What form should music intervention take?

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.

How to collaborate as a multidisciplinary team?

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.

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.

Where should the music therapy intervention take place?

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:

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.

When should music therapy sessions run?

Regarding the timing of the music therapy sessions, consideration was given to:

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.

Michael

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

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.

Instrumental groups

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.

Singing group

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.