evaluation of music and memory program white...

EvaluationofMusicandMemoryProgram

WhitePaper

October,2016

UniversityofWisconsin‐MilwaukeeHelenBaderSchoolofSocialWelfare&

CenterforAgingandTranslationalResearch

JungKwak|UWM.EDU/SOCIALWELFARE/

Authors:

JungKwak,MSW,PhD

KatharineO’ConnellValuch,MA

Withthanksto:MichaelBrondino,PhD;HollyNeuman,WhitneyWelch,HotakaMaeda,ChrisCho,SheilaFeay‐Shaw,MatthewRichie,JohnFennimore,PriscillaKennedy,andSamanthaRatzlafffortheircontributionstotheproject.

Thisevaluationwasfundedbythefollowing:

ClaudePepperCenter,FloridaStateUniversity BaderPhilanthropies MyChoice,FamilyCare WisconsinDepartmentofHealthServices

Copyright©2016,JungKwak,PhDandKatharineO’ConnellValuch,MA

Allrightsreserved.Nopartofthisworkmaybereproducedorcopiedinanyformorbyanymeans—graphic,electronic,ormechanical,includingphotocopying,recording,taping,Internetorinformationstorageandretrievalsystems—withoutthewrittenpermissionofJungKwak,PhD.andKatharineO’ConnellValuch,MA


TABLEOFCONTENTS

ExecutiveSummary.....................................................................................................................1

Background.....................................................................................................................................4

KeyFindingsFromtheEvaluation.....................................................................................10

Recommendations.....................................................................................................................20

References.....................................................................................................................................28

Appendix........................................................................................................................................31

UniversityofWisconsin‐Milwaukee 1


EXECUTIVESUMMARYWHYWEEVALUATEDMUSIC&MEMORYPROGRAMThe Music and Memory (M&M) program has been increasingly adopted in

nursinghomesacross theU.S. tosupportpersonswithdementia.M&Muses

personalized music playlists delivered on digital music players set up and

maintainedbycarestafftrainedintheprogram(MusicandMemory,2013).The

underlying premise of M&M is that these musical favorites tap into deep

memoriesnot lost todementia, thereby facilitating resident communication,

engagement, and socialization. However, few rigorous evaluations of this

popularnon‐pharmacologicalternativehavebeenconducted.

Asapartofongoingeffortsatimprovingdementiacare,theStateofWisconsin

decided to implement statewide theMusic andMemory program as a non‐

medicationbasedmethodthatmay:(1)reducetheratesofnegativebehaviors

typicallytargetedbymedication,therebyreducingtheneedformedication,and

(2)improvethequalityoflifeofpersonswithdementiabyprovidingaccessto

anactivityenjoyedbythepersonsusingit.In2014,theWisconsinDepartment

ofHealthServices(WIDHS)awardedagranttotheUniversityofWisconsin‐

MilwaukeetoevaluatetheeffectoftheMusic&Memory(M&M)programon

outcomes for residents, staff, and family caregivers from nursing homes

participatinginthestatewideM&Mprograminitiative.Withadditionalfundingsupport from Claude Pepper Center, Florida State University, Bader

Philanthropies,andMyChoice,FamilyCare,theUWMresearchteamconducted

comprehensiveevaluationoftheM&Mprogrambetween2014and2016.

TheM&Mevaluationhadmultiplepartsincluding:(1)acrossoverstudywith

59nursinghomeresidentswithdementia from10Wisconsinnursinghome

facilities;(2)apre‐andpost‐surveyonmedicationuseamong1,500residentswho received M&M in 100 facilities participating in Phase 1 of the M&M

statewide initiative; (3) a secondary data analysis of theMinimumData Set

(MDS) to compare nursing home resident outcomes between facilities that



participated in the M&M at different time points; and (4) a key informant

survey with administrators of Wisconsin nursing home facilities about

implementationandsustainabilityofM&M.

WHATWEFOUNDSomeimportantmethodologicallimitationsoftheevaluationnotwithstanding,

resultsfromallcomponentsoftheevaluationleadtoasimilarconclusion,that

is, M&M had no or minimal effect on nursing home resident behavioral

outcomes,andverymodesteffectonpsychotropicmedicationuse.However,

many facilities viewed theM&Mprogramas valuable, noting improvementsobservedinresidentssuchasenjoymentandimprovedmoodwithcaveatsthat

neithertheM&Mprogram(ormusic),norusingheadphonesoriPods,workfor

everyone.

SeveralM&Mprogramimplementationrelatedissueswerealsofound,which

provideatleastsomepartialexplanationforminimaleffectivenessoftheM&M

program found in the evaluation. There was considerable variability in theratesatwhichtheiPodswereusedacrossresidentsandacrossfacilitieswith

theratesatmostfacilitiesbeinglow.Inotherwords,manyresidentswerenot

receivingM&M for long or often enough for the program to have sufficient

effect.

SeveralkeybarrierstoconsistentlyandeffectivelydeliveringM&Mfortargetresidentswerealsofound.Theyincludealackofbuy‐infromalllevelsofcare

staff and management and a lack of or limited time available to staff to

implement and maintain the program. For many busy direct care staff,

developing the individualized playlist for each resident was quite time

consuming.Otherbarriersincludeddifficultiesinunderstandingtheoperation

ofthemusicdevices,issuesinidentifyinganaccessibleandsecurelocationfor

storageandcharging,problemsunderstandinghowthedevicesinterfacedwith

computers,andissuesassociatedwiththecostsofreplacingbrokenequipment,

purchasingadditionalnewequipmentandpurchasingnewsongs.



WHATWERECOMMENDTogether,thefindingsfromtheevaluationofM&Mandpastresearchonmusic

anddementiasuggestthatseveralimprovementscanbemadetoimprovethe

program implementation fidelity, efficacy and sustainability.Recommendations to improve the program efficacy include: (1) select

individualswhoaremostlikelytobenefitfromM&M;(2)assess,identifyand

setspecificgoalsfortheM&Mintervention;(3)developindividualizedplaylists

andlisteningschedulestailoredtoeachindividualperson;and(4)implement

asystemicprocessevaluationoftheM&MprogramandincorporateM&Minto

aformalcareplanningprocess.

Recommendations to enhance sustainability of the program include: (1)

increase buy‐in from all involved in the process; and (2) develop and test

training programs for volunteers such as students to implement the M&M

program.Buy‐inmaybeincreasedbyhelpingstafftorecognizeanypositive

impacts ofM&Mon residents. Anotherway to facilitate buy‐inwould be to

approach M&M like other care interventions or programs that require a

systematic approach to assess, develop the playlist, deliver and monitor

consistently. To make this possible, offering incentives or education and

training among direct carewill be important for integratingM&M into care

plans. Tohelp facilitiesdevelop individualizedplaylists,which canbequite

timeconsumingandasignificantbarrierfortheprogramtobesustainedover

time,futureeffortsshouldfocusondevelopingstrategiestoinvolveandtrain

residents’ families aswell as volunteers todevelopplaylists anddeliver the

musicwillhelpreduceburdenondirectcarestaff.

Inconclusion,theliteratureconcerningtheuseofmusic‐basedinterventions

with persons with dementia suggests that there is the potential for such

interventions toprovidepleasure andaid in the remediationof undesirable

behavioralsymptoms.ThereislittlereasontobelievethattheM&Mprogram

cannotachievegreaterimpactifcarefullyimplemented.



BACKGROUNDDEMENTIAANDAGITATIONIn2014,morethanfivemillionAmericans,nearly1ofevery9olderAmericans,

werediagnosedwithAlzheimer’sdiseaseoranother formofdementia 1. In

casesofAlzheimer’s,themostcommonformofdementia,impairmentsoccur

incognitiveability,memory,language,reasoning,andjudgment.

Up to 90 percent of

persons with dementia

(PWDs) experience

secondary behavioral or

psychological symptoms,

which become more

prevalent in advanced

stages2,3. Among nursing

home residents with

dementia, secondarybehavioral symptoms

affect 75% of those with

dementia4, with the most

frequent problems being apathy (36%), depression (32%), and

agitation/aggression(30%)4.

TheseproblemsarechallenginganddistressingtonotonlyPWDsbutalsotofamilyandprofessionalcaregivers,andareoftencitedas thekeyreason for

institutionalization6‐10.Thesebehavioralsymptomsarefurtherassociatedwith

care‐related stress by staff and increased costs of care in the nursing home

environment.

TREATMENTAPPROACHESTOAGITATIONA common approach to managing these symptoms, especially in nursing

homes,istheuseofpsychotropicmedication.Oneestimatesuggeststhat33%



of residents with dementia receive such medication11. However, given the

evidence for limited efficacy and serious potential side effects of

pharmacologicaltreatments,therehasbeenanincreasingefforttodevelopand

implement non‐pharmacological interventions to address the behaviors

targetedbymedications.

Approaches to reduce agitation and

improvemoodincludestaff/caregiver

education and training; structured

activities; stimulation‐oriented

treatments such as recreational

activities; and therapies involving

music, art, pets or programs that

increase the number of pleasurable

activities21,22. The risks associatedwith these non‐pharmacologic

treatments, such as increased

agitation for some residents, are less

frequent and severe than those risks

associated with anti‐psychotic

medications(e.g.,mortality)7.

One of the increasingly popular

approaches being adopted in nursing home facilities is to use music,

individualizedmusiclistening(IML)programsinparticular,andtheMusicand

Memory(M&M)programisanexampleofIML.

POTENTIALBENEFITSOFINDIVIDUALIZEDMUSICLISTENINGIndividualizedmusiclistening(IML)isapassivetypeofmusicinterventionthat

involvesPWDslisteningtotheirpreferredmusicwiththegoalsofpromoting

relaxationandenhancingtheemotionalstate.IMLprogramssuchasMusic&

Memoryareincreasinglyusedinlong‐termcarefacilitiesbecauseoftheirlow

costofimplementationandeaseofdelivery.



Indeed,IMLhasthepotentialtoimprovequalityoflifeamongPWDsandthe

carepracticesofdirectcarestaff.Theliteratureonqualityoflifeanddementia

documents the clinical benefits of increasing pleasant events in treating

depression and improving quality of life.4 The neuroscience literature also

supports theconclusion thatmusicenablePWDstoretrievememories, and

elicitpositiveemotions.5Studieshavereportedthatpeoplewithmoderateto

severe dementia24 are able to correctly perceive the pitch and melody of

music25‐27, recognize the titles of familiar songs28 and also recall familiar

lyrics29.Preferredmusiclisteningmayhaveimportanttherapeuticbenefits.

IMLsbasedonthePWD’sautobiographicalmemoryandmusicalpreferences

can function as a

pleasant sensory

stimulation that helps

trigger retrieval ofpleasant memories,

shifts attention away

from stressful

environmental stimuli,

increases attention,

improves mood, and

reducesagitation.Asa

result of observing

such positive

behavioral changes,

direct care staff

relationshipswithandattitudestowardsPWDscanimprove,whicharecentral

toPWDs’qualityoflife.6

EVIDENCEBASEFORIMLDespitethesubstantialbodyofliteratureconcerningthetherapeuticeffectsof

music, surprisingly few rigorous empirical studies are available to date that



tested the efficacy of IML in reducing behavioral problems associated with

dementia.

Acomprehensivereviewofempiricalresearchonmusictherapyorlistening

programswithPWDsbyVink,Bruinsma,Scholten33foundonlytenrandomized

controlledtrials(RCTs)thatmettheirselectioncriteriaforrigorousresearch

design.Thisreviewwasbuiltontwopreviousliteraturereviewsonthesame

topic, and three reviews together identifiedover500publishedarticles that

hadreferencetomusictherapyanddementia.Only10studieswereRCTsthat

mettheirreviewcriteria.Moreover,onlythreeofthetenstudiesexaminedthe

effectsofIML34,35.Sincethepublicationofthe2011reviewbyVink,onlyone

studybySakamoto,Ando,Tsutou36waspublishedwhichutilizedanRCTdesign

toexaminetheeffectofIML.Overall,thecombinedevidencefromtheseeleven

studies support that the claim that IML and active groupmusic therapy are

moreeffectivethannointerventioninreducingagitationandaggression33,36.Methodological limitationsofthesmallnumberofRCTs,however,precluded

definitiveconclusionsregardingefficacyofIML.

Thelimitedevidence‐basethatiscomprisedofrelativelyolderstudiesonIML

programsmotivatedtheevaluationofM&MbytheresearchteamatUniversity

ofWisconsin‐Milwaukee(UWM),whichisdescribedinthiswhitepaper.

THISEVALUATIONISONEOFTHEFIRSTLARGE,COMPREHENSIVEEVALUATIONSOFANIMLPROGRAM:

MUSIC&MEMORY(M&M)



MUSIC&MEMORYTodate,Music&Memory(M&M)hasbeenadopted

in over 1,000 nursing homes in the U.S. alone to

supportpersonswithdementia37.Theprogramusespersonalizedmusic playlists delivered on iPods or

otherdigitaldeviceswhicharesetupbycarestaff

whoaretrainedintheprogram37.

According to the resources and training materials

available on the M&M website, M&M defines the“individualized”musicplaylist followingGerdner35,

whostatedthat:“[Individualizedmusic]isdefinedas

musicthathasbeenintegratedintotheperson’slife

and is based on personal preference. The musical

selectionmusthavespecificmeaningtotheperson’s

life”(p.51).

The M&M program emphasizes creating a playlist

based on music that has personal meaning. The

program suggests that persons with dementia or

familymembersarethebestsource for identifying

an individual’s music preferences and songs

significant to that person’s life experience. The

program also suggests that in case a person is no

longer communicative and family members have

little information about their relative’s music

preferences,caregiverscanplaymusicpopularfrom

the timethe individualwasachildoryoungadult,

includingmusic played on the radio or in popular

televisionshows,andjudgewhatispreferredbased

ontheindividual’sreactiontothemusic.

M&M

TheMusic&MemoryprogramwasdevelopedbyDanCohen,whowentontocreatetheMusic&Memorynon‐profitorganizationin2010.Moreinformationabouttheprogramcanbefoundontheirwebsite:

musicandmemory.org



ImplementingM&M(fromHowtoCreateaPersonalizedPlaylistforYourLoved

OneatHome37)includesthefollowingsteps:

1. Createaregularschedule/systemfordeliveringindividualizedplaylists

such as “three 30‐minute listening sessions—morning, afternoon and

evening”.

2. Deliverthemusicatcertaintimesthroughouttheday(butthemanual

does not specify when). For persons with Alzheimer’s disease, the

manual emphasizes that “timing is very important. You can greatly

reduceorheadoffagitationbyplayingmusictodistractandcalm”.

3. If an individual becomes more agitated while listening to music, try

changingthemusicselection.



KEYFINDINGSFROMTHEEVALUATIONOVERVIEWOFTHEEVALUATIONThestatewideinitiativeto implementM&MinWisconsinbeganinJuly2013

when the Wisconsin Department of Health Services began soliciting

applicationsforparticipationinPhaseIoftheinitiative.TrainingintheM&M

programwasconductedinOctober2013withthe100nursinghomesthatwere

selected from the applicanthomes toparticipate inPhase I of the initiative.

Equipment for theM&Mprogramwasdistributedtonursinghomesstarting

December 2013 after the nursing homes completed the Resident Selection

Survey.Therewerethreephasesofthestatewideimplementation:2014asthe

implementation year for Phase 1, 2015

forPhase2,and2016forPhase3.

The M&M evaluation by the UWM

research teamhad fourparts.The first

studywasconductedusingacrossover

study design with 59 nursing homeresidents with dementia from 10

Wisconsinnursinghome facilities from

Phase 1. The second studywas a pre‐ and post‐ survey onmedication use

among 1,500 residents who receivedM&M in 100 facilities participating in

Phase1oftheM&Mstatewideinitiative.Thethirdstudywasasecondarydata

analysisof theMinimumDataSet (MDS) to comparenursinghomeresident

outcomesbetweenfacilitiesthatparticipatedinM&Matdifferentphasesofthe

initiative,Phase1,Phase2,andPhase3.Thelaststudywasakeyinformant

surveywithadministratorsofWisconsinnursinghomefacilitiesaboutpositive

aspects and challenges in implementing and sustaining the program, and

recommendationstoaddresschallengesorbarriers.



OVERALLEFFECTIVENESSOFM&MINIMPROVINGRESIDENTOUTCOMESTheresultsfromthecrossoverstudysuggestthat,contrarytoourexpectations,

theM&Mprogramhadlittleornoeffectonimprovingresidentoutcomesinthe

areasof cognition,memory,agitation,mood,movementandmedicationuse.Forexample,duringthefirst8weeksofthecrossoverstudy,residentsreceiving

M&Mshowedimprovementinagitationandotherbehavioralsymptomswhile

thecontrolgroupwithoutM&Mdidnot.Thesedifferences,however,werenot

statistically significant and disappeared over time (see Figures 1 & 2). The

analysisoftheMDSdataonnursinghomeresidentsfurthersupportthemain

findings fromthecrossoverstudy, that therewerenostatisticallysignificant

differences in resident outcomes, behavioral problems, communication,

Figure1.Selectfindingsfromthecross‐overstudy.



mobility,andmood.TheMDSanalysis,whileshowingdecreasesinmedication

use also indicted that the decreaseswere greater in the nursing homes not

usingM&MrelativetothehomesthathadimplementedM&Mbetween2014

and 2015. The pre‐ and post‐survey findings suggest, however, that the

implementation of the M&M program may have had a small effect on the

reductionof theuse of anti‐anxietymedications among residentswhowere

selected to participate in the program. There are several possible

methodologicalissuesrelatedtotheevaluationdesignandtheM&Mprogram

related explanations for such findings. They include but are not limited to

reliance on staff reports on key resident outcome measures, lack of

Figure2.Selectfindingsfromthecross‐overstudy.



randomization(despitematching)intheMDSdataandpre‐andpost‐survey,

andlackofrandomsamplinginpre‐andpost‐survey.

M&MIMPLEMENTATIONFIDELITYMusic listeningdatafromthecrossoverstudyand

key informantsurveywithnursinghomefacilities

data suggest there was either low fidelity to the

guidelinesrecommendedbytheM&Mprogramor

that the M&M guidelines are insufficient when

comparedtotheevidence‐basedpracticeguidelines

onindividualizedmusiclisteningprograms.

Two notable areas of low fidelity were: (1)

improper development of the individualized

playlistbasedon theprinciplesof familiarity, and

autobiography, and (2) inconsistent and targeted

useofthedevices.

The evaluation found that musical genre

preferences varied considerably across residents

although a few genres such at jazz, (then)

contemporarypopandbigbandwerefairlyuniform

across residents. This seems to show that effortsweremadeto includeavarietyofmusicalchoices

thatwouldrelatetothestudyparticipants.Further

investigation of the specific pieces, however,

showed that many would not have been used as

listeningchoicesbyindividualsintheyearsbefore

theonsetofdementiawhichiscriticalformemory

connectivity.Songswithcopyrightinthepast10‐20

years which were found in music listening data

would likely have limited familiarity before

Thereweretwokeyconcernswithimplementationfidelity:

1. Improperdevelopmentofplaylists

2. Inconsistentuseofdevices

KEY FIDELITY CONCERNS



progressionofthedisorder,dependingontheageofthesubject.

Also, therewasconsiderablevariability intheratesatwhichthe iPodswere

used across residents and a similar patternwas foundbetween thenursing

homes themselves but with the rates at most facilities being low. Some

residentshadafixedscheduleforM&Mdeliveryandsomehadvaryingtime

dependingonthemoodoftheresidentaswellasavailabilityofstafftodeliver

M&M.Lengthofthedeliveryvariedfrom15minutespersessiontounlimited

time per session. To some extent, nursing home staff were attempting to

provideM&M at times thatwould assistwith curbing behavioral problems,

howeverthedurationofM&Mdeliveryvariedconsiderably,andit isunclear

howroutinelytheprogramimplementationguidelineswerefollowed.

VALUEOFM&MThe key informant survey with

administrators of Wisconsin

nursinghomefacilitieswasacross‐sectional survey with a response

rate of 40% from all Wisconsin

nursinghomes.Themajorityofkey

informant survey respondents

valuedtheprogramandviewedthe

M&Mprogramfavorably.

Aspects of M&M that were valued

includedeaseofuse,fitforhelping

residents experience andmaintain

personhood, and better social

interactions and engagement.

Respondents noted that M&M had

theeffectsof improvingmoodand

enjoyment among residents if the

programwasimplementedconsistently.



SUBSETOFRESIDENTSMOSTLIKELYTOBENEFITFROMM&MTheM&Mprogram is intended tobeusedwith individualswhohaveapast

connectiontomusiclisteningintheirlives.CasestudiessuchasCuddy,Duffin46andtheEDGEProjectinNewYork49demonstratethatindividualswithanappreciation for, enjoyment of or experiencewithmusic have the strongest

potential to benefit from this intervention. However, personal history of

enjoyingmusicmaynot alwaysmean that the personwith dementiawould

enjoyM&M. Anecdotally, the research teamwas told that some residents

cherishedtheirtimelisteningandthatmorethanoneresidentwassaidtobe

upsetanytimetheiPodsweretakenawayfromthem.Otherresidentsweresaid

tohavelittleornointerestintheiruseortodisliketheiruseoutright.Asimilar

observationwasmadeby themajorityofkey informantsurveyrespondents

whoobservedthattheM&Mprogramormusicasatherapeuticformingeneral

doesnotworkforeveryone.Moreover,wearingheadphonesdidnotworkfor

someresidents,andinsteadspeakershadtobeusedforsomeresidents.Lastly,

althoughreasonsarenotclear,MedicaidresidentsreceivingM&Mexperienced

improvementsinoverallbehavioralproblemsandrejectionofcare.

RESIDENTOUTCOMESM&MLIKELYTOIMPROVEMOSTTheoverall evaluation results suggestminimalormodesteffectsofM&M in

improving agitation, mood, and medication use. Still, the majority of key

informant survey respondents valued the program. Respondents notedobserving improvedmoodandenjoymentamongresidents,andemphasized

thatthepersonalizednatureofthemusicwasthekeytoenjoyment,triggering

memories,andimprovingmood.AlsonotedwerethecalmingeffectofM&M,

and the positive effect of headphones blocking noise and allowing each

individualresidenttolistentothemusictheyprefer.



Therefore,M&Mappearstofunctionasapleasanteventtohaveatleastshort‐

term(i.e.,withinafewhoursoflisteningtomusic)effectsofelicitingpositive

moodandrelievingboredomatleastamongresidentswhorespondtomusic

positively.Indeed,theliteratureonqualityoflifeanddementiadocumentsthe

clinical benefits of increasing pleasant events in treating depression and

improvingqualityoflife.4Moreover,theneuroscienceliteraturesupportsthe

effectsofmusicinenablingPWDstoretrievememories,andelicitingpositive

emotions.5

Thus,iftheM&Mplaylistisdevelopedbasedontheresident’sautobiographicalmemoryandmusicalpreferences,anddeliveredtoresidentswhohavepastconnectionswithmusicandrespondpositivelytolisteningtomusic,M&Mhasthepotentialtoincreaseattention,improvemood,andreduceagitation,atleastfortheshort‐term.



EFFECTSOFM&MONFAMILYANDDIRECTCARESTAFFOUTCOMESPre/postsurveyresultsfromthecrossoverstudygenerallydidnotindicateany

significant changes in family satisfaction with care or relationship quality

betweenthe familymembersandresidents.Directcarestaffwhocompletedboth thepre‐ andpost‐survey regarding feelingsabout their jobsandabout

workingwithresidentswithdementiadidnotindicateanysignificantchanges

in those perceptions between the beginning and end of the data collection

period(about14weeksinduration).Methodologicalissuessuchaserrorsor

biasesinherentinsurveydatacollectedfromasmallnon‐randomsamplewith

a low response rate may contribute to these results. Moreover, numerous

factorsarerelated to jobsatisfactionandburnout,and it is likely thatother

factorsexperiencedbytherespondents(suchaschangesinmanagement)have

agreatereffectontheexaminedoutcomevariablesthanasingleintervention

orprotocol.



BARRIERSANDCHALLENGESINIMPLEMENTINGANDSUSTAININGM&MINNURSINGHOMESTwokeybarrierstoconsistentlyandeffectively

deliveringM&Mfortargetresidentswere:(1)a

lack of buy‐in from all levels of care staff and

management, and (2)a lackofor limited time

availabletostafftoimplementandmaintainthe

program.

Lackofbuy‐inaffectedallstepsoftheprocessof

implementing and maintaining the program.

AlthoughM&M is a relatively easy and simple

programtoimplementcomparedtoothertype

of music interventions, for many activity and

directcarestaff,thetimecommitmentrequiredisnotminimal.Forexample,developingatruly

individualizedmusicplaylistdoestaketimeto

interview not only residents but also family

members. In fact, key informant survey

respondents reported identifying preferred

songsasabarrierbecausenotallfamiliesknow

and often residents are not communicative.

Hence,therewillbetrialanderrortocreatean

optimalplaylistanddeliveryschedule.

Moreover,monitoringlisteningbytheresidents

duringthedeliveryandattheendofsessionalso

requires serious commitment on the part of

staff.Withresidents locatedatdifferentwings

or floors with different direct care staff with

varying schedules (and high turnover) in

Thereweretwokeybarrierstoimplementation:

1. Lackofbuy‐in

2. Timerequiredtoimplement

Adequatelyaddressingthesetwobarrierscanincreasefidelityofimplementation,aswellasrateofimplementation.

KEY BARRIERS



nursinghomeenvironment, implementingM&Minawaythatwillmaximize

therapeuticbenefitsandresultinconcreteresultsisnoteasy.

Otherbarriersincludeddifficultiesinunderstandingtheoperationofthemusic

devices,issuesinidentifyinganaccessibleandsecurelocationforstorageand

charging,problemsunderstandinghowthedevicesinterfacedwithcomputers

andissuesassociatedwiththecostsofreplacingbrokenequipment,purchasing

additional new equipment and purchasing new songs. Respondents

acknowledgedthegrantfromthestatetobeavaluableresourcetoinitiateand

implementtheprogram.However,aremainingconcernwassustainabilityof

the program‐ how they will continue the program for existing and new

residentsasadditionalcostswillbeincurredtoreplaceexistingequipmentand

buynewsongs.



RECOMMENDATIONSThe overall findings from the

evaluation of M&M and pastresearch on music and dementia

suggest that improvements could

bemadetohowtheM&Mprogram

is implementedandmonitored to

increase its impact on resident

well‐being and quality of life.

Theseare:

1. Select individuals who are

mostlikelytobenefitfromM&M

First consideration for placement

of residents in music listeningprogramslikeM&Mistoassessthe

importance of music in the

person’s background.48 Similarly,

theM&M program is intended to

beusedwithindividualswhohave

a past connection to music

listeningintheirlives.

The Personal Music Assessment

form, or something similarly

designed at each facility could help understand the importance ofmusic in

resident’slives.Autobiographicalinformationaboutresidentsthatcanbetaken

atthetimeofintakeincludebutnotlimitedtopersonalinterestsinlisteningto

music, specific listings of favorite songs, key autobiographical eventswith a

musicassociation,favoritegenresandartists,etc.Thisinformationcanbeused

RECOMMENDATIONS TO

IMPROVE THE EFFICACY OF

M&M PROGRAM INCLUDE:

(1) Selectindividualswhoaremost likely to benefit fromM&M;

(2) Assess, identify and setspecific goals for the M&Mintervention;

(3) Develop individualizedplaylists and listeningschedules tailored to eachindividualperson;and

(4) Implement a systemicprocess evaluation of theM&M program andincorporate M&M into aformal care planningprocess.



toidentifypersonsappropriateforthistypeoflisteninginterventionandallow

foramoreappropriatestructuringofplaylistsatafuturepointintime.

Other additional

considerations inselecting

residents for the program

are whether residents

oftenexperienceagitation,

enjoy listening to music,

and can tolerate

headphones being placed

over their ears. Music

listeningconditionscanbe

altered to accommodate

certainresidentssuchasaresidentcanlistentomusic

over speakerswhile inhis

or her room instead of

using headphones.

Residents without

agitation may also enjoy

listening to individualized

musicplaylistsalthoughtheymaynothavethesamebehavioralproblemsthat

theuseofM&Misintendedtoameliorate.Nevertheless,residentswhodonot

enjoylisteningtomusicshouldnotparticipateintheprogram,asparticipation

may increase anxiety or agitation symptoms and could increase problem

behaviors. Therefore, monitoring of their response to the intervention is

important.Whileabenefitofthisinterventionisa“lackofsideeffects”50,the

neurocognitiveconnectionsoutlineddohavethepotentialtoelicitnegativeas

wellaspositiveconnections.

Lastly, it is helpful to keep in mind that persons with different forms of

dementiamay react differently tomusic. For example, the study by Hsieh,



Hornberger,Piguet,Hodges51foundpersonswithAlzheimer’sdiseasearemore

likely to maintain some ability to attach emotional meaning to facial

expressions or music when listening to familiar music than persons with

semantic.

2.Assess,identifyandsetspecificgoalsfortheM&Mintervention

Notable non‐pharmacologic interventions that have been shown to have

positive effects are those that are directed at single behaviors such as

agitation.22Personswithdementiawillmanifestvaryingtypesanddegreesof

challengingsymptoms.Somepersonswithdementiamayhavemorereserved

memory and cognitive abilities than others and for those, improving or

maintainingcognitivefunctionmaybethedesirableoutcome.Forotherswith

a more advanced stage of dementia, the targeted areas may be agitation,

aggression,anxiety,depressionorapathy.Thekeyistoidentifyandtargetone

ortwokeysymptomsthatseemtoaffecttheindividualthemost.

Hence, identifyingthekeytargetareasofM&Minterventionwillbeacrucial

stepbeforedevelopingtheindividualizedplaylistandmusiclisteningschedule.

Forexample,theplaylistforaresidentwithagitationoraggressionsymptoms

mayneedtobedevelopedwiththegoaltohelptheresidentrelaxandincreasepositivemood,whiletheplaylistforaresidentwhoareemotionallyorsocially

withdrawnmaybeneedtofocusedonthegoaltohelptheresidentbeenergized

andactivelyengagedwiththeenvironment.

KEYCONSIDERATIONSINIDENTIFYINGAPPROPRIATERESIDENTSFOR

M&MARE:WHETHERRESIDENTSHAVEAPPRECIATIONFORMUSICLISTENING(I.E.,RESIDENTSHAVESPECIFICLISTOFFAVORITESONGS,GENRES,ANDARTISTSTHATAREASSOCIATEDWITHAUTOBIOGRAPHICALEVENTS),HAVEAGITATIONTHATNEEDSTOBETREATED,ANDCANTOLERATELISTENINGTOMUSICWITHAHEADPHONE.



3.Developindividualizedplaylistandlisteningscheduletailoredtoeachindividualperson

Theliteratureonmusicanddementiasuggeststhattheindividual’sfamiliarity

ofthemusicandautobiographicalconnectionbetweenthepersonandmusic

areessentialfortheM&Mprogramtopositivelyaffecttheoutcomes.

Thepremiseofthislisteningapproachtotherapeuticmusicisthatthe

naturalistictaskofmusiclisteningrequireslowretrievaldemandsmakingit

accessibleevenasAlzheimer’sprogresses.Therateofatrophyinthemedial

prefrontalcortexforAlzheimer’sisslowerthanotherformsofdementia,

allowingthisregion(whichisresponsibleforassociatingmusic,emotionsand

memory)tobepreservedlongerandabletorecognizemusicalstructure

whichiskeytomemoryretrievalcues30,32,47,51,52.Ascognitiondecreasesin

Alzheimer’s,thefamiliarityofmusicalworksiscrucialtoactivateprior

connections53,54.

IDENTIFYINGTHEKEYTARGETAREASOFTHEM&MINTERVENTION

WILLBEACRUCIALSTEPBEFOREDEVELOPINGTHEINDIVIDUALIZED

PLAYLISTANDMUSICLISTENINGSCHEDULE.



Therefore, it is critical for

staff or volunteers to

identify some key

autobiographical events

andspecificpiecesofmusic

ormusicalgenrethatmight

be associated with such

events by interviewing

residents as well as

families.

Careshouldbetakeninthe

selection of music and

modification of playlists,

especially when residentsare not able to clearly

communicate preferences

formusic.Careshouldalso

betakentousedevicesfor

delivery ofmusic thatwill

not result in increased

frustration for the

residents,whichcouldlead

to problem behaviors

and/or increased labor for

staff beyond regular M&M

program implementation

requirements.

Anothercriticalelement tosuccessfulM&Minterventionwouldbe to timing

and amount of exposure to music listening. Persons with dementia have

differenttimeofthedayoreventsortasksthatmaytriggeragitationsuchas

mealtime,lateafternoon,orbathing.Observationandassessmentofspecific



agitationwhichimpactsanindividual’squalityoflifeoractivitiesofdailyliving

canhelpstafftoidentifytheperiodfortargetedmusiclistening.Also,according

tolisteningguidelines,atleast30minutesoflisteningfromtheindividualized

playlistshouldbeutilizedpriortotheidentifiedperiodtoreducethesymptoms

ofanxietyandagitation36,48.

4.ImplementasystemicprocessevaluationoftheM&MprogramandincorporateM&Mintoaformalcareplanningprocess

TheM&Mprogrammightbestbeutilizedasatreatmentinterventionsimilarly

to other specific therapeutic approaches, whether administered by a music

therapistunderspecificprescription,oridentifiedbyacareteamthatinvolves

aresident’sfamilymembers.Specificgoalsforreductionofphysical,emotionalorpsychologicaldisturbancesshouldbeidentifiedasdesiredoutcomesamong

personswithadvanceddementia. Moreover,ongoingmonitoringforsuccess

should be formalized and recorded48. The protocol for developing

individualizedmusicalplaylists,auditingtheprocessforusedesignedaround

specificperiodsofagitationandongoingassessmentcriteriashouldbeclearly

presentedtofacilitiesparticipatingintraininganddemonstration.

Lastly, the initial and ongoing assessment and development of goals, and

progressshouldbediscussedandcoordinatedwithothercareteammembers

routinelywithfacilities.

ITISCRITICALTHATTHEMUSICSELECTEDHAVESOMEAUTOBIOGRAPHICALCONNECTIONFORTHEINDIVIDUAL.ITISALSOESSENTIALTHATTHETIMINGANDEXPOSUREOFMUSIC

LISTENINGTOBETAILOREDTOEACHINDIVIDUAL.



RECOMMENDATIONSFORSUSTAINABILITYTosustaintheprogram,itisessentialtohavebuy‐infromeveryone–residents,

family members, direct care staff, activity staff, music therapists, IT staff,

administrators, and volunteers. Buy‐inmay be increased by helping staff to

recognizeanypositiveimpactsofM&Monresidents.

Anotherway to facilitatebuy‐inwouldbe to approachM&M likeother care

interventions or programs that require a systematic approach to assess,

developtheplaylist,deliverandmonitorconsistently.Tomakethispossible,

offering incentives or education and training among direct care will beimportantorintegratingM&Mintocareplans.RespondentsdescribedM&Mas

a program that heavily relies on direct care staff to deliver to residents

especiallyduring evening andnight time.Althoughactivity and recreational

staffmaydeveloptheplaylistandsetupaschedule,theyalsorelyondirectcare

stafftodelivertheiPod/headphoneasneededandbasedonasetscheduleeven

duringdaytime.Atthesametime,carestaffreportedthatwhiletheprogram



enhancedthequalityof lifeofPWDs,developingindividualizedplaylistswas

tootimeconsumingforstaff,makingitasignificantbarrierfortheprogramto

besustainedovertime.Therefore,developingstrategiesto involveandtrain

residents’ families aswell as volunteers todevelopplaylists anddeliver the

musicwill help reduce burden on direct care staff. Several programs have

indicatedincreasedsuccessinsupportingtheirexistingprogramthroughthe

recruitmentofvolunteerstohelpdistributethedevicestotheresidents,track

theiruse,maintain theplaylistsandmusicdevicesandbyraisingmoney for

newequipmentbyreachingouttocommunity‐basedgroupsincludingservice

societies,localschoolsandothervolunteergroups.

Inconclusion,efficacystudiesshouldcontinuetoreviewindividualoutcomesacrosstheprograminmultiplefacilitiestodeterminethegeneralizabilityoftheprogram’ssuccess.

Theliteratureconcerningtheuseofmusicbasedinterventionswithdementiaafflictedpersonssuggeststhatthereisthepotentialforsuchinterventionstoprovidepleasureandaidintheremediationofundesirablebehavioralsymptoms.

ThereislittlereasontobelievethattheM&Mprogramcannotachievegreaterimpactifcarefullyimplemented.



REFERENCES1. Alzheimer'sAssociation.2014Alzheimer'sDiseaseFactsandFigures.2014.2. LyketsosC,CarrilloM,RyanJ,etal.NeuropsychiatricsymptomsinAlzheimer'sdisease.

Alzheimer's&Dementia.2011;7(5):532‐539.3. TrivediD,GoodmanC,DickinsonA,etal.Aprotocolforasystematicreviewofresearchon

managingbehaviouralandpsychologicalsymptomsindementiaforcommunity‐dwellingolderpeople:evidencemappingandsyntheses.SystematicReviews.2013;2(1):1‐9.

4. LyketsosC,LopezO,JonesB,FitzpatrickA,BreitnerJ,DeKoskyS.Prevalenceofneuropsychiatricsymptomsindementiaandmildcognitiveimpairment:ResultsfromtheCardiovascularHealthStudy.JAMA.2002;288(112):1475‐1483.

5. SullivanSC,RichardsKC.Predictorsofcircadiansleep‐wakerhythmmaintenanceinelderswithdementia.Aging&mentalhealth.2004;8(2):143‐152.

6. DesaiA,SchwartzL,GrossbergG.Behavioraldisturbanceindementia.Currentpsychiatryreports.2012;14(4):298‐309.

7. AgencyforHealthcareResearchandQuality.Non‐pharmacologicInterventionsforAgitationandAggressioninDementia.2014;http://effectivehealthcare.ahrq.gov/index.cfm/search‐for‐guides‐reviews‐and‐reports/?pageaction=displayproduct&productid=1999,2015.

8. GauglerJ,KaneR,KaneR,NewcomerR.Thelongitudinaleffectsofearlybehavioralproblemsinthedementiacaregivingcareer.PsychAging.2005;20:100‐116.

9. HopeT,KeeneJ,GedlingK,FairburnCG,JacobyR.Predictorsofinstitutionalizationforpeoplewithdementialivingathomewithacarer.Internationaljournalofgeriatricpsychiatry.1998;13(10):682‐690.

10. PollakCP,PerlickD.Sleepproblemsandinstitutionalizationoftheelderly.Journalofgeriatricpsychiatryandneurology.1991;4(4):204‐210.

11. KambleP,ChenH,ShererJ,AparasuR.UseofantipsychoticsamongelderlynursinghomeresidentswithdementiaintheUS:Ananalysisofnationalsurveydata.Drugs&Aging.2009;26(6):483‐492.

12. LanctotK,BestT,MittmanN,etal.Efficacyandsafetyofneurolepticsinbehavioraldisordersassociatedwithdementia.TheJournalofClinicalPsychiatry.1998;59(10):550‐561.

13. SchneiderL,PollockV,LynessS.Ameta‐analysisofcontrolledtrialsofneuroleptictreatmentindementia.JAmGeriatrSoc.1990;38:553‐563.

14. AranaG.Anoverviewofsideeffectscausedbytypicalantipsychotics.TheJournalofClinicalPsychiatry.2000;61(Suppl*):5‐11.

15. ShekelleP,MaglioneM,BagleyS,etal.ComparativeEffectivenessofOff‐LabelUseofAtypicalAntipsychotics.ComparativeEffectivenessReviewNo.6.(PreparedbytheSouthernCalifornia/RANDEvidence‐basedPracticeCenterunderContractNo.290‐02‐0003).Rockville,MD:AgencyforHealthcareQualityandResearch;2007.

16. GillS,BronskillS,NormandS,etal.Antipsychoticdruguseandmortalityinolderadultswithdementia.AnnalsofInternalMedicine.2007;146(11):775‐786.

17. SchneiderL,DagermanK,InselP.Riskofdeathwithatypicalantipsychoticdrugtreatmentfordementia:meta‐analysisofrandomizedplacebo‐controlledtrials..JAMA.2005;294(15):1934‐1943.

18. McCurrySM,Ancoli‐IsraelS.SleepDysfunctioninAlzheimer'sDiseaseandOtherDementias.Currenttreatmentoptionsinneurology.2003;5(3):261‐272.

19. YesavageJA,FriedmanL,Ancoli‐IsraelS,etal.DevelopmentofdiagnosticcriteriafordefiningsleepdisturbanceinAlzheimer'sdisease.Journalofgeriatricpsychiatryandneurology.2003;16(3):131‐139.



20. NationalInstitutesofHealthStateoftheScienceConferencestatementonManifestationsandManagementofChronicInsomniainAdults,June13‐15,2005.Sleep.2005;28(9):1049‐1057.

21. AmericanPsychiatricAssociationWorkGrouponAlzheimer'sDiseaseandotherDementias.PracticeguidelinesforthetreatmentofpatientswithAlzheimer'sDiseaseandotherdementias.2007:http://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/alzheimers.pdf.

22. GitlinL,KalesH,LyketsosC.Nonpharmacologicmanagementofbehavioralsymptomsindementia.JAMA.2012;308(19):2020‐2029.

23. AldridgeD.MusicTherapyResearchandPracticeinMedicine:FromoutoftheSilence.London:JessicaKinglseyPublishers;1996.

24. NorbergA,MelinE,AsplundK.Reactionstomusic,touchandobjectpresentationinthefinalstageofdementia.Anexploratorystudy.IntJNursStud.2003;40(5):473‐479.

25. DrapeauJ,GosselinN,GagnonL,PeretzI,LorrainD.Emotionalrecognitionfromface,voice,andmusicindementiaoftheAlzheimertype.AnnNYAcadSci.2009;1169:342‐345.

26. SamsonS,DellacherieD,PlatelH.Emotionalpowerofmusicinpatientswithmemorydisorders:clinicalimplicationsofcognitiveneuroscience.AnnNYAcadSci.2009;1169:245‐255.

27. VanstoneA,CuddyL.MusicalmemoryinAlzheimerdisease.AgingNeuropsycholCogn.2010;17(1):108‐128.

28. JohnsonJ,ChangC,BrambatiS,etal.MusicrecognitioninfrontotemporallobardegenerationandAlzheimerdisease.CognBehavNeurol.2011;24(2):74‐84.

29. PrickettC,MooreR.TheuseofmusictoaidmemoryofAlzheimer’spatients.JMusicTher.1991;27(2):101‐110.

30. WilkinsRW,HodgesD,LaurientiP,SteenM,BurdetteJ.Networkscience:anewmethodforinvestigatingthecomplexityofmusicalexperiencesinthebrain.Leonardo.2012;45(3):282‐283.

31. Musicandemotionsinthebrain:Familiaritymatters.2011.32. JanataP.Theneuralarchitectureofmusic‐evokedautobiographicalmemories.Cerebral

Cortex.2009;19:2579‐2594.33. VinkA,BruinsmaM,ScholtenR.Musictherapyforpeoplewithdementia.TheCochrane

Library.2011(4):1‐48.34. ClarkM,LipeA,BilbreyM.Useofmusictodecreaseaggressivebehaviorsinpeoplewith

dementia.JournalofGerontologicalNursing.1998;24(7):10‐17.35. GerdnerL.Effectsofindividualizedversusclassical'relaxation'musiconthefrequencyof

agitationinelderlypersonswithAlzheimer'sdiseaseandrelateddisorders.InternationalPsychogeriatrics.2000;12(1):49‐65.

36. SakamotoM,AndoH,TsutouA.Comparingtheeffectsofdifferentindividualizedmusicinterventionsforelderlyindividualswithseveredementia.InternationalPsychogeriatrics.2013;25(5):775‐784.

37. MusicandMemory.org.MusicandMemory.2013;http://musicandmemory.org.Accessed09/23/2013.

38. Cohen‐MansfieldJ.Agitatedbehaviorsintheelderly:II.Preliminaryresultsinthecognitivelydeteriorated.JAmGeriatrSoc.1986;34:711‐727.

39. Cohen‐MansfieldJ,MarxM,RosenthalA.Adescriptionofagitationinanursinghome.JournalofGerontology:MedicalSciences.1989;44(3):M77‐M84.

40. WoodS,CummingsJ,HsuM,etal.TheuseoftheNeuropsychiatricInventoryinnursinghomeresidents:Characterizationandmeasurement.AmJGeriatrPsychiatry.2000;8(75‐83).



41. HughesC,BergL,DanzigerW,CobenL,MartinR.Anewclinicalratingscaleforthestagingofdementia.BJP.1982;140:566‐572.

42. BergL.ClinicalDementiaRating(CDR).PsychopharmacologyBulletin.1988;24:637‐639.43. AdamsK,McClendonM,SmythK.Personallossesandrelationshipqualityindementia

caregiving.Dementia:TheInternationalJounralofSocialResearchandPractice.2008;7(3):301‐319.

44. SpruytteN,VanAudenhoveC,LammertynF,StormsG.Thequalityofthecaregivingrelationshipininformalcareforolderadultswithdementiaandchronicpsychiatricpatients.PsychologyandPsychotherapy:Theory,Research,andPractice.2002;75(3):295‐311.

45. FritschT,KwakJ,GrantS,LangJ,MontgomeryR,BastingA.ImpactofTimeSlips,acreativeexpressioninterventionprogram,onnursinghomeresidentswithdementiaandtheircaregivers.TheGerontologist.2009;49(1):117‐127.

46. CuddyL,DuffinJ.Music,memory,andAlzheimer'sdisease:ismusicrecognitionsparedindementia,andhowcanitbeassessed?MedicalHypotheses.2005;64:229‐235.

47. Variabilityinprefrontalhemodynamicresponseduringexposuretorepeatedself‐selectedmusicexcerpts,anear‐infraredspectroscopystudy.2015.

48. GerdnerL,SchoenfelderD.Evidence‐basedguideline:Individualizedmusicforelderswithdementia.JournalofGerontologicalNursing.2010;36(6):7‐15.

49. NewYorkStateDepartmentofHealth.IndividualizedMusicInterventionOutcomes.2007;http://www.health.ny.gov/diseases/conditions/dementia/edge/interventions/indiv_music/indiv_music_intervention_casestudy.htm.Accessed7/3/2015,2015.

50. VasionyteI,MadisonG.Musicalinterventionforpatientswithdementia:ameta‐analysis.JournalofClinicalNursing.2013;22:1203‐1216.

51. HsiehS,HornbergerM,PiguetO,HodgesJ.Neuralbasisofmusicknowledge:evidencefromthedementias.Brain.2011;134:2523‐2534.

52. KoelschS.Towardsaneuralbasisofmusic‐evokedemotions.TrendsinCognitiveSciences.2010;14(3):131‐137.

53. BloodA,ZatorreR.Intenselypleasurableresponsestomusiccorrelatewithactivityinbrainregionsimplcatedinrewardandemotion.ProceedingsoftheNationalAcademyofSciences.2001;98(20):11818‐11823.

54. Gebauer L, Kringelbach M, Vuust P. Ever‐changing cycles of musical pleasure: The role of Dopamine and anticipation. Psychomusicology: Music, Mind, and Brain. 2012;22(2):152‐167.

31

APPENDIXTable1.SummaryofMethodsofEachEvaluationComponent

CrossoverStudy Pre‐PostMedicationUse

MDSAnalysis AdministratorSurvey

Purpose ToevaluateefficacyofM&Mtoreduceresidents’behavioralproblems,useofpsychotropicmedication,andtoimprovesatisfactionwithcareandrelationshipqualitybetweenresidentsandfamily,andstaffattitudestowardresidentsandjobsatisfaction.

ToevaluateeffectivenessoftheM&Minreducinganti‐psychoticandanti‐anxietymedicationusein1,500residentsinfacilitiesparticipatinginthePhaseIofthestatewideimplementation.

ToevaluateeffectivenessoftheM&MinimprovingbehavioraloutcomesandreducingpsychotropicmedicationuseinresidentsinallfacilitiesparticipatinginM&MintheStateofWI.

ToidentifybarriersandchallengesinimplementingandsustainingM&M,andrecommendationstoaddressthebarriersinfacilitiesparticipatingintheM&Mstatewideimplementation.

Researchquestions

DoestheM&Mreduceanxiety,depression,agitation,anduseofanti‐psychoticandanti‐anxietymedications?

DoestheM&Mreduceagitation‐relatedmovementsandimprovesleepquality?

DoestheM&Mimprovefamilycaregiver‐residentrelationshipqualityandsatisfactionwithcare?

DoestheM&Mimprovestaffattitudestowardresidents?

DoestheM&Mreduceanti‐psychoticandanti‐anxietymedicationuse?

DoestheM&Mreducebehavioralproblemsandimprovecommunication,mobility,andmood?

DoestheM&Mreducepsychiatricmedicationuse?

WhatarethebarriersandchallengesinimplementingandsustainingM&Minnursinghomefacilities?

WhatisvalueofM&M? WhatarethebestwaystofostereffectiveimplementationandongoingsustainabilityofM&Minnursinghomefacilities?

Design Crossover,RCTwithtwoconditions‐Condition1receivingtheM&Minterventionforasix‐weekperiod(PhaseI)andCondition2receivingtheM&Minterventionfor6weeksaftertheCondition1receivedtheM&Mandatwo‐weekwashoutperiod(PhaseII).

Familymembersanddirectcarestaffmembersfortheparticipatingresidentsassessedatpre‐(baseline)andpost‐(endofthestudy)survey.

Pre‐andpost‐M&Mimplementationsurveyconductedonline.

SecondaryanalysisofMDSdataonnursinghomeresidentsinallWisconsinnursinghomefacilitiesin2014,and2015.

Cross‐sectionalmailorwebsurveytoallnursinghomefacilitiesinWisconsin

32

Table1.SummaryofMethodsofEachEvaluationComponent



Sample 59residentsfromastratifiedrandomsampleof10nursinghomesinMilwaukee,Ozaukee,RacineandWaukeshacounties.

28Familymembersofparticipatingresidents.

63carestafffrom10nursinghomes.

1,500residentsselectedtoparticipateintheM&Mby100nursinghomesthatparticipatedinthePhaseIoftheM&Mstatewideinitiative.

Pre‐surveywasconductedbetweenDecember2013andMay2014whilepost‐surveywasconductedbetweenFebruary2015andJanuary2016.

ResidentsinnursinghomesparticipatinginM&MstatewideimplementationatPhaseI(2014),PhaseII(2015)andPhaseIII(2016)withresidentsinnon‐participatinghomesservingascontrols.

161nursinghomes(41%)inWisconsinwhorespondedtothemailsurvey.

DataCollectionandMeasures

Staffreportonmemory/cognition(ClinicalDementiaRatingScale),agitation(Cohen‐MansfieldAgitationInventory),andmood(NeuropsychiatricInventory).

Chartreviewonanti‐psychoticmedicationuse.

MovementmeasuredbyActiGraphGT3Xwornonthenon‐dominantwristsofnursinghomeresidents.

MusicdatacollectedviaappinstalledoniPods.

Onlinesurvey AnalysisoftheMDSdata MailSurveyorweb‐basedsurveyformatselectedbyrespondents

Analysis Generalizedlinearmixedmodel(GLMM)ANOVA,randomizationtestsusingaresamplingapproach,WilcoxonSigned‐rankstests.

GLMMandGeneralizedLinearModel(GLM)ANOVA.

Differences‐in‐differenceanalysesusingfixedeffectsconditionallogisticregression.

Descriptiveandcontentanalysis.

33

Table2.SummaryofFindingsofEachEvaluationComponent



Results Nostatisticallysignificantdifferenceswerefoundin:memory/cognition,agitation,andmood.

ActualratesofuseduringthetotaldaystheiPodswereavailablewerequitelowforthemajorityoftheresidents.

Nostatisticallysignificantdifferenceswerefoundinstafforfamilyoutcomes.

TestsofdifferencesinvectormagnitudeswereallnonsignificantindicatingM&Mhadnoapparenteffectonmovement.

Statisticallysignificantmeanreductionsinanti‐psychoticandanti‐anxietymedicationuse.

ItisunclearfromthedatatheextenttowhichM&Mcontributedtothemedicationusereductionduetodatalimitations.

SignificantdifferencesindifferencetestsfornumberofdaysofantipsychoticuseandanyuseofantipsychoticsfortheWave1versusWave2and3nursinghomes.ReductionsinantipsychoticuseweregreaterinnursinghomesnotparticipatinginM&M.NosignificantdifferencesindifferencetestsforWave2andWave3comparisons.Insub‐groupanalysisofMedicaidresidents,reductionsinanti‐anxietyusedaysweregreaterinnursinghomesnotparticipatinginM&MwhilereductionsinbehavioralproblemsandrejectionofcareweregreaterinWave2.

TwokeybarrierstoconsistentlyandeffectivelydeliveringM&Mfortargetresidentswere:(1)alackofbuy‐infromalllevelsofcarestaffandmanagementand(2)alackoforlimitedtimebystafftoimplementandmaintaintheprogram.

Otherbarriersincludedtechnologyandcostasadditionalcostwillbeincurredtoreplaceexistingequipmentandbuynewsongs.

ValueofM&Minclude:enjoymentandimprovedmood,personalizednatureofthemusic,thepositiveeffectsofheadphonestoblocknoiseandalloweachindividualresidenttolistentothemusictheyprefer.

Implications Resultsfromthestudycallintoquestion(1)theefficacyoftheM&Mprograminaffectingtheresidentoutcomes,and(2)otherissuessuchaslowfidelitytotheguidelinesrecommended

FindingsprovidesomeindicationthattheimplementationoftheM&Mprogrammayhavehadsome

FindingssuggestthatM&Mmadenoimprovementorhadworseimprovementsonuseofpsychiatricmedicationthanno

AlthoughM&Misperceivedasavaluableprogramtoenhancequalityoflifeofresidents,M&Mdoesnotworkforeveryone,andmoreeffortsareneededtoenhancebuy‐infromalllevelsofstaffinfacilities,increase

34

Table2.SummaryofFindingsofEachEvaluationComponent



bytheM&MprogramorinsufficientguidelinesfromtheM&Mprogram.

partialeffecton thereductionoftheuseofanti‐anxietymedicationsamongresidents.

M&MwhileMedicaidresidentsexperiencedsomepositiveimprovementsinbehavioralproblemsandrejectionofcare.

supportfromfamiliesandvolunteers,andtoimprovefidelityoftheprogramimplementation.

Limitations Smallsamplesize,useofglobalmeasuresoffunctioningcollectedoverseveralweekintervals,andrelianceonstaffreportsonkeyresidentoutcomemeasures

Lackofrandomsamplingofresidentsandfacilities,andlackofrandomassignment(i.e.,nocontrolgroup)

Lackofrandomsamplingorresidentsandfacilities,andlackofrandomassignment.

Cross‐sectional,descriptivesurveywith40%responserate.

Recommendations FortheM&MProgram:1)selectindividualswhoaremostlikelytobenefitfromM&M;(2)assess,identifyandsetspecificgoalsfortheM&Mintervention;(3)developindividualizedplaylistandlisteningscheduletailoredtoeachindividualperson;and(4)implementasystemicprocessevaluationoftheM&MprogramandincorporateM&Mintoaformalcareplanningprocess.

Futureresearchshouldincludelargersamplesizes,directbehavioralobservationsusingvalidatedmethods,andtheevaluationofdifferentprotocolsfortheimplementationofM&Monbehavioraloutcomes.

Additionalresearchisneededtodeterminewhether,andperhapstheextenttowhich,theuseoftheM&Mprogrameffectstheuseofpsychotropicmedicationsinnursinghomeresidents.

AdditionalresearchisneededtoidentifyresidentandfacilitylevelrelatedfactorsaccountingdifferentialresidentoutcomesinWave1,2,and3,andtoexaminefurtheronpotentialreasonsfordifferencesinoutcomesbetweenMedicaidandnon‐Medicaidresidents.

Buy‐inmaybeincreasedby:(1)helpingstafftorecognizeanypositiveimpactsofM&Monresidents;(2)approachingM&Mlikeothercareinterventionsorprogramsthatrequireasystematicapproachtoassess,developtheplaylist,deliver,andmonitorconsistently;and(3)offeringincentivesoreducationandtrainingamongdirectcarestaffwillbeimportant,orintegrateM&Mintothecareplanningprocess.

UniversityofWisconsin‐MilwaukeeHelenBaderSchoolofSocialWelfare&

CenterforAgingandTranslationalResearch

EnderisHall2400E.HartfordAve.Milwaukee,WI53211Phone:414.229.4852

http://uwm.edu/socialwelfare

evaluation of music and memory program white...

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