one form of
medication (antipsychotics, sedatives and/or drugs for AD)
(H.-c. Sung et al., 2006).

9. Intervention: Overview
Music therapy intervention:
– Music of Interest: Biblical Hymns
– 5 days a week (M-F)
– Post afternoon activity (3pm)
– 30 Minute Sessions (music therapy)
– Duration of 6 weeks (total of 30 sessions)
– Orchestrated in a private activity room within the ADHS
facility

10. Intervention: Detailed Description
• Staff member rated the participant’s agitated
behavior according to frequency of occurrence using
the Cohen-Mansfield Agitation Inventory (CMAI)
evaluation scale, which consists of 29 observable
agitated behaviors rated on a 7-point scale (1-7)
ranging from never (1 point) to several times an hour
(7 points), with a minimum score of 29 and a
maximum score of 203 (Y. Lin et al., 2010).
• Staff member evaluated occurrence of agitated
behavior each day between 4pm – 5pm for a total of
9 consecutive weeks (baseline, intervention, post
intervention).

11. Intervention: Detailed Description
• Staff member orchestrated 30-minute
sessions of continuous music (via CD player) at
3:00pm Monday – Friday.
• The music chosen was Biblical Hymns because
this is the target participant’s favorite genre of
music.
• 3:00pm was chosen because the target
participant was reported to exhibit agitation
due to confusion and disorientation of place
and time, location of his wife and why he
wasn’t allowed to leave the facility.

12. Design & Intervention Length
A  Pre-Intervention = 5 days (1 week)
B Intervention = 30 days (6 weeks)
A  Post-Intervention = 10 days (2 weeks)
*Number of days per week = 5 (M-F)
*Duration of 9 consecutive weeks

13. Design: ABA Single-Subject Design
3 phases:
1. Pre-intervention (baseline) *A*
 Staff member rated agitated behavior according to
frequency of occurrence, using the CMAI
assessment tool, between 5pm – 4pm each day (1
week: 5 days).
2. Intervention (treatment) *B*
 Staff member introduced music therapy (Biblical
Hymns) to the participant from 3pm to 3:30pm and
continued to rate occurrence of agitation daily; 4pm
– 5pm (6-weeks: 30 days)
3. Post-intervention (baseline) *A*
 Staff member discontinued the Biblical Hymns music
therapy and continued to rate the occurrence of
agitation daily; 4pm – 5pm (2-weeks: 10 days).

14. Measures & Procedures
Dependent Variable
 Occurrence of agitated behavior
Independent Variable
 Music therapy intervention (Biblical Hymns)
Quantifying the Dependent Variable
 Agitated behaviors were quantified by one staff
member rated (daily) agitated behavior according
to frequency of occurrence experienced by the
target dementia (DAT) participant on a 7-point
scale (never = 1 point; several times an hour = 7
points).

15. Measures & Procedures
Data Collection
 Agitation was recorded daily using the CMAI
assessment tool, which includes 29 items (4
categories), each rated on a 7-point scale (1-7),
with a minimum score of 29 points and a
maximum score of 203 points.
 Four categories of behavior include physically non-
aggressive, physically aggressive, verbally non-
aggressive, and verbally aggressive.

16. Goal
The goal of the intervention (music therapy) is to
decrease the dependent variable (agitated behavior).

17. Results
This graph represents a portion of the agitation trends over the length of the
study.
This snap shot graph indicates the participant’s agitation ratings at week 1, 2, 7
and 9, and the differences in agitation between the 3 Phases.

18. Discussion
Effectiveness of Intervention
o Levels of agitation were significantly lower during the
Music Therapy Intervention Phase
 Pre-intervention Average: 6.2
 Intervention Average: 2.6
 Post-Intervention Average: 2
o The CMAI assessment tool was used to evaluated any
changes to the DV (agitated behaviors) with the
introduction of the IV (music therapy); the effectiveness
of the intervention was assessed by the visual trends
(increase or decrease of DV) that occurred over the
length of the study; the DV was evaluated (using ABA
research design) at Pre-intervention Phase (5x),
Intervention Phase (30x), and Post Intervention Phase
(10x).

19. Discussion
Literature Review
 This SSD was inspired by three research articles that explored
the effectiveness of music therapy as an intervention against
the occurrence of agitation among persons with Dementia.
 Each of the three articles used a form of the CMAI assessment
tool to determine changes in agitation (i.e., Chinese-CMAI,
Modified-CMAI, or original CMAI).
 I chose to utilize the research article titled, “Effectiveness of
group music intervention against agitated behavior in elderly
persons with dementia” by Yu Lin et al., because it
demonstrated the strongest Rigor, Reliability and efforts to
control for Extraneous Variables and Threats to Validity.
Furthermore, this study also used repeated measures to
indicate changes in agitation (Yu Lin et al., 2010).

20. Discussion
Strengths
• Several precautionary measures were made to control for
Extraneous Variables and Threats to Validity.
• Used repeated measures to indicate changes in the DV (CMAI
content validity index was 0.99 = good reliability and validity).
• Used the same person and the same methods (both IV and
DV) to collect and record agitation changes to ensure
consistency.
• Caregiver (wife of participant) committed to maintaining the
couples regular routine, which ensured DV (agitation) changes
were true to the IV (music therapy).

21. Discussion
Weaknesses
• Inclusion into institutional settings or ADHS programs may be
limited by flexibility (operations), lack of understanding or
commitment by employees, and ultimately funding
limitations.
• Only had one person within the study; lacking control group.
• Duration of the study lacked a significant time frame (non-
longitudinal).
• The stage and progression of the participant’s dementia was
not accounted for.
• Did not take into account whether or not the participant was
taking medications (or at what dose) for agitation (Y. Lin et al,
2010)

22. Discussion
Practice Implications
 Results indicate, inclusion of Music Therapy (MT)
demonstrates high efficacy for persons with DAT;
therefore, it represents a possible alternative
treatment method for DAT symptoms.
 There are several benefits associated with the inclusion
of music, and at the very least MT represents a
complimentary treatment method that could be used
in conjunction with the traditional treatment methods
(chemical and physical restraints).
 MT as an alternative treatment method for persons
with DAT is a relatively new area of research; however,
the results, thus far, certainly warrants further
exploration.

23. Discussion
Practice Implications: Improvements
 Increasing the length of the study would allow the
researcher to evaluate the trends that occur over an
extended period of time, which would increase the
study’s rigor and validity.
 Incorporating a larger sample and of different
geographical areas would increase the generalizability
of the findings.
 Select a neutral person to conduct assessments of the
participant’s agitation in order to avoid biased results,
rather than a staff member whom interacts with the
participant daily.

24. Conclusion
 This study demonstrates a positive correlation between music
therapy (MT) as an intervention and a reduction in the occurrence
of agitated behaviors for persons with dementia (DAT).
 Traditional psychopharmacological treatment methods and physical
restraint methods may have worked well in the past to address the
symptoms of DAT, but research has found that these methods may
cause adverse effects, which include; further decline and more
rapidly; increased number of injuries, to self or other; often create
more agitation; and is an indicator of poor quality of care in
institutional settings (H.-c. Sung et al., 2006).
 MT provides a more positive and liberating perspective on treating
behavior disturbances accompanied with DAT. Furthermore, MT
allows persons with dementia, and their caregivers, to experience a
better quality of life that doesn’t include an invasive or harmful
treatment method.

25. References
Latest Alzheimer's Facts and Figures (2013). Alzheimer’s Association: alz.org. Retrieved September 30, 2015,
from http://www.alz.org/facts/overview.asp
Types of Dementia (2015). Alzheimer’s Association: alz.org. Retrieved September 30, 2015, from
http://www.alz.org/dementia/types-of-dementia.asp
What is Alzheimer’s? (2015). Alzheimer’s Association: alz.org. Retrieved September 30, 2015, from
http://www.alz.org/alzheimers_disease_what_is_alzheimers.asp
Huei-chuan Sung, Shu-min Chang, Wen-li Lee, Ming-shinn Lee, (2006). The effects of group music with
movement intervention on agitated behaviours of institutionalized elders with dementia in Taiwan.
Complementary Therapies in Medicine. 2006; 14: 113-119.
Yu Lin, Hsin Chu, Chyn-Yng Yang, Chiung-Hua Chen, Shyi-Gen Chen, Hsiu-Ju Chang, Chia-Jung Hsieh, and Kuei-Ru
Chou (2010). Effectiveness of group music intervention against agitated behavior in elderly persons with
dementia. International Journal of Geriatric Psychiatry. 2011; 26: 670-678.
Mizue Suzuki, Masao Kanamori, Motoko Watanabe, Shingo Nagasawa, Emi Kojima, Hajime Ooshiro &
Daiichirou Nakahara (2004). Behavioral and endocrinological evaluation of music therapy for elderly
patients with dementia. Nursing and Health Sciences. 2004; 6: 11-18.
Schäfer, T., Sedlmeier, P., Städtler, C., & Huron, D. (2013). The psychological functions of music listening.
Retrieved November 10, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3741536/
10 facts on dementia. (2015). Retrieved November 13, 2015, from
http://www.who.int/features/factfiles/dementia/en/