Mrs. Adams was an 88 year old White widowed female who had resided in a semi-private room of a long-term care facility for two years. She was non-ambulatory and required extensive assistance with daily cares. Mrs. Adams was frequently incontinent of bowel and bladder. She had a medical diagnosis of dementia with severe cognitive impairment as evidenced by a Global Deterioration Scale score of 6. Prescribed oral medications included: Docusate Sodium 100 mgs. twice per day and Risperdal .5 mg. twice per day.
Following lunch, Mrs. Adams usually became increasingly restless and called out for help and repeatedly asked "what are we going to do now?" Nearby residents frequently responded by yelling "Oh, shut up!". When certified nursing assistants (CNAs) attempted to intervene, Mrs. Adams grabbed them and became verbally agitated, culminating in verbal aggression (i.e., cursing). The mean frequency of agitated behaviors exhibited by Mrs. Adams between 2:00 p.m. and 3:00 p.m. ranged from 22. 5 to 31.3 behaviors per 10-minute interval (refer to baseline in Figure 1). Staff became increasingly frustrated with Mrs. Adams "lack of cooperation".
Mrs. Adam's daughter, Annie, usually visited two times per week during mid-afternoon but her visits were generally cut short because she did not understand her mother's behaviors and became discouraged by failed attempts to communicate and calm her mother. Annie was highly critical of the staff and felt that they neglected her mother's needs.
Staff explored possible causes for Mrs. Adams agitation. There were no overt signs of pain. For example, she was not rubbing her stomach and there were no bruises or lacerations on her body. Her urine was clear amber with no abnormal odor. She had no elevated temperature. She usually had a bowel movement every morning following breakfast. Staff began monitoring the temporal patterning of her behavior. It was discovered that Mrs. Adams generally reached a peak level of agitation at approximately 2:30 p.m.
Staff met with Annie about the possibility of using individualized music as an alternative intervention for the management of agitation. Annie completed the Assessment of Personal Music Preference (Family Version) form (PDF, 44KB, 2pgs) since severe cognitive impairment prevented her mother from doing this. Annie purchased a portable audio cassette / CD player as an early birthday present for her mother and furnished an audio-tape of preferred music from her mother's personal library. Mrs. Adams had played both the piano and organ but especially enjoyed playing the organ. Music was classified as being moderately important in her life prior to the onset of cognitive impairment. An individualized plan of care (PDF, 15KB, 2pgs) was developed based on the staffs' assessment of Mrs. Adams agitated behaviors and the information provided by Annie regarding music preference.
Individualized music (Golden Organ Favorites featuring Bob Ralston/Jerry Burke and the Magic Organ) was presented for 30 minutes daily from 2:00 to 2:30 p.m. by the CNAs. Mrs. Adams appeared less agitated while music was being played and often taped her feet or hands in rhythm to the melody (Click here for figure 1) (PDF, 11KB, 1pg.). On several occasions she even hummed or sang the words to several of the songs (You are my Sunshine, Somewhere my Love, I'm Looking Over a Four Leaf Clover, When the Saints Go Marching In). On one occasion she stated, "I used to play the organ - I love music."
Although Mrs. Adams continued to "call out" for help, she did so with less frequency. The frequency of agitation during the presentation of music ranged from 3.2 to 6.4 behaviors per 10-minute interval. There was a gradual increase in the frequency of agitation ranging from 7.3 to 12.7 per 10-minute interval during the 30 minutes following the completion of the individualized music (refer to Figure 1). Importantly this remained less than at baseline.
The staff enjoyed playing the prescribed music for Mrs. Adams because they could see a positive response in her behavior. This served as a motivating factor to facilitate compliance (TQM) (PDF, 31KB, 1pg.). Annie also played music for her mother during visits and enjoyed seeing her mother's response.