Occupational Therapy Department Creighton University P/OTD 541 Critical Analysis of Occupational Therapy Practice OTD 601 Capstone CRITICALLY APPRAISED TOPIC (CAT) WORKSHEET Focused Question: What is the effectiveness of music on individuals with dementia to reduce anxiety in preparation for engagement in activities of daily living? Prepared By: Joy Marie Ashley Date Review Completed: November 14, 2014 Clinical Scenario: Dementia is not a disease, but a collection of symptoms resulting in cognitive dysfunction that significantly impacts every day activities (Schaber & Lieberman, 2010). Symptoms of dementia transpire when brain cells stop working properly interfering with their ability to communicate with one another, resulting in cell death (National Institute of Neurological Disorders and Stroke [NINDS], 2013). Impairments associated with dementia include but are not limited to memory, judgment, language and motor skills. Many forms of dementia exist with Alzheimer s disease and vascular dementia being the primary and secondary forms of Dementia (Schaber & Lieberman, 2010). As the prevalence rate of Alzheimer s disease and age related dementias continue to increase, the need for occupational therapists throughout the continuum of care will persist to assist individuals with the engagement in meaningful activities. Progressive forms of Dementia, such as Alzheimer s disease progresses through stages. Individuals in early stage Alzheimer s will require more assistance with complex tasks such as instrumental activities of daily living. Instrumental activities of daily living are activities that support daily life within the home and community that often require more complex interactions, such as caring for others, financial management, meal preparation, and cleaning (AOTA, 2008, p. 631). As individuals progress to later stages they will require more assistance with basic activities of daily living, such as bathing, dressing, and toileting. Not only is the ability to perform a task effected, but behavior concerns arise interfering with an individual s ability to complete the task (Schaber & Lieberman, 2010). Behavior concerns are most apparent with the task of bathing. According to Twelftree and Qazi (2006), anxiety is highly prevalent in dementia and is linked to reduced functional status in performing activities of daily living and overall cognitive decline (Twelftree & Qazi, 2006). It alters an individual s ability to engage in occupations causing a multitude of symptoms including agitation. Behavior disturbances coupled with an inability to perform three or more activities of daily living (ADLs) is attributed to high rates of institutionalization (Shaber & Lieberman, 2010). The institutionalization of an individual may relieve the primary caregiver of any burdens associated with dementia. However, the problems experienced in the home may continue to be present and possibly magnified within the facility if therapeutic intervention is not provided. Pharmacotherapy is often the first line of treatment for behavior disturbances for individuals with dementia. Pharmacotherapy may fix the problem but it is often expensive and associated with side effects (Nair, Browne, Marley & Heim, 2013). Anxiety may be a behavior disturbance that is easily treated with medication. However, the side effects of this medication may cause the individual 1
to become so lethargic that participation in activities of daily living continue to be limited (Nair, Browne, Marley & Heim, 2013). Music may be a cost effective form of treatment to reduce symptoms of anxiety to enable participation in meaningful activities for individuals with dementia. It is no secret that music can transcend across cultures to affect various levels of the human spirit. Research detected neurocognitive effects associated to various forms of music (Nair, Browne, Marley & Heim, 2013). The occupational therapy profession believes that health and well-being is established through engagement in meaningful activities (AOTA, 2008, p. 625). Activities provided with the correct modifications may lead to feelings of independence and promotion of continued engagement of a given activity. It may be beneficial for occupational therapists to use music as a therapeutic intervention to reduce anxiety and agitation for participation in activities of daily living. Summary of Key Findings: Summary of Levels I, II, and III Level I: Research indicated that music as a therapeutic intervention can be effective at regulating negative behaviors associated with a diagnosis of dementia. Musical interventions can be implemented in a variety of ways, yielding variable degrees of effectiveness. A 40 minute live music program that facilitated engagement with singing and listening for three times a week for eight weeks, was found to be no more significant than interactive reading groups as an intervention for agitation and anxiety in individuals with dementia (Cooke, Moyle, Shum, Harrison, & Murfield, 2010, Level I). Individually tailored music was effective at decreasing behavior disturbances (i.e. anxiety, agitation, aggression) in individuals with dementia when played during bathing and at mealtimes (O'Connor, Ames, Gardner, & King, 2009, Level I). Music implemented in therapy longer than 3 months had a moderate effect on anxiety symptoms in individuals with dementia (Ueda, Suzukamo, Sato, & Izumi, 2013). A variety of music interventions yielded high but insignificant results for reducing behavioral disturbances in individuals with dementia (Vasionytė & Madison, 2013, Level I). No Level II studies were apprised Level III: Multisensory stimulation including music intervention provided four times a week over a three week period resulted in an increase in cognition and a decrease in behavioral disturbances. These results were effective three weeks following intervention protocol (Ozdemir & Akdemir, 2009, Level III). Summary of Level IV No level IV studies were appraised Contributions of Qualitative Studies: No qualitative studies were appraised Bottom Line for Occupational Therapy Practice: The clinical and community-based practice of OT: Research regarding music as an effective intervention tool can be controversial and contradictory. Some research studies indicate that 2
3 music is an effective intervention for reducing anxiety while others promote insignificant results. The research study regarding 40 minute live musical programs for three times a week for eight weeks was no more beneficial than engaging participants in an interactive reading group. Indicating that more research would be required before attempting the aforementioned intervention. However, the research study did indicate that this intervention may be more beneficial when used as a habilititive tool rather than a rehabilitative tool. Another research study suggests that anxiety is no more than an unmet need that may be met through musical intervention secondary to research indicating that music enhances cognitive functioning. Individually tailored music provided to individuals with dementia during activities that can be anxiety provoking such as bathing and at mealtimes resulted in a reduction in symptoms of anxiety. Any intervention that will increase the cognitive state and socialization of an individual with dementia will inadvertently assist with the reduction of depression and anxiety. More research is required to determine the scientific benefit of music therapy as an effective intervention for engagement in daily life activities. Following the conduction of this research, only then can the true effectiveness of music on negative behaviors (i.e. anxiety) be determined. However, from a clinical perspective, knowing that your patient is motivated by music is an automatic indicator that music can be utilized as a therapeutic intervention to elicit change. Currently, no protocol exists on how to effectively use music as an intervention. More research is need to determine best practices for using music as a therapeutic occupational therapy intervention. Program development: Music has the capability to decrease negative behaviors associated with dementia. However, knowing when to use music and what form/type of music to be used needs to be determined. These articles touch on the various forms of music intervention and its effectiveness. However, they yield varying results. A program indicating how to use music as a therapeutic outlet to enhance occupational therapy intervention would be highly beneficial. Music can be included as a part of Cognitive Stimulation Therapy to reduce anxiety and increase quality of life in individuals with dementia and their caregivers. A program that has the potential to increase cognitive functioning can be beneficial from an occupational therapy perspective. The musical intervention should only be utilized as a component/ in conjunction with occupational therapy intervention in order to keep from infringing upon music therapy s scope of practice. Societal needs: We will always be searching for a cost effective/efficient way to reduce negative behaviors associated with dementia. Dementia is very prevalent and its rates are only expected to increase. Anxiety amongst other behavioral disturbances are highly prevalent in dementia. Behavioral disturbances are often treated with medication. Medication is often associated with negative side effects that can lead to more problems. Music as an intervention is a potential non pharmacological intervention that may reduce anxiety and boost participation in activities of daily living. A protocol for music intervention could be beneficial when treating individuals with dementia because it is cheap and easy to transport. Occupational therapist can teach caregivers how to use music as a therapeutic intervention to increase quality of life for all individuals involved. Therefore, there is a societal need for a cost-effective and efficient intervention to treat behavioral disturbances associated with dementia. It can also be expected to reduce the (financial/emotional) burden of care for individuals with dementia. Healthcare delivery and health policy: Music intervention should always be used in conjunction with other cognitive stimulants to enhance its effectiveness. As it goes for any intervention, music may not be beneficial for every client and should be utilized on a case-by-case basis. Clinical reasoning should always be utilized to determine appropriateness of care. The research regarding the efficacy of music on anxiety is not strong enough for any form of legislation by itself. Determining the effect music has on the engagement in occupation for
individuals with Alzheimer s resulting in decreased anxiety is worth the research and funding. Especially if results were deemed reliable and valid. Education and training of OT students: Music intervention is a potential tool that entry level occupational therapist should know how to use in part of a behavior modification program for individuals with dementia. No higher form of entry level education would be required for studying musical intervention. Validating the effectiveness of music on anxiety in individuals with dementia is scarce. Students can be used as a catalyst for change. They could be used conduct research and give back to the profession in order to determine best practices. Indicating the effectiveness of using types of music to elicit therapeutic change in our patients would be very beneficial. Music intervention should be taught within the educational curriculum, as it can be used as a preparatory method or intervention and is very inexpensive. Refinement, revision, and advancement of factual knowledge or theory: More research is required to determine the effectiveness of varying musical interventions. Based on the information gleaned from the research studies, there is not enough information to rationalize why music alone is any more beneficial than other therapeutic interventions such as therapeutic massage, painting or interactive reading groups in reduction of anxiety symptoms in individuals with dementia. Conducting research with a larger sample size will increase the generalizability and reliability of the results identified thorough the research. The fact that humans tie emotional connections to music is inherently known. However, additional research is required in order to provide evidence based intervention. Review Process The focus question was developed out of a pervious focus question about the effectiveness of cognitive stimulation on cognitive functioning to increase engagement in activities of daily living for individuals in mid-stage Alzheimer s disease. The complexity of the previous question prompted a more feasible focus question. Given that cognitive stimulation is a very broad intervention, the music component of cognitive stimulation is the primary intervention. Mid-stage Alzheimer s disease as the primary population was too specific. Therefore, dementia became the primary population focus. Increased engagement in activities of daily living is too broad of an outcome to effectively measure. Therefore, reduction in anxiety will be used as the primary outcome. The new and ultimate sought out focus question was developed. What is the effectiveness of music on individuals with dementia to reduce anxiety in preparation for engagement in activities of daily living? Following focus question approval, MeSH and key terms were utilized to perform a comprehensive literature search The instructor of record (IOR) of OTD 601 performed a follow-up comprehensive literature search to ensure all databases had been exhausted A total of 13 articles were found as a result of the comprehensive literature search The articles were reviewed to ensure they correlated with the inclusion criteria 8 of the 13 articles were eliminated based on the inclusion criteria Five articles met the inclusion criteria and were analyzed in the evidence table The evidence table was reviewed by the IOR for accuracy Upon approval of the evidence table, appraised articles were formulated into the critically appraised topic Procedures for the selection and appraisal of articles 4
Inclusion Criteria: Article must address P (individuals with dementia), I (music), and O (reduce anxiety) Article must be Level I-IV Article must be written in English Article must be published in a peer-reviewed journal Exclusion Criteria: Exclusion of articles appraised in any retained systematic review Articles below Level IV study design were not appraised Non-peer reviewed journals Articles 5 years or older were excluded to ensure most current research is utilized in this appraisal Search Strategy Categories Patient/Client Population Intervention Outcomes Key Search Terms MeSH terms: Dementia, Alzheimer s disease/th Key Terms: Dementia or Alzheimer s MeSH terms: Music, Music Therapy Key Terms: Music or Music Therapy, Music Intervention MeSH terms: Anxiety Key Terms: Anxiety Databases and Sites Searched Medline, CINAL, PsychINFO, AgeLine, Cochrane Library Quality Control/Peer Review Process: Focused question reviewed and approved by IOR Author identified key terms used to conduct a comprehensive literature review using the aforementioned databases. IOR conducted a follow-up search of comprehensive literature review to ensure all databases were exhausted. Following comprehensive literature review feedback, author changed focused question to increase clarity of question. Updated focused question and comprehensive literature review was reviewed and approved by IOR. IOR reviewed evidence table for accuracy and rigor CAT was completed based on the revisions and consultations of the author and IOR Results of Search Summary of Study Designs of Articles Selected for Appraisal I Level of Evidence Study Design/Methodology of Selected Articles Systematic reviews, meta-analysis, randomized controlled trials Number of Articles Selected 4 5
II III IV V Two groups, nonrandomized studies (e.g., cohort, 0 case-control) One group, nonrandomized (e.g., before and after, 1 pretest, and posttest) Descriptive studies that include analysis of outcomes 0 (single subject design, case series) Case reports and expert opinion, which include 0 narrative literature reviews and consensus statements Qualitative Studies 0 TOTAL 5 Limitations of the Studies Appraised Levels I, II, and III Level I: Insensitive outcome measures. Some research indicates that the MMSE is not a sensitive predictor of severity of dementia. (Cooke, Moyle, Shum, Harrison, & Murfield, 2010, Level I) Interference of multiple interventions, thereby affecting outcome data. Subjects continued taking pharmaceuticals that potentially addressed behaviors i.e. depression, anxiety, etc. (Cooke, Moyle, Shum, Harrison, & Murfield, 2010, Level I) Studies reviewed contained small sample sizes inhibiting the generalizability of data. (O'Connor, Ames, Gardner, & King, 2009, Level I); (Vasionytė & Madison, 2013, Level I) No uniformity amongst the articles utilized in this systematic review (i.e. different requirements for participants). Difficult to generalize results when articles used different protocols. (Ueda, Suzukamo, Sato, & Izumi, 2013, Level I) Lack of intervention description interfering with validity and reliability of research. (Vasionytė & Madison, 2013, Level I) Poor methodological qualities of the studies utilized within the meta analysis. Description of guidelines used to gather and validate knowledge in the articles are lacking. (Vasionytė & Madison, 2013, Level I) No Level II studies appraised Level III: Small sample size limits the versatility of results. (Ozdemir & Akdemir, 2009, Level III) Lack of intervention description interfering with ability to replicate this study in the future. (Ozdemir & Akdemir, 2009, Level III) Levels IV and V No Level IV studies apprised No Level V studies appraised Articles Selected for Appraisal 6
Cooke, M., Moyle, W., Shum, D., Harrison, S., & Murfield, J. (2010). A randomized controlled trial exploring the effect of music on agitated behaviours and anxiety in older people with dementia. Aging & Mental Health, 14(8), 905-916. doi:10.1080/13607861003713190 O'Connor, D., Ames, D., Gardner, B., & King, M. (2009). Psychosocial treatments of psychological symptoms in dementia: A systematic review of reports meeting quality standards. International Psychogeriatrics / IPA, 21(2), 241-251. doi:10.1017/s1041610208008223 Ozdemir, L., & Akdemir, N. (2009). Effects of multisensory stimulation on cognition, depression and anxiety levels of mildly-affected Alzheimer's patients. Journal of the Neurological Sciences, 283(1-2), 211-213. doi:10.1016/j.jns.2009.02.36 Ueda, T., Suzukamo, Y., Sato, M., & Izumi, S. (2013). Effects of music therapy on behavioral and psychological symptoms of dementia: A systematic review and meta analysis. Ageing Research Reviews, 12(2), 628-641. doi:10.1016/j.arr.2013.02.003 Vasionytė, I., & Madison, G. (2013). Musical intervention for patients with dementia: A meta analysis. Journal Of Clinical Nursing, 22(9/10), 1203-1216. doi:10.1111/jocn.12166 Other References American Occupational Therapy Association. (2008).Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62,625 683. National Institute of Neurological Disorders and Stroke. (2013). The Dementias: Hope through research (NIH Publication No. 13-2252). Retrieved from http://www.ninds.nih.gov/disorders/dementias/the-dementias.pdf Nair, B. R., Browne, W., Marley, J., & Heim, C. (2013). Music and dementia. Degenerative Neurological & Neuromuscular Disease, 3. Schaber, P. & Lieberman, D. (2010). Occupational therapy practice guidelines for adults with Alzheimer s disease and related disorders. Bethesda, MD: AOTA Press. Twelftree, H., & Qazi, A. (2006). Relationship between anxiety and agitation in dementia. Aging & Mental Health, 10(4), 362-367. 7