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• To enhance your awareness of the potential benefits of music therapy for people with dementia
• To learn about how a music therapy intervention was implemented in a dementia inpatient unit
• To understand the experiences of people with dementia attending individual and group music therapy sessions
There is a growing evidence base to suggest that music therapy is an effective clinical intervention for people with dementia, having positive effects on mood, emotion, communication and memory, and reducing agitation, anxiety and apathy. However, the evidence to support this is predominantly from community settings such as residential care homes or people’s own homes. This article captures the authors’ experiences and reflections regarding their implementation of a music therapy intervention in a dementia inpatient unit. It explores some of the considerations and learning points gained from their experience, including the practicalities around engaging individuals and staff, the use of space, the timing of sessions, available resources and the potential benefits for patients, family members and the unit as a whole. The authors’ experiences suggest that the benefits of music therapy appear to be transferable to the dementia inpatient setting.
Nursing Older People. doi: 10.7748/nop.2023.e1453Peer review
This article has been subject to external double-blind peer review and checked for plagiarism using automated softwareCorrespondence
Atkinson C, Martin K (2023) Implementing music therapy interventions in a dementia inpatient unit: reflections and practicalities. Nursing Older People. doi: 10.7748/nop.2023.e1453
Published online: 04 October 2023
Music therapy is a psychologically informed clinical intervention that uses music as a medium for supporting people whose lives have been affected by trauma, illness or disability, through supporting their psychological, emotional, cognitive, physical, communicative and social needs (British Association for Music Therapy 2020).
Dementia is a term for several diseases that affect memory, thinking and the ability to perform daily activities, and its effects vary between individuals (World Health Organization 2023). The cognitive changes associated with dementia can include issues with different types of memory, attention, visual-spatial abilities, executive functioning and psychological and/or behavioural changes (Langa et al 2004, Solomon et al 2019). Dementia brings challenges as individuals and their family adjust to the diagnosis and knowledge of what the condition may entail, its day-to-day effects and its progression (Adelman et al 2014, Cheng 2017, Kuring et al 2018).
There is a growing evidence base to suggest that music therapy is an effective clinical intervention for people with dementia, but this evidence is predominantly gained from community settings, either with people living in their own homes or in residential care homes (Livingston et al 2014, Hsu et al 2015, Schall et al 2015, Hack et al 2021). Evidence indicates that music therapy can offer many benefits to people with dementia, such as having positive effects on mood, emotion, communication, self-expression and memory, and reducing agitation, anxiety and apathy (Bright 1997, Melhuish 2013, Ridder et al 2013, Hsu et al 2015). Music therapy is also a recommended psychological intervention for promoting well-being in the National Institute for Health and Care Excellence (2019) quality standard on dementia.
Establishing a music therapy training placement for a student in a dementia inpatient unit enabled the authors to explore whether these benefits could be transferred to patients in this setting. The placement also offered an opportunity to explore various considerations when introducing music therapy as an intervention in such a setting. It is beyond the scope of this article to provide detailed outcomes of this project and a separate evaluation has been published which reports on these in greater depth (Drewitt et al 2022). Instead, this article focuses on the process of implementing the music therapy intervention, discussing the considerations, potential benefits and learning points gained from the experience.
The unit is a specialist dementia inpatient setting in central England that aims to help patients who are experiencing the challenges and symptoms of dementia. It comprises a men’s ward and a women’s ward linked by a shared corridor which can be used for group activities. Patients are typically admitted to the unit due to a crisis, deterioration in their dementia symptoms or a breakdown in their care. They may be admitted from home, care homes or specialist facilities. Patients’ length of stay varies greatly; some are on the unit for a few weeks while they are assessed and suitable care is put in place, while others require a longer period to settle and for staff to adjust their medicines, assess their needs and find suitable ways to meet these needs.
While the unit comprises specialist dementia wards, sometimes patients with mental health issues that are not related to dementia are placed there because of a lack of bed availability elsewhere. At any time, the patient mix can vary considerably in terms of dementia presentation, primary diagnoses, severity of symptoms and levels of functioning abilities.
The literature outlines a range of music therapy interventions that have proved successful with people with dementia. These include group work using primarily musical improvisation, singing groups, individual sessions and sessions with family members present (Clair 1996, 2000, Brotons and Marti 2003, Pavlicevic et al 2015, Baker and Yeates 2018, Melhuish et al 2019).
To offer patients a range of opportunities that would suit their abilities and preferences, two types of music therapy groups were offered on the unit: a group that primarily entailed instrumental improvisation, and a singing group. There was an additional opportunity for two patients to have individual music therapy sessions.
The authors considered how to organise the groups; that is, whether the groups would be open, allowing anyone from the unit to attend any week, or closed, comprising the same limited group of people each week. Due to the nature of the inpatient setting, the patient group was transient and fluctuating. Therefore, offering a closed group was considered impractical because regular, consistent attendance from the same group of people could not be guaranteed from week to week for any length of time.
Another consideration was the nature of an instrumental group compared with a singing group. The authors thought that people might need a higher music therapist-to-patient ratio for instrumental improvisation work, since this would enable the music therapist to respond more effectively to individual patients within the group. Conversely, the authors thought that a singing group would not need such a high music therapist-to-patient ratio and patients might find greater benefit from having more voices present, both male and female. Therefore, they decided to provide two separate instrumental groups for the male and female wards, and to join the two wards together to form one larger singing group. All the groups would be open to anyone who wanted to attend each week.
The support of nursing staff was integral to setting up a music therapy intervention that could be incorporated into, and sustained in, the inpatient setting. The authors were reliant on discussions with management, care staff and activity coordinators to identify which patients would be able to access group work and which patients would find a group too challenging. Effective collaboration between the therapists and nursing staff was important to facilitating patient attendance, engagement and support. Careful thought was given to encouraging nursing staff to feel part of the process, to understand the main principles and aims of music therapy, and to feel able to support patients attending the groups.
• Music therapy can be a valuable intervention in dementia inpatient settings
• Music therapy may not only benefit people who attend the sessions, but can also have wider systemic effects
• Careful consideration of the area used for music therapy is necessary to ensure it is accessible, comfortable and protected from interruptions during sessions
• Instruments readily associated with particular stages of life or which hold meaning for patients should be made available
• It is important to spend time investigating people’s musical preferences, cognitive abilities and challenges to promote engagement and attention, and accommodate sensory sensitivity
The music therapy student – referred to as Ashley – facilitated workshops for the ward staff which offered practical experiences of improvising together, discussions about the theoretical principles that underpin the music therapy process and opportunities to watch video clips of music therapy with people with dementia.
Inpatient wards for people with dementia can be busy and chaotic, often causing feelings of bewilderment and disorientation among patients. Additionally, many people with dementia become increasingly sensitive to noise, either becoming easily overwhelmed or needing greater levels of auditory stimulation (Rhodus et al 2022). Therefore, consideration was given to:
• Finding a space large enough to accommodate participants that was physically accessible to all.
• Choosing a room where interruptions could be minimised and attendance could be maximised, in a location that would preserve the quietness of the rest of the ward.
• Using the same room, laid out in the same way each week, to establish a sense of familiarity and expectations for the patients.
• Selecting the texture and timbre of the instruments consistently available, to offer the appropriate level of stimulation according to people’s needs.
The space chosen for the groups had comfortable chairs and was on the ward, so required less physical ability and effort for people to attend. It had the additional advantage of enabling people who felt ambivalent about the groups to sit apart and experience them from a distance if they wished. It was hoped that these patients might feel able to participate once the groups became more familiar to them. However, remaining on the edges of the group, within hearing and/or visual distance, might still be beneficial in offering some stimulation and emotional connection for patients.
Regarding the timing of the music therapy sessions, consideration was given to:
• Avoiding clashes and replicating other interventions that were being offered to patients.
• Minimising sensory and cognitive overload.
• Maximising patients’ ability to engage, given the fluctuating nature of dementia symptoms.
Patients met with their clinical care team during ward rounds, which could be cognitively demanding and emotionally challenging for some of them, so might affect their ability or motivation to engage in other activities. Therefore, running sessions on the same day as ward rounds was avoided.
Initially the singing and instrumental groups ran on the same day, but this was later changed so that the groups ran on different days. This provided further opportunities for patients to attend and reduced the potential for sensory and cognitive overload.
Examples of the work undertaken in individual sessions with two patients are outlined as vignettes to demonstrate the practical application of the areas that were considered when designing the music therapy intervention. Names and details have been changed to protect confidentiality.
Michael was a 78-year-old man with vascular dementia who had been admitted to the ward due to a deterioration in his symptoms. Michael was quiet and reflective. He often found verbal communication challenging and needed an unhurried, low stimulatory approach to support him to process and engage in conversation. The lounge chosen for his sessions was private and could be protected from interruptions. Each week the same range of instruments were available to him to establish a sense of familiarity, and he always chose the triangle. He would then improvise with Ashley. At the beginning of the sessions Michael barely spoke, but following improvisational music making his speech increased in fluency and he was able to recall significant events from his past. During one of the first sessions, Michael relayed that when he was at school he was not allowed to play any musical instruments, but that they ‘trusted me to play the triangle’. This was a link to his past which was stimulated and accessed through playing the triangle, enabling him to relive a part of his personal narrative.
Retaining memories of the past and being able to recall lived experiences may contribute significantly to one’s sense of self-identity and existence. When personal memories begin to fade as dementia progresses, people can become disoriented and anxious as they lose hold of their life stories; they can lose a sense of who they are (Kotai-Ewers 2000, Matthews 2015). Through playing the triangle – something familiar to him – Michael was able to access memories of his formative years, which appeared to reassure him and give him a sense of presence.
For Michael it was important to use an accessible space that was private and uninterrupted, and to provide familiarity and an unhurried approach. This may have helped to maximise Michael’s ability to engage with the sessions and to connect with his past and self-identity.
Faye was an 88-year-old woman with Alzheimer’s disease who had been on the ward for four weeks. Faye frequently experienced restlessness. She regularly wandered around the ward, finding it challenging to settle in one place for any length of time. She also found it challenging to engage meaningfully with any activities. Any pressure put on her to participate in activities seemed to cause her to feel overwhelmed, which she expressed through physical aggression. The authors felt that it would be most helpful for Faye to be offered therapy in a room that was situated centrally on the ward, so that she could access it readily without assistance. This enabled Faye to self-regulate her sensory and cognitive stimulation by coming and going as she wished.
Faye needed a different approach from Michael to maximise her willingness to attend. She was invited to the room at the start of the session, then left to decide whether she wanted to attend or not. Ashley remained in the designated room, with the door open, for the duration of the session. The central position of the room on the ward enabled Faye to hear Ashley playing an instrument or singing in the room from wherever she was on the unit. Staff were asked not to prompt Faye to attend or to put any pressure on her to engage after the initial invitation. Ashley wanted to offer a secure base for Faye to return to if and when she felt able (Gomez 1997, Bowlby 2005), so that Faye could decide her level of engagement.
In the first session Faye chose not to enter the room at all, but during the second session, as Ashley stood in the doorway to the room gently playing the rainstick, Faye showed interest and focused on it for about a minute from the corridor. During the third session, Faye was able to enter the room and remain for 20 minutes, with the door left open. It appeared that Faye was fully aware of Ashley, what was being offered to her and that she was in control of whether she attended or not. The authors suggest that this may have facilitated feelings of empowerment in Faye, which in turn may have led to her feeling safe enough to begin to make connections and relate to Ashley through the music.
Michael and Faye had varying needs regarding a suitable room to use for their sessions and needed different approaches to maximise their willingness to engage. For each of them it was important to establish familiarity and expectations in a space where distractions, pressure and the potential for sensory and cognitive overload were minimised.
The music therapy groups were held over a seven-week period in January and February 2020. Each group was attended by up to six people and 59 attendances were recorded over the course of the project.
To aid the patients’ familiarity and orientation, the groups had the same beginning and end to the session. Each group session was attended by a psychology trainee who supported patients as needed and helped to complete outcome measures for the instrumental groups. Staff supported patients where necessary by holding instruments, assisting them to move around the room or to leave the group if they wished.
Some examples of the music therapy group process and outcomes are taken from the women’s instrumental group. The group always started by passing the bongo drums around the group and inviting members to greet each other. As the weeks progressed and the women became increasingly familiar with the process and the setting, their drumming greetings became more elaborate. Each week they demonstrated further exploration of rhythm as they each began to discover their musical voices using the instruments. They became playful, building on each other’s ideas, and whoever was the last player each week invariably finished with a universally known rhythm. This began to draw the group together.
In the group improvisations that followed the drumming, the women began to show an awareness of their cohesion as a group. The first piece they performed in each group usually reflected that they had come to the session as individuals; it was less unified and more fragmented. This was demonstrated by comments such as ‘it’s a clash on the ears’ and ‘that didn’t sound very nice’. However, by the second piece the women were becoming increasingly aware of each other, listening and adapting to each other and valuing each other’s contributions to the music. Comments at this point included ‘that was more satisfying’, ‘it was more musical’ and ‘it was nicer on the ear’.
A comfortable, accessible space away from the busyness of the main ward area contributed to maximising attendance. Familiarity with the process and the setting appeared to enable participants to feel secure enough to explore and develop their relationships and self-expression.
The singing group was a rare opportunity for the two wards to meet, offering an important social element to the sessions. Patients would sometimes attend with their family members if visits coincided with the group time, and at times ward staff would also attend. All of them would then participate in the singing.
Careful thought was given to the repertoire of songs used over the course of the groups. Discussions took place with patients, families and staff to learn about individual musical tastes and to incorporate songs that patients would recognise or have some association with. This meant that patients whose communication was affected by dementia were also considered, since people who knew them well could advocate for them, for example by providing information about their preferred music and songs.
Using songs familiar to the patients prompted recollections and discussions about their earlier lives. One woman shared how she used to dance with her husband to one of the songs, while others spoke about their memories of the original artists who sang them. On one occasion a song was requested and a patient indicated that he wanted to dance with his wife, who had joined the session. This was the song they had danced to on their wedding day. The music from the group had reminded him of this moment, an event which his wife believed he had forgotten. They danced and reminisced together, providing a moment of connection, whereas typically he had difficulty recognising who she was. The room was accessible and large enough to accommodate people dancing together and the patient and his wife felt comfortable to connect in this way in the space.
Detailed information on the findings and outcomes of this project and its evaluation are available in Drewitt et al (2022). The findings suggested that music therapy is an effective intervention for people with dementia in inpatient settings, with potential benefits such as increased engagement and a reduction in behaviours that challenge. Familiar music and songs appeared to stimulate memories from the past, linking people to important times in their lives, to others and to their personal stories.
The effects of the music therapy intervention also appeared to reach beyond those directly participating in the group. A sense of connection was observed between staff and patients during the sessions, as staff learned which music patients enjoyed and this stimulated the sharing of mutual interests. The use of music also enabled the ward staff to see patients in a different light and context; they were able to see patients who usually found it challenging to engage with activities were seen to pay attention and display curiosity about the music or singing. Staff commented that they found it rewarding to be able to see patients enjoying themselves and could report to family members that their loved ones had engaged in the music and songs. This may have given families a sense that their loved one was able to experience some enjoyment in their lives and was being cared for. Additional research is warranted to further explore this sense of connection and the effects of music on relationships in the context of inpatient dementia care.
The positioning of the music groups within the main ward area also had several benefits. It enabled patients to move freely in and out of the room, with some choosing to wander past or to sit outside the room, which enabled them to observe others or listen to the music on their own terms. The authors observed that one benefit of this freedom to engage receptively was that patients’ dementia symptoms and mood often improved when they were engaged in the activities, and this led to fewer incidents of behaviour that challenges.
One effect of having several patients taking part in the group was that it left other areas of the ward physically quieter, with fewer people moving around. This may have benefited patients who, because of their dementia, typically found this movement and noise overstimulating. It also left a higher staff-to-patient ratio for the patients who were not participating in the groups. Staff commented that they were relieved when music therapy sessions were taking place, as these enabled them to concentrate on patients who required additional support to engage in other activities.
The following learning points arose from this project:
• Music therapy can be a valuable intervention in dementia inpatient settings.
• Music therapy may not only benefit people who attend the sessions, but can also have wider systemic effects.
• It is important to work collaboratively with the ward team to ensure the music therapy sessions are valued and supported.
• Space is often limited in inpatient settings, so careful consideration of the area used for music therapy is necessary to ensure it is accessible, comfortable and protected from interruptions during sessions, and the space is consistent from one session to another.
• People’s sensory processing may be affected in the advanced stages of dementia, so consideration needs to be given to the timbre and texture of instruments to avoid sensory overload. Instruments readily associated with particular stages of life, such as childhood, or which hold meaning for patients, should also be made available.
• It is important to spend time investigating people’s musical preferences, cognitive abilities and challenges to promote engagement and attention, and to accommodate sensory sensitivity.
Further research is recommended to explore which forms of music therapy provide the greatest benefit and the duration of the effect of music therapy on individual outcomes. Research could also be undertaken to capture other important outcomes such as staff attitudes towards, and experiences of, music therapy.
Music therapists are trained to provide specialist individual and group interventions and can oversee music therapy interventions in inpatient settings, designing, coordinating and supervising their delivery by other professionals (Pavlicevic et al 2015, McDermott et al 2018). However, various additional music resources are available that do not require specialist input and can be used by ward staff, family members, carers and patients themselves. Box 1 provides some examples of these.
• Platforms such as Playlist for Life (www.playlistforlife.org.uk), which guide carers to collate lists of songs that hold special meaning across the duration of a person’s life. This can then be used by the person with dementia or those around them
• Music for Dementia Radio (m4d Radio), which can be accessed at www.m4dradio.com. This enables songs to be played from a certain decade or songs to be selected based on the year someone was born
• Groups such as Singing for the Brain, which are available in various settings across England, Wales and Northern Ireland (Alzheimer’s Society 2023)
This project offered an opportunity to explore the diverse ways in which music therapy can be used as an intervention in dementia inpatient settings and to identify the expertise and equipment required to facilitate this. Music therapy appeared to have several benefits for patients, such as increasing engagement and reducing behaviours that challenge, as well as wider systemic effects for staff, family members and the unit. The authors’ experiences suggest that the benefits of music therapy interventions appear to be transferable to dementia inpatient settings.
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