An Individualized Music-Based Intervention for Acute Neuropsychiatric Symptoms in Hospitalized Older Adults With Cognitive Impairment: A Prospective, Controlled, Nonrandomized Trial

When patients are admitted to the geriatric inpatient unit, psychiatric, medical, and psychosocial evaluations occur. History is taken, medications are examined, lab values are inspected, and imaging of the head (if indicated) is obtained to identify potential issues that might be causing agitation and behavioral disturbances. If underlying medical issues are identified, these are treated. Psychiatric conditions are often treated via both medication (dependent upon previous prescriptions, current condition, and physician preference) and behavioral management (e.g., group and recreational therapies). Acute neuropsychiatric symptoms are addressed via both medication (commonly haloperidol or lorazepam) and behavioral management (e.g., removal of triggers that cause symptoms, participation in therapeutic groups, reassurance). Throughout the course of hospitalization, other disciplines are consulted, as needed, including pharmacy, neuropsychology, occupational therapy, and physical therapy to identify and treat comorbid issues. Prior to discharge, family meetings occur to ensure that patient and family questions and goals are addressed.

Building off of prior research, published guidelines, and professional recommendations (e.g., Gerdner, 2012; Raglio et al., 2012; Sung et al., 2010), the authors of the current study utilized an individualized music-based intervention program that would likely appeal to patients hospitalized on a geriatric inpatient unit. To do so, 31 music playlists were created, with songs grouped according to decade (1940s-1970s), music genre (Country, Big Band, etc.), and, in some instances, individual artist (Elvis Presley, Frank Sinatra, etc.). Patients were asked which type of music they previously enjoyed listening to. If a patient was unable to provide an answer to this question, a family member provided information regarding the patient’s music preferences. Playlists were then chosen for each patient based upon their music preferences.

Each patient received an iPod shuffle with Bluetooth-enabled cordless headphones on which to listen to their individualized music. It was recommended that patients listen to music for at least 30 min each day in the late morning. In addition, iPods were available on an “as needed” (staff suggested as patient irritability starts to increase) or “as requested” (patient request) basis as long as this PRN iPod usage did not interfere with treatment as usual (e.g., mandated groups and medical consultations). The iPods were set up and provided to patients by a recreational therapist and/or nursing staff.

The outcome variables examined in this study included level of agitation, negative mood, positive mood, resistance to care, number of one-on-one nursing staff interventions, and number of agitation-related PRN medications. All variables were documented by nursing staff who were trained to identify and rate each of the behaviors comprising the variables. Nursing staff used behaviorally anchored Likert-type scales to do so (see Figures 1 and 2). Documentation of outcome variables was performed twice daily, at the end of nursing staff shifts (approximately at 7:00 a.m. and 7:00 p.m.). Nurses were instructed to complete the rating scales based on patient behaviors over the entirety of their shifts. This resulted in each patient being rated every 12 hr during the hospital stay. While nursing staff completed these assessments, they were not informed that the items contained on them would be used as outcome variables for this study.

Comparisons between the two clinical groups across baseline characteristics did not reveal significant differences for any variable (see Table 1). As indicated by Table 2, there were significant group differences on all symptom-based outcome measures. Five of six agitation symptoms, five of eight negative mood symptoms, and three of six resisting care symptoms evidenced significant group differences, which were consistently lower for the music-based intervention group, indicating less severe and/or persistent symptoms. Similarly, six of eight items on the positive mood scale evidenced significant group differences, which were consistently higher, indicating more positive mood behaviors for the music-based intervention group. The scores reported in Table 2 represent the sample median rating for each behavior as averaged across the course of hospitalization.

Table 3 shows statistics for the index-level outcome variables. The music-based intervention group had significantly lower scores on the agitation (1.81 vs. 4.08, p ≤ .01) and negative mood scales (4.51 vs. 6.84, p ≤ .01) and a significantly higher score on the positive mood scale (11.84 vs. 9.28, p ≤ .01), indicating less pathology and better mood in this group. The effect size was large for all three variables (d = 1.10-1.59). The music-based intervention group also had a significantly lower score on resisting care level (1.00 vs. 2.96, p ≤ .01), with a medium effect size demonstrated (r = −.69). Statistically significant group differences were not found for number of PRN medications administered (0.39 in the intervention group vs. 0.91 in the treatment as usual group, p = .04) or number of one-on-one nursing staff interventions (0.61 in the intervention group vs. 1.67 in the treatment as usual group, p = .05). Of note, when only individuals with major neurocognitive disorder were examined, agitation, negative mood, positive mood, and resisting care remained significantly different between the study groups, while number of PRN medications administered and number of one-on-one staff interactions remained nonsignificant. Finally, no significant differences were found between males and females for any of the variables in the intervention group.

This is the first study to examine whether an individualized music-based intervention can result in improved neuropsychiatric symptoms when applied to patients on a psychogeriatric hospital unit. It was found that patients in the intervention group had significantly less agitation, improved mood, and less resistance to care than patients receiving treatment as usual. Furthermore, the effect sizes for the significant findings were medium to large, indicating that there was a high degree of clinical impact from the intervention.

In addition to demonstrating that this intervention can have a positive impact on neuropsychiatric symptoms in this patient population, it is noted that the intervention was well tolerated by patients and easily implemented by hospital staff. There were no adverse events from the intervention, nursing staff qualitatively indicated that patients appeared to have enjoyed listening to the music, and nursing staff reported that the intervention seemed to have improved quality of life for patients while on the hospital unit. Nursing staff additionally indicated that administration of the intervention did not result in any hardship for them. The intervention does not require staff to possess any musical ability, it can be easily implemented by existing staff, and it requires only a one-time, relatively low expense, start-up cost. All items can be reused after patients are discharged from the hospital.

As others have recommended, we suggest that music be individualized to each patient (Gerdner, 2000, 2012; Sung et al., 2010). The music was based on artists or genres that patients enjoyed listening to when they were in their early adulthood years. Using familiar and preferred music from a patient’s past is thought to be of importance, as knowledge of and emotions associated with this previously enjoyed music are more likely to be retained than knowledge of and emotions associated with newer music in patients with dementia (Cuddy & Duffin, 2005; Sung & Chang, 2005). We also suggest that the music be played prior to peak levels of agitation, when possible, as interventions for agitation are thought to be most beneficial before agitation fully emerges (Gerdner, 2000; Hall & Buckwalter, 1987).

It is noted that while patients who received the music-based intervention had significantly improved mood and agitation when compared with their treatment as usual counterparts, the rate of PRN medication prescription for agitation was not statistically different between the two groups. It is unclear why significant differences in this outcome did not emerge, but issues related to degree of intervention effectiveness, level of maintenance versus adjustment of staff care routines, study limitations, or a combination of the aforementioned factors are conceivable. More specifically, while significant improvements in agitation and mood resulted from the intervention, the improvements might not have been to such an extent that it significantly altered PRN medication administration practices in this acute care setting. It is questioned whether providing feedback to staff on the results of the intervention and/or educating staff about the utility of nonpharmacological interventions might help to adjust care approaches. It is also conceivable, though, that the lack of significant difference might be related to a limitation of the study: a somewhat small sample size that resulted in reduced statistical power. While the p value did not reach significance at .01, it was trending in that direction (p = .04), the effect size was found to be medium, and it was noted that those in the music-based intervention group received 60% fewer PRN medications for agitation per nursing staff shift than those in the treatment as usual group.

An additional limitation of the study is that two adjacently timed convenience samples were utilized. Because of this, differences regarding history and selection could not be controlled for explicitly. At the same time, it was found that patient background and demographic variables could not explain the significant findings, as patients included in the two study groups did not have significant differences in age, education, sex, race, rate of admittance from long-term care residences, length of hospital stay, degree of cognitive dysfunction, or frequency of neurocognitive diagnoses.

Finally, it is noted that the assessment scales utilized in the current study were not previously published tools. Published assessment scales that would be appropriate for this study’s patient population and/or purposes did not exist. Because certain mood and agitation symptoms can differ between adults and older adults (Cummings et al., 2015; Yesavage et al., 1982-1983), the authors searched for tools that would assess for mood and agitation symptoms that are likely to occur in older adults. Furthermore, observer-rated tools were sought because it was known that many of the inpatients would be too cognitively impaired to accurately provide ratings of their agitation and mood disturbance. In addition, the authors searched for tools that would allow them to rate behaviors as they occur over brief intervals (i.e., 12 hr) because hospital stays can be brief and agitation in older adult inpatients can significantly fluctuate over a short period of time (Cohen-Mansfield, Marx, & Rosenthal, 1989; Cole, 2004). While a number of measures were reviewed, none met all of these criteria. Therefore, observer-rated behaviorally anchored scales, which were comprised of items derived from evidence-based sources, were utilized. The fact that these scales differentiated between the music-based intervention and treatment as usual groups suggests that they are efficacious in assessing symptoms in older adults on a psychogeriatric inpatient unit.