A-Z List


Dementia

Problem Areas for Clients

Music therapy goals for targeting these problem areas

& Music Therapy methods used for treatment

Music therapy is a new and fairly unexplored option for families, caregivers, and clients who are living with dementia. For example, I have worked in the health care field for seven years, but the only contact I have had with music therapy was just recently when my advisor recommended this course. I have worked in the psychiatric, homelier, long-term, acute, and the childbirth health care settings and not once have I witnessed the therapeutic use of music. However, I have used music in long-term and psychiatric settings intuitively. I was unaware that music was a treatment modality available by trained professionals. A reason for my being unaware is that music therapy exists during a time period when society is desperate to hinder costs and enhance quantity of life at the expense of quality of life. This fact is very unfortunate, but it should serve as a motivate for music therapists to advocate for the use of therapeutic music. Those living with dementia need holistic care involving music.

Music can be used therapeutically with caregivers, clients, and their families living with dementia. I believe that the information I am providing will prove useful for the general public as well as for health care professionals. I have witnessed smiles, tears, increased physical activity, and increased socialization provoked by the use of music in a novice manner. Now perhaps, I can put rationale behind the use of music in a novice and professional manner. Also, I hope that you as the reader, will be motivated to implement music in the lives of those living with dementia.

First, let me define dementia. Dementia is a common clinical syndrome characterized by a decline in cognitive function and memory of previously attained intellectual levels, which is sustained over a period of months to years. The dementia affects the individual's ability to work and to perform activities of daily living, including communication. Areas of mental activity involved include language, memory, vision, spatial awareness, emotion or personality, and cognition. Readers of this paper need to be aware that dementia is an umbrella term that encompasses many distinct subtypes. I will not be referring to any specific types or causes of dementia but rather to the behaviors and changes associated with dementia.

Dementia jeopardizes the human qualities of memory, personality, recognition, awareness, and emotional senses, therefore robbing the clients of their families and themselves. Problem areas for the client with dementia include problematic behavior. Problematic behaviors may include: concealing and denying memory loss; stubbornness; sundown syndrome; wandering; repetition; hiding, losing and hoarding items; sexual misconduct; following others around; providing insults and accusations; sleeping problems; telephone problems; excessive anxiety; irritability; noncompliance with hygiene cares; and decreased intake. The reader needs to keep in mind that when working with the demented client, music therapists would collaborate with other health care professionals to provide appropriate interventions.

Primary goals for the person afflicted with dementia include: maximizing independent functioning; maintaining self-esteem; developing meaningful activities; creating new living experiences; providing an acceptable energy outlet; stimulating intellectual growth; encouraging physical activity; discovering individual interests-needs; providing supportive friends; alleviating anxiety; combating depression; providing "something to share"; offering opportunity for choice; providing an all inclusive activity; providing an activity for staff and clients to anticipate, participate in, socialize within and about; and feel revitalized about.

Goals would also include stopping problematic behavior, redirecting the client's energy into positive musical activities, and providing reassurance. The music therapist must be observant of absent-mindedness and be understanding and patient. Also, a client with dementia often stubbornly refuses to comply. The music therapist needs to be aware that noncompliance is often related to the individual not comprehending or feeling threatened by requests and demands. In this situation it is often helpful to be direct. The music therapist will want to state what the client is to do while physically showing the client or demonstrating for the client. This modeling will provide visual and verbal stimuli to aid in comprehension. The music therapist may also attempt compromising or offering bribes such as "shake the bell and we’ll get some juice." If the attempts still fail, then the therapist should stop attempting and try later.

Another behavior area includes the sundown syndrome. Sundown syndrome creates mental deterioration and increasing behavior problems for the demented client as the evening ensues. This is why it is a good idea to schedule music therapy sessions in the morning and afternoon rather than in the evening. However, music therapy held in the afternoon in response to the onset of sundown behavior can be beneficial. The sundown client may be responding to the human need and ritual of "going home at the end of the day and taking care of their families". Music can validate these feelings with music related to the client's needs. If the client is in need of "going home" then the music played can be about going home. Validating the client's needs can also be achieved with music that relates to the time period about which the client is reminiscing, i.e., 1920’s to 1940’s music. The Iso-principle may be useful in assisting in changing the sad and lonely client's feelings to happiness and comfort.

Whether used in the morning or the evening, music should be soothing with minimal distractions in a safe environment. Try to minimize distractions by turning off televisions and radios, maintaining privacy, reducing the number of things going on, and basically keep things simple. Because new environments often increase wandering, the music therapist should host sessions in the same room at the same time, therefore increasing familiarity. Also, if the client is new to the environment, allow sufficient time for the client to familiarize himself or herself.

Persons with dementia may become fixated on one task, constantly repeating it. If the repetitive tasks are interfering with the music therapy, the music therapist can give verbal directions to "stop" or use redirecting tactics with touch and voice. Also, the client with dementia will often hide, lose, and or hoard items. It is of utmost importance for the music therapist to organize him or herself. The music therapist must remain aware of which items are present at the beginning and the end of activities. The demented client will also often make false accusations. The music therapist must always remember that it is usually the dementia talking, not the person. The confusion, disorientation, and fear often combine into paranoia. The music therapist must remember not to argue with the demented person providing the insult. Instead, the music therapist should attempt to validate the client's feelings with soothing words and then gently change the subject or redirect their attention elsewhere.

Sleep disturbances are also a familiar behavior problem with demented clients. The client will often sleep less and wander more at night. The music therapist is of great benefit here because music and exercise is known to improve sleep quality and quantity. Increased activity or exercise should take place in the morning because of the sundown syndrome and the fact that exercise in the evening makes sleep difficult for a few hours. The final behavior problem I will address is a decreased appetite or decreased intake that may be improved by the use of music. Studies have indicated that during music periods, clients were less irritable, anxious, and depressed which stimulated increased intake.

In addition, music may be used to structure time when there is nothing more appropriate happening but not as a replacement for music therapy. For example, music can be used early in the morning when the residents are sitting in the lounge quietly waiting for breakfast. At this time in the morning the facility is often very quiet, few staff members are around, usually no activities occur until after breakfast, and the clients and the staff may benefit from the motivation of music in the morning. The music may stimulate memory, discourage sleep, encourage spontaneous movement, and initiate smiles, humming, singing, and independent socialization.

Music may be used during one-on-one or in group activities. I will discuss the use of music with group activities because the group information is also applicable to the individual. From my own experiences, I realize that it is often difficult to allocate the time or resources to provide lengthy or even intermittent one-on-one sessions and therefore the group session appears more tangible to me.

Songs are the key activity during group music therapy sessions and are often accompanied by other stimuli. The songs usually focus on a theme. Themes may include: the twelve months of the year; holidays; common moments in time such as weddings and graduations; career changes; relocating; countries; the weather; body structures; love and romance; friendship; loss; grieving; forgiveness; reminiscence; ethnicity; religion; mothers and fathers; grandparents and grandchildren; and patriotism and veterans. Many more ideas are plausible and will be left up to your imagination.

A weekly session provides an informal home-like atmosphere where people gather, share an experience, and then provides a topic for discussion at a later date. The weekly session will usually be anticipated by clients and staff members. The weekly sessions may have a positive effect on employee-client relations because they provide a shared experience for meaningful discussion later during visits or personal care. The clients may attend group immediately or may work individually first, then join the group atmosphere later.

Each musical activity should be preceded by advance announcements of the topic at least one week in advance to create anticipation among staff, clients, and families. The announcements should match the functioning level of the population they are targeting, taking into consideration the ability of the reader to see, hear, and or comprehend the message. The music therapist must be aware of the cognitive abilities of the clients because dementia has many types and subtypes, forms and stages. In addition, when the day of the activity arrives, be sure to write and verbalize that it is "today at such and such a time" for the confused, demented, forgetful clients. Second, try to schedule the group sessions at the same time each time, creating familiarity. Third, if clients miss a group session, it is important to express that they were missed to increase self-esteem and strengthen the sense of belonging. Fourth, the room used for the music session should be used consistently, should be home-like, distractions should be minimal, be arranged in advance of the scheduled time with allowance of wheelchair placement, avoid crowding, and maintain optimal room temperature. Fifth, the instruments used during the sessions should be in-tune because an out-of-tune instrument can cause stress. Also, the instruments used should be familiar to the clients, and for those instruments that the client will use, they should be of adequate level for the physical and mental functioning of the user. When the session begins is a good time for greetings and touching with handshakes and pats on the back. This interaction provides a sense of acceptance and belonging and an exchange of communication. Finally, the sessions should begin and end with the same song to signify the onset and closure of the activity and provides a sense of accomplishment. This song may be sung at the beginning and the end of each session to signify the onset and summation of the session, therefore creating familiarity and increasing the ease with which new members may join in. The words, tune, and motions should be periodically explained to acquaint new residents and visitors with the purpose.

A musical activity might also include singing about a specific year that has meaning for the group or an individual in the group. Each person in the group is given the opportunity to choose a year that is significant or to select one at random. A music book is consulted for a list of songs published that year. The list may be read aloud for further choices or the leader may select familiar songs and begin to play them without giving a title. Some people may enjoy identifying the song or singing through to the end before the title comes to mind. Of course, clues can be given to help identify the mystery song. The purpose is to experience the music and teach others through the use of the chronological list. Spontaneous conversations are prompted by the titles, music or years mentioned. The activity would continue until all of the members have had a chance to choose a song. Again, close the session using the same song with which the group began to reinforce familiarity and closure. Supporting this music activity is the idea that domain specific information and factual knowledge facilitates performance by reducing the time needed to process the information. This concept uses the past to maintain and extend relationships with others, can sustain interest in current interactions, and promotes bonding. In addition, autobiographical memories construct self-concepts and self-histories, and personal memories exemplify the traits of interests a person attributes to himself.

Songs referring to an anatomical body structure may be used to provide an opportunity for discussion and touch. An example is "Take My Hand, Precious Lord". Poetry, music, paintings, and pictures about hands may be used to enhance the session. Pictures and photos of hands may be available for the clients to view upon arrival.

Singing songs from A through Z may provide a continuous array of topics to sing about and therefore a long-term goal to complete the book. Many clients may feel a sense of accomplishment at finishing the alphabet of songs. It is suggested that a semi-circle be maintained for group activities to maintain eye contact. Always allow time for personal observations, discovery of titles, and opinions during the sessions.
Also, as people come and go during each session, call them by their name to increase familiarity.
Weather discussion can also be implemented in music involvement sessions. To enhance the experience, a staff member or client may bring in photos, slides, hand drawn pictures, verbal stories, etc. Also remember that the attention spans of some of the residents may be shorter than others, so do not plan to have a long session each time. Also, if pictures or visual objects are to be viewed, be sure that they are large enough for use with the visually impaired. Visual aids should be discussed and provided for tactile stimulation, if possible, for the benefit of those who cannot see. Choose songs about the weather, places with different types of weather, what we like about the weather and what activities we do not like or did like to do during different seasons. Spark the memory and create discussion. Colored scarves and leis may also be used for different aesthetic and tactile stimulation. For olfactory stimulation, add a cologne or flower, but always be aware of allergies and/or dislikes. Souvenirs are also beneficial for the tactile experience. The use of external memory aids may stimulate memory more than imagining or thinking about it.

Songs which will involve physical activity and movement patterns may need to be accompanied by visual modeling and physical assistance. The activity should proceed gradually through a system of levels to facilitate the acquisition of skills from simple to complex. Start by securing the rhythmic speech responses, next integrate stationary muscle responses, and then proceed to locomotion. Rehearsal will serve as a motor plan allowing feedback systems to guide actual performance. Finally, the use of high and low pitches may be used to indicate either upward stretching or lower limb movements.
In conclusion, the main goal of the music therapist working with a dementia client is to establish contact. Contact may include getting the client to experience the music by listening to or by actively participating in a musical activity. If music can evoke or preserve any of the human qualities of memory, personality, recognition, awareness, or emotional senses, then it is a worthwhile intervention. Music may preserve an individual's sense of humanness.

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