1. Single-Subject Design:
Individualized Music Therapy for Older Adults in
Memory Assisted Care Facilities with Dementia.
Sarah JoD’Ann Smith
• Alzheimer’s disease is a social problem. It is the sixth-leading cause of
death and it afflicts more than 5 million Americans. Additionally, 15.4
million non-paid caregivers are providing care (Alzheimer’s
Association). Alzheimer's disease is a progressive brain disorder leading
to memory loss, changes in thinking, mood and behavior changes, and
eventually difficulty with speaking, swallowing, and even breathing.
• More than 80% of persons with dementia will eventually display
agitated behaviors (Jost, B. C., & Grossberg, G. T., 1996). Changes in
personality and a challenge for continued active engagement. Specific
interventions for behavioral disturbances beyond traditional
pharmacological therapy, which may cause adverse physical and
psychological effects beyond that of the original agitation, are often not
used or in conjunction with customary recreational and psychological
interventions.
• Agitation: The construct of agitation is complex, encompassing great
variability between behaviors and individuals. Agitation is
conceptualize as "an inappropriate verbal, vocal, or motor activity that is
not explained by needs or confusion.” Agitation can be operationalized
into three behaviors. 1). Aggressive behavior towards self or others
(hitting, cursing etc.) 2). Physically nonaggressive behavior (pacing,
inappropriate disrobing). 3).Verbally agitated behaviors (complaining,
repetitive phrases).
• Dementia is associated with short-term memory loss, while remote
memory often remains intact. It is theorized that music based on
personal preference may stimulate remote memory and change the focus
of attention and providing an interpretable stimulus, thus overriding
meaningless or confusing stimuli in the environment.
• The elicitation of memories associated with positive feelings will have a
soothing effect, which in turn prevents or alleviates agitation (Gerdner,
2005).
If older adults who have mid to late stage Alzheimer’s or related dementia
who are displaying behavioral changes of agitation and/or social
withdrawal and live in a memory assisted living facility are given
individualized music therapy, will that decrease agitation?
The Social Work student searched for Randomized Controlled Trials to
compare 2 different groups. The terms used were: Individualized music
therapy, dementia, Alzheimer’s disease, agitation and the inclusion criteria
were: Older adults, dementia, memory ALFs, English, 2005 +. Databases
related to dementia treatments, like the Alzheimer’s Association or
PubMed, were used.
Review of literature: Gerdner (1992) was the first to systematically
investigate the use of individualized music as an intervention for agitation
in persons with dementia. The majority of research evaluating the effects
of individualized music therapy have used agitated behaviors as the
primary outcome measure. Studies have shown an overall statistically
significant reduction in agitation during the use of individualized music.
• Client: is a 91 year old African-American women who resides in a Long Term Care Memory facility in
Charlotte, NC with severe dementia and displays frequent agitation behaviors. The intervention used was
described in the article Use of Individualized Music by Trained Staff and Family: Translating Research into
Practice by Linda Gerdner, (2005) because it was less time consuming than other variances, and CNAs are
trained to recognize agitation behaviors.
• A single-subject ABAB design was used over a 23 week period to evaluate the music intervention on
agitation frequency.
• The resident was observed and agitated behavior and the time was recorded for a week to determine the
frequency of agitation and temporal patterning. The intervention works best when implemented before
peak agitation.
• Family members completed the Assessment of Personal Music Preference about the resident’s music
preferences and identified the importance of music in the resident’s life. There is a positive correlation
between the significance that music had in the person's life and the effectiveness of the intervention. Per
the family, this resident enjoyed gospel music and had been an avid participant in her church choir.
• The music therapy was implemented using a compact disc player and a personalized CD.
• Each music intervention session lasted 30 minutes in a location where the resident spends the majority her
time.
• CNAs collected baseline data once a week during a 5-week baseline period using the Short Form Cohen-
Mansfield Agitation Inventory. CNAs administered individualized music during the subsequent 2 months
and collected data once a week for an 8-week intervention period using the same SCMAI scale. The
SCMAI was used every week for another 5-week post-intervention period, and again for another 5-week 2nd
intervention period when the same music intervention was reintroduced. CNAs documented the duration
and frequency of each of the 14 behaviors present for each shift so a SCMAI score could be assigned for
each week based on the log.
Quantifying the Dependent Variable: The SCMAI is a 14 item instrument designed to assess the frequency
of agitated behaviors over a two week period. The Social Work student shortened this time to once a week in
order to establish a baseline within a reasonable timeframe. The frequency of each behavior is rated on a scale
of one to five. A score of 1= never, a score of 5= A few times an hour or continuous for half an hour or more
on most of the days. The total score for all 14 behaviors are added up for an agitation score of anywhere
between 14 and 70.
Pre-intervention (A): The level of agitation trend shown here is flat. The mean agitation score is 48.2; Intervention phase
#1 (B): The level of agitation shows a decreasing trend. The mean agitation score is 35; Post-intervention (A): The level of
agitation shows an increasing trend. The mean agitation scores is 30.8; Intervention phase #2 (B): The level of agitation
shows a decreasing trend. The mean agitation score is 25.8.
• There is a clear decreasing trend throughout the single subject study with the exception of the post-intervention phase.
• The purpose of individualized music therapy (the independent variable) is
to reduce and to prevent the frequency and severity of agitation episodes
(the dependent variable) in adults with dementia.
• This intervention appears to be effective, as the descending trend line
indicates. The mean score during the first intervention phase is higher
than the post-intervention phase, but this seems to be due to fewer data
points and that the trend is increasing from a lowered scale score per the
intervention. Once the intervention is initiated a second time, the trend
reverts back to decreasing in level of agitation.
• The major threat to fidelity of the intervention would be the temporal
timing of the intervention, as peak agitation must be assessed. This
requires careful observation and knowledge of what constitutes as
agitated behaviors.
• The internal validity of a single case design is enhanced when there are
enough data points to show a stable trend which makes extraneous factors
unlikely. This SSD had five baseline data points and an additional five
data points when the intervention was withdrawn. This controlled for
extraneous factors and gave grounds for inferring that it was most likely
the intervention that accounted for the decrease in agitation.
Strengths for practice:
• Very little knowledge and training is needed to acquire music preferences
and play the music 30 minutes a day. Minimal time and cost expenditure
is required for implementation.
• Person centered care is an expanding philosophy and model for long
term care. It is about seeing the person before the clinical factor or task
while still providing quality medical care. Individualized music is using
individual preferences to increase quality of life.
• This intervention has the possibility to manage agitation in high-risk
clients without the use of physical restraints or psychotropic drugs.
Weaknesses or concerns for practice:
• Strategies for achieving conformity across the intervention and
measurement is more challenging and time consuming than the actual
intervention itself in this case.
• Training for intervention delivery and assuring that CNAs have the
necessary skills in recognizing agitation and temporal timing needed for
the intervention, is the greatest challenge to implementation.
• Other less restrictive forms of assessment could be used such as
measuring the use of psychotropic medication, expressed satisfaction, or
meaningful interaction with others.
Alzheimer’s Association. (2015). What we know today about Alzheimer's disease and
dementia. Retrieved from
http://www.alz.org/research/science/alzheimers_research.asp#hallmar
Cohen-Mansfield, J., & Billig, N. (1986). Agitated behaviors in the elderly: I. A conceptual
review. Journal of the American Geriatrics Society, 34(10), 711-721.
Gerdner, L. A. (January 01, 2005). Use of individualized music by trained staff and family:
translating research into practice. Journal of Gerontological Nursing, 31, 6, 22-30.
Jost, B. C., & Grossberg, G. T. (January 01, 1996). The Evolution of Psychiatric Symptoms in
Alzheimer's Disease: A Natural History Study. Journal- American Geriatrics Society, 44,
9, 1078-1081.
INTRODUCTION INTERVENTION DISCUSSION
IMPLICATIONS
RESULTS
LITERATURE REVIEW
SCHOOL OF SOCIAL WORK
PROBLEM STATEMENT
REFERENCES
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23
Intervention 45 43 39 39 29 31 25 29 29 27 25 25 23
Pretest/Postest 50 45 49 47 50 26 31 33 30 34
15
20
25
30
35
40
45
50
55
60
SMCAISCORE
Top: Number of weeks 1- 23
bottom 2: SMCAI score each week
SMCAI Scale Score by Week