Music

Eight studies of music intervention were rated as having high risk of bias.^{8,17,20,43,46,54-56} Both the Sung studies were participatory with the first involving movement, and the second involving percussion instruments;^54,55 Narme et al., was a group music therapy intervention.⁴³ The other five studies used individual interventions;^{8,17,20,46,56} Clark et al. used pre-recorded soothing music for residents with a history of aggression during bathing; Hicks-Moore et al. used pre-recorded music participants' indicated they enjoyed paired with a hand massage; Gerdner et al. compared listening to recordings of preferred music rather than recordings of classical music; Svansdottir et al. used a music therapist to engage patients in singing and instrument-playing compared to an undefined control; and Ridder et al. tested the effects of individual in-person music therapy compared with usual care (which often included group music therapy).⁴⁶ These studies are briefly summarized below.

In a cross-over design with 18 subjects, Clark at el. examined the effects of prerecorded music on aggressive behavior among people with severe Alzheimer's type dementia during bath time in a 2-week period, compared with usual care.⁸ Significant decreases were found in hitting behaviors during the intervention, and “discussions with caregivers” was associated with less agitation during the intervention.

Hicks-Moore et al., in an unblinded, repeated-measures design, reported randomizing 41 residents with mild to moderate dementia to music, hand massage, both combined, or control.²⁰ The actual number randomized was unclear, as was attrition. Participants in the music conditions received 10 minutes of pre-recorded music they indicated was their favorite song, artist, or type. There were no significant differences between groups for aggression at posttreatment.

Gerdner, et al., in a cross-over design, 39 residents participated in a study comparing 30 minute periods listening to recordings of relaxing classical music versus recordings of preferred music during their lives, as determined by family members completing a preferred music questionnaire on their behalf.¹⁷ Dose was 30 minutes 2 days a week. The outcomes were measured by the Temporal Pattern in Assessment of Agitation (TPAA) scale, which was modified from the CMAI. The study compared the immediate and 30-minute residual effects of the individualized music. Positive findings are reported, but the raters of outcomes were the ones who applied the intervention.

Sung, et al. studied a 1-month study of 30-minute, twice weekly sessions of group music therapy with movement compared with usual care in a single large Taiwanese nursing home.⁵⁴ The authors reported significant decrease in episodes of agitation by week 2 and week 4 using CMAI.

Sung et al. randomized 60 residents from a Taiwanese residential care facility to the intervention (active participation in music therapy with percussion instruments and exercise for 30 minutes twice-weekly for a month versus usual care).⁵⁵ Authors reported no differences in agitation but significantly less anxiety on the RAID measure in the music group compared with the control group.

Narme, et al. randomized 48 residents with dementia in a single nursing home in France to music therapy or a cooking group;⁴³ 37 remained in the study for analysis. Groups lasted for an hour, and were conducted twice weekly for 4 weeks. They found no differences in reduction of agitation between the new groups measured by CMAI and by NPI.

Svansdottir et al. randomized 38 residents with moderate to severe Alzheimer's disease in four locations in Iceland to small-group music therapy or an undefined control. Residents in the intervention were either engaged in singing and instrument-playing with a certified music therapist or sat listening for 30 minutes thrice weekly for 6 weeks. The authors reported significant decreases in activity disturbances during the intervention, but no lasting effects.

Ridder et al. conducted a cross-over trial in 14 nursing homes in Denmark and Norway.⁴⁶ Forty-two paired participants were randomized to 6 weeks of individualized music therapy or 6 weeks of usual care, which could include group music therapy. In this nonblinded study, the experimental group experienced a significant reduction in agitation while the control group was reported to have had a significant increase in psychoactive medication prescriptions.

Massage

Hicks-Moore et al., in an unblinded, repeated-measures design, reported randomizing 41 residents with mild to moderate dementia to hand massage, music, both combined, or control.²⁰ However, the actual number randomized was unclear, as was attrition. Based on a previously-developed protocol, participants in the hand massage group slow, light pressure applied to each hand for five minutes. There were no significant differences between groups for aggression at posttreatment.

Aromatherapy

Smallwood et al. randomized 21 district general hospital ward patients into three groups: aromatherapy and massage, conversation and aromatherapy, and massage only (seven per group).⁵² The intervention is not well explained, but it appears that the aromatic oil was used for massage in the combined group, conversation occurred during aromatherapy for the second group, and ordinary oil was used for massage in the last group. Each individual received treatment twice weekly, after which the patients' behavior was recorded. Treatment time of day was rotated in each period so that over the course of the study each person received treatment twice in each period of the day. The study used a single-blind design. Frequency of behaviors was based on daily recordings. Findings showed no overall difference in frequency of behavior across groups. Aromatherapy and massage showed a reduction in the frequency of excessive motor behavior (one of the domain on the scale) of all three conditions which reached statistical significance between 3 p.m. to 4 p.m. (P<0.05).

Acupoint

Mariko et al., randomized 23 residents with moderate to severe dementia to either acupoint touch twice daily for four weeks, a or control.³⁹ Randomization, blinding, and analysis methods were not reported. Antipsychotics were prescribed as needed, but unclear for which groups. General behavior symptoms decreased significantly from baseline in the intervention condition, but not in control. Comparisons were not reported between groups.

Tailored Interventions

Three studies involving individual assessments and tailored activity interventions to reduce agitation were identified but rated as having a high risk of bias. One is an earlier study of the TREAS model;¹⁰ a later study of TREAS was rated as having lesser risk of bias and is included in our analysis.⁹ The second selected activities tailored towards patients' skill level, personality, and interests.²⁷ The third is a study which tailored an intervention to optimize a mix of simulation and withdrawal.³² The three studies are briefly described below.

Cohen-Mansfield et al. tested the efficacy of an algorithm for providing individualized nonpharmacological approaches to reduce agitation tailored to individual profiles of each resident's unmet needs, physical, cognitive, and sensory abilities; and with interventions based on residents' lifelong habits and roles as well as abilities: TREA (Treatment Routes for Exploring Agitation).¹⁰ Interventions were applied for 10 days during the 4 hours of the individual's greatest agitation. The study was conducted in 12 Maryland nursing homes, 6 used as experimental and 6 used as controls. The implementation of personalized, nonpharmacological interventions resulted in statistically significant decreases in overall agitation in the intervention group relative to the control group from baseline to treatment and implementation of individualized interventions for agitation resulted in statistically significant increases in pleasure and interest.

Kolanowski et al. tested the efficacy of intervention activities based on validated cognitive and personality assessments versus control activities (domestic activities such as sewing cards, hanging laundry) to a random order by having 10 residents with dementia in one nursing home serve as their own control.²⁷ Activities were performed at least 15 minutes a day for one week. The authors reported fewer dementia behaviors observed on intervention days compared to control days, although this was not significant.

Lawton et al. randomized residents from two Dementia Special Care Units in the same nursing home to the condition of receiving a package of care according to individually assessed needs for stimulation or release from stimulation (retreat).³² The study was conducted over 2 years, with considerable difficulty in implementation because of noncooperation of care teams and interference of prescribed the stimulation-retreat cycle with staff duties and resident schedules. Over time most functions worsened for both groups, agitated behavior did not decline more in the experimental unit, and there was marginal improvement in external engagement and lesser declines in positive affect and greater increases in negative affect in the experimental group.

Family Involvement in Care

Jablonski et al. tested family involvement in care using contracts to identify the type, frequency, and duration of involvement and activity that the family agreed to have.²⁶ The intervention is the Family Involvement in Care (FIC) protocol, whereby a primary family member is oriented to the facility, educated on potential involvement in resident care, and contracts to participate in a specified number of care activities in nine possible areas of care) for a specified amount of time. The dosage is calculated across all types and amount of activities. The experimental group exhibited less global deterioration but inappropriate behavior remained the same.

Creative Activity Program (TimeSlips)

Houser et al. tested a creative story telling intervention called TimeSlips.²¹ This small pilot study evaluated the creative story-telling activity known as TimeSlips (wherein residents react to a picture with story ideas that are recorded and then read back to participants as their collective story) for its effect on behavioral symptoms and mood. The intervention group of 10 residents received two 1-hour TimeSlips sessions for 6 weeks and the comparison group of 10 residents received standard activity programming for 6 weeks. In this pilot study no statistically significant differences in mood or behavior were found.

Validation Versus Sensorial Reminiscence Versus No Treatment

Deponte et al. compared validation therapy to sensorial reminiscence to no control and measured outcomes with the NPI.¹²

Simulated Presence

Garland et al. tested simulated family presence (15-minute audiotapes by a family member about a positive experience from the past), music preferred by the resident in earlier life, and a placebo condition of reading from a horticultural text, to usual care.¹⁶ The tapes were applied once a day for 3 days a week for 3 weeks. Family presence and preferred music both led to reduced counts of physically agitated behavior, and simulated presence (but not music) resulted in significantly reduced counts of verbally agitated behaviors. The placebo tape also was associated with benefits over usual care.

Hatakeyama et al. tested an intervention consisting of modified television watching by screening a person's home-made DVD with favorite pictures and greetings of family members.¹⁸ Patients in a large Japanese long-term care setting who had a dementia diagnosis participated and were assigned to a homemade or comparable length commercial DVD for 2 hours each afternoon, for 4 weeks. Positive results in agitation are reported on the NPI.

Multisensory Stimulation

Staal et al. compared multisensory behavior therapy with a structured activity session.⁵³ The study took place on a geriatric psychiatric unit using a single-blinded, between-group study design. Twenty-four participants were randomized to MSBT or structured activity. Outcomes included the Pittsburgh Agitation Scale and the Scale for the Assessment of Negative Symptoms in Alzheimer's disease. Combination treatment of MSBT and standard psychiatric care reduced agitation and apathy more than standard psychiatric inpatient care alone (P = 0.05). Multiple regression analysis predicted that within the multisensory group, apathy and agitation were reduced (R2 = 0.42; p = 0.03).

Milev et al. used multisensory stimulation (MSS) study (using a Snoezelen room), in this case a dimly lit room that included many objects pertaining to the five senses: fiber-optic cables, aroma therapy, different music/sounds, water columns of different colors, textured balls to touch, and screen projectors, among others.⁴² Subjects were assigned to one of three groups. The control group received no experimental treatment for the entire duration of the study and had only care as usual. The first experimental group had one Snoezelen session per week, and the other experimental group had three Snoezelen sessions per week for 12 weeks. Each session lasted for 30 minutes on a 1:1 basis with a qualified Snoezelen facilitator. At the end of the 12 weeks, all participants received no Snoezelen treatment for another 12 weeks. The 21 participants were randomly assigned to one of three groups. Outcomes included DOS mean scores. Patients who received one and three Snoezelen treatments per week had a consistently lower DOS mean score (i.e., they improved), without much fluctuation when compared with the control group. The effect was sustained even 12 weeks after the cessation of intervention.

Bathing

Sloane et al. randomized residents with dementia and a history of agitation during bathing to person-centered showering, a towel bath (i.e., a person-centered, in-bed, bag-bath with no-rinse soap), or usual care bathing.⁵¹ The study was done in nine Oregon and six North Carolina facilities using a cross-over design between the two experimental conditions with randomization at the facility level. The Care Recipient Behavior Assessment (CAREBA), a modification of the CMAI, was used to rate behaviors for the videotaped bathing experience. All measures of agitation and aggression declined significantly in both treatment groups but not in the control group, with aggressive incidents declining 53 percent in the person-centered shower group (P<.001) and 60 percent in the towel-bath group (P <.001). Discomfort scores also declined significantly in both intervention groups (P <.001) but not in the control group. The two interventions did not differ in agitation/aggression reduction.

Multisensory Stimulation Versus Reminiscence

Baillon, et al. used Snoezelen versus reminiscence sessions as an attention control.² Each subject was allocated one of three research staff with whom they had all their intervention sessions. This staff member spent time with the resident prior to commencing the interventions. Sessions lasted up to 40 minutes every day for 2 weeks. The study was done at the Bennion Centre, Glenfield General Hospital, at Foxton Grange, which is a charity-run nursing home for older people, and at the Evington Centre, Leicester General Hospital. Subjects were randomized to one of two groups using a sealed envelope technique. Outcomes included the ABMI with reference to 3-minute samples before, immediately after, 15 minutes after, and 30 minutes after each therapy session. No statistically significant differences were seen between Snoezelen and Reminiscence sessions in terms of the change in level of agitation from pre-session to immediately post-session (CI -4.3 to 2.0) or from pre-session to 15 minutes post-session (CI -2.0 to 3.4).

Exercise

Landi et al. studied and exercise program in nursing homes in managing dementia residents' behaviors and use of antipsychotic drugs.³¹

Therapeutic Touch

Woods et al. studied therapeutic touch on behavior of nursing home residents with dementia.⁶³