Melanie Burton, two case studies.

Melanie Burton, two case studies.
“The benefit of music therapy to those with late-stage dementia” Queen Margaret University MSc Music Therapy 2012 If you have experience using music therapy with those with dementia and would like to be included in a Ph.D. aimed at reducing the use of anti psychotic medication for those with dementia please add your name to my list. Today I'm going to talk about the dissertation I wrote as part of my M in MT, that I completed in 2012 at Nordoff Robbins Scotland. I will outline the project with aims and methodology then discuss two of the three case studies included.

Gave me ideas for future study
THE PROJECT Prior to my Music Therapy course I had experience as a care assistant in homes in Oxon, CAMBS and Scotland Gave me ideas for future study As part of my dissertation in my second year approached a nursing home with my project idea. Began with 3 clients, once a week for 8 weeks. Prior to my training as a music therapist I worked as a care assistant and had plenty of time to contemplate what I would do when I finally became a music therapist. Over this time I had met some incredible carers who told me they thought one shouldn't take it for granted that people with LSD can't hear and understand us and we should treat them as we would any other person. This seemed logical enough to me. However, I increasingly saw staff, carers, managers, medical staff, family members and others who thought this was not the case, that people with LSD were simply too difficult to reach by any method. (PAUSE)

Gave me ideas for future study
THE PROJECT Experience as a care assistant prior to the project Gave me ideas for future study Approached a nursing home with my project idea. Began with 3 clients, once a week for 8 weeks. I began to want to show - - that people in LSD are capable of processing information about their world and expressing it, it's just not very obvious to the observer on first glance. Finding a way of assessing this was also troublesome. With my idea in mind I approached a nursing home, they were delighted at the idea and I started seeing 3 clients once a week.

Svansdottir and Snaedal 2006
LITERATURE OVERVIEW Music Therapy for those with early to mid stage dementia Belgrave 2009 Suzuki et al 2007 Ledger and Baker 2007 Svansdottir and Snaedal 2006 A large proportion of the literature reviewed focused on those in mid-to early dementia. The majority of the literature reviewed utilised case study design. For those with early to mid dementia - Belgrave focused on alertness using expressive touch in MT. Suzuki et al measured stress levels in saliva and observed behaviour. Ledger and Baker used known songs and observed behaviour. Svansdottir and Snaedal observed behaviour changes during MT.

Svansdottir and Snaedal 2006
LITERATURE OVERVIEW Music Therapy for those with early – mid stage dementia Belgrave 2009 Suzuki et al 2007 Ledger and Baker 2007 Svansdottir and Snaedal 2006 ALL highlight symptoms of the syndrome as limitations to the research I found it interesting to note that these studies all highlight symptoms of the syndrome as limitations to the research

Is music therapy of benefit to those with late-stage dementia?
Report PROJECT AIMS Is music therapy of benefit to those with late-stage dementia? Is the rating scale 'How the client is...' relevant for use with those in late-stage dementia? What are the perceived benefits of the intervention of music therapy by an observer? Looking at project aims. I wanted to see if MT was of benefit to those with LSD. The literature reviewed highlighted a gap in research on the use of MT for those with dementia. In addition evaluating the benefits of any intervention with this client group remains lacking. I formulated the questions you see here, to explore for and of myself. The last question was for the carer, LUCY who was present in all my sessions.

SCALE 1 RATING SHEET: HOW THE CLIENT IS THE RELATIONSHIP CONTINUUM
NAME OF CLIENT DATE OF SESSION NUMBER OF SESSION EVENTS FIRST EVENT (__________) PREDOMINANTLY ____ SECOND EVENT (_________) THIRD EVENT (___________) FOURTH EVENT(_________) TOTAL: DIVIDED BY NUMBER OF EVENTS (__), _________ ACQUIRED AN OVERALL SCORE OF ___ This is the scale I used to observe changes in the clients behaviour. This gave me both quantitative and qualitative data. This scale is called 'How the client is..' and was first drafted by Nordoff and Robbins, subsequently adapted by James Robertson. Each activity within the session is evaluated using two scales. The first measures the level of participation from the client and the second the qualities of resisitiveness.

6 Crisis toward resolution 7 Sense of accomplishment
EVALUATIONS LEVELS OF PARTICIPATION 1 Unresponsive 2 Ambivalence 3 Limited response 4 Relationship develop 5 Co-activity 6 Mutuality 7 Stability QUALITIES OF RESISTIVENESS 1 Oblivious 2 Uncertainty 3 Defensive 4 Perversity 5 Perseverative 6 Crisis toward resolution 7 Sense of accomplishment Each level of participation and resistiveness follows on to the next, clients are not expected to progress in a linear fashion, but to fluctuate between levels. Each level is sub-divided and described in great detail in Creative Music Therapy.

Scale was evaluated by Mahoney (2009)
'HOW THE CLIENT IS....' Scale was evaluated by Mahoney (2009) Found 74% interrator congruence, even in non-Nordoff Robbins trianed music therapists As used by Groß, Linden and Ostermann (2010) “Effects of music therapy in the treatment of children with delayed speech development – results of a pilot study” Scale to assess musicality in autristic children. MAHONEY NOTED IT CAN ALSO BE Useful for other populations. Mahoney found 82% congruence in those from NR and 74% out of NR. It's been used in some studies, like this one by Grob, Linden and Osteramnn.

The trouble with Carers....
Participant Observer (carer) LUCY From the outset she was very skeptical When I met her I knew it would be difficult to persuade her that what I was doing was of value to the clients

The trouble with carers
At the outset she was very sceptical She was incredibly observant! She sat in with me – taking notes! She was very observant and sometimes her observations were different to mine and incredibly useful!

The trouble with carers
At the outset she was very sceptical She was incredibly observant! By the end of the eight sessions she was championing music therapy and it's use for clients with dementia. One of the most important outcomes was that she came to sincerely believe in the developing process she saw each week. She saw the clients taking an interest and interacting with me. Before music therapy she had been at a loss, unsure how to talk to the clients and unsure if they could respond. But she told me that she learnt a lot during her observations of MT and uses some of the techniques every day. More about that later....

Report PROJECT AIMS Is music therapy of benefit to those with late-stage dementia? Is the rating scale 'How the client is...' relevant for use with those in late-stage dementia? What are the perceived benefits of the intervention of music therapy by an observer? Getting back to the project itself. Project aims – MT of benefit>? - rating scale effective for LSD? - observer benefits?

CASE STUDY 1 - MARY MARY was unable to walk. She could have moments of lucidity. Mary had parkinsons disease and dementia. Mary was able to express her emotions through vocalisations No walking No talking Moments of lucidity Expressed emotions throguh vocalisation

Known songs Ledger and Baker (2007)
CASE STUDY 1 – MARY Use of various musical idioms Known songs Ledger and Baker (2007) Improvisation Magee (2007) Listening activities Showed a preference for modal music Ledger and Baker focused on the use of known songs and showed that clients aggression was reduced. Magee highlights the use of improvisation to aid reintegration of new identities for people with acquired and long term illness. Based on this I inlcuded both known songs and improvisation in this project.

CASE STUDY - MARY Goodbye song – 'So Long, Farewell' Mary reaches to pluck ukulele string This clip is of..SO LONG FAREWELL.. I used this as her goodbye song. Remembering I was less experienced as a music therapist, my usual instinct was to jolly her along and make it quick which was taken over by another instinct to stop and allow her space to pluck the strings.

CASE STUDY 1 – MARY Clip 1 – Goodbye song
Mary sitting in an armchair, music therapist next to her with a ukulele. Music therapist plays 'So long, farwell, a known song to Mary. After many repeats Mary reaches out to touch a string. She let's out a deep sigh. This is one of the only times she plays an instrument. 1 minute a2

CASE STUDY - MARY Mary seemed to concentrate on making the movement necessary to pluck the string. Mary was in subsequent sessions more vocal Mary used her voice to communicate To Lucys surprise Mary seemed to concentrate on making the movement necessary to pluck the string. Mary was in subsequent sessions more vocal Mary used her voice to communicate – I felt this work linked very much to NR's work on the music child, or person. No matter how ill someone is they can still respond musically....

CLIP 2 – MARY Next clip is by Mary's bedside On this occasion Mary could be heard from three floors away, she sounded restless Mary had responded well to improvisations around her vocalisations Mary showed signs of responding to musics structure, I used this to encourage Mary to interact After this session Mary was quiet and was able to rest IN THIS NEXT CLIP Mary is in her bed due to ill health. On this occasion I could hear Mary three floors away Mary had responded well to improvisations around her vocalisations Mary showed signs of responding to musics structure, I used this to encourage Mary to interact, more about that later After this session Mary was peaceful and was able to rest

CLIP 2 - Bedside Mary is in bed, sighing deeply. Music Therapist is opposite with a violin Mary sighs loud and long, therapist matches with violin Mary pauses Music therapist allows a melody around the note Mary sang Mary continues to sigh, becoming less frequent, quieter, face becomes relaxed Therapist uses C# to draw Mary into interacting ENDS – Mary face looks more relaxed, seems more peaceful 3mins PAUSE AFTER SHOWING CLIP......

Taking Mary's D as the tonic
MARYS' TONIC THE IMPORTANCE OF STRUCTURE Taking Mary's D as the tonic Consciously using the C# to encourage interaction Encouraging continued interaction by never resolving the melody Aspects of atonal/ modal playing to avoid implication of mood, and resolution D E F G A B C D During the course of this project I became more and more interested with the affects of musics structure, in this clip you can hear how I use the note Mary is singing, a D, as the tonic and weave a melody around it, consciously using the C# to encourage Mary to continue vocalising. I also drew on aspects of atonality and modal playing, as Mary had responded well to this in the past, and I wanted to remove any implication of mood and resist the temptation to resolve the melody.

OUTCOMES RELATED TO MARYS CASE STUDY
Mary responded to structure – this maybe an important area for more research Mary was able to respond to music Mary was aware of the therapist and her music Mary grew familiar with the therapist OUTCOMES IN RELATION TO MARYS MT Mary responded to structure She responded to music she was aware of the therapist and her music And she BUILT a good therapeutic relationship with the therapist

GERALDINE Case Study 2. Geraldine “Don't take her, we haven’t found a way of interacting with her...” (Carer) “don't take it for granted that they can't hear or understand us” The very reason I started this project! I do find it interesting that the very comment that led me on this journey “don't take it for granted they can't hear and understand” came up here – we can't interact with her.... don't have her. Geraldine sitting in an armchair clapping and talking to herself – or her daughter. Geraldine could see hallucinations most of the time. She did speak, but the words were jumbled and didn't follow logically. I thought she was perfect for the project. So I saw that she was recruited.

GERALDINE Geraldine was confused, very introverted and isolated with periods of agitation and anxiety. Use of 'Hello Song'. Geraldine showed a preference for blues I used a variety of playing songs and improvising with Geraldine. Geraldine was confused, very introverted and isolated with periods of agitation and anxiety. Use of 'Hello Song'. Geraldine showed a preference for Blues

CLIP 1 – HELLO SONG Use of hello song Geraldine claps, then sits back Music is repetitive First ever music therapy session with this client group... e1

CLIP 1 – HELLO SONG Moments of interaction / moments of still attentiveness Getting to know one another Notice how the other clients are in the room? As Geraldine became more used to the sessions she began to anticipate the Hello Song Geraldines movements alternate between moments of movement and moments of stillness. During her still moments it is important to note that Geraldine left to her own devices does not sit this still.

CLIP 1 – HELLO SONG Moments of interaction / moments of still attentiveness Getting to know one another Notice how the other clients are in the room? As Geraldine became more used to the sessions she began to anticipate the Hello Song During this time I really battled with the duality of the carer I had always been and the music therapist I was becoming. AT this time I felt pressured to include other residents in the music space, as is the nature of care homes. Subsequently it confirmed my belief that group sessions are not beneficial to this client group.

CLIP 1 – HELLO SONG Moments of interaction / moments of still attentiveness Getting to know one another Notice how the other clients are in the room? As Geraldine became more used to the sessions she began to anticipate the Hello Song Geraldine noticed the Ukulele falling off the piano – she responded to her environment. In line with Magee (2007) Magee, W A Comparison Between the Use of Songs and Improvisation in Music Therapy with Adults Living with Acquired and Chronic Illness. Australian Journal of Music Therapy 18 In subsequent sessions I began to question Geraldines responses to my music – was she simply clapping as she normally would have done? Then in one session the ukulele fell off the piano – she stopped clapping and said 'Oh'. This helped me know that what I was doing was helping Geraldine stay grounded in the here and now – Another moment of lucidity. As in Magees work this project found that MT can aid clients to remain in the moment.

Stillness / movement CLIP 2 – IMPROVISATION
In this next clip Geraldine is responding in her usual pattern Stillness / movement Lucy's surprise at Geraldine's responses

CLIP 2 - IMPROVISATION Geraldine suddenly sways her shoulders during an improvisation! Observer says 'That's nice!' Therapist laughs Geraldine touches therapist on the shoulder looks her in the eye and says 'I knew you would laugh, I knew you would laugh!' 30 seconds long

CLIP 2 - IMPROVISATION Greater sense of knowing each other. Sense of fun emerging She spoke directly to me for the first time – Outcome, aiding in maintaining lucidity and remaining in the here and now Interruptions into the music therapy room In this clip you can see Geraldine swaying to the music, then she touches me on the shoulder and says “I knew you would laugh! I knew you would laugh!”. This was the first time she addressed me directly. A rare moment of lucidity – but aided by music therapy! A wonderful outcome. As with my current work, there were frequent interruptions, here you see another carer come in, despite being asked not to.

MAOIRI'S WEDDING Use of known songs Frequent movement of hands – putting on wedding ring?

Use of a blues style to encourage interaction
CLIP 3 – BLUES... ISH Use of a blues style to encourage interaction Using this table a pattern of behaviour can be seen – in time with each repetition of the 7th chord As my playing is a little amateur I have included markers for each bar on the video BAR 1 2 3 4 5 6 7 8 REPETITION 1 BEGINS clapping REACHES therapist + QUICKER clapping SLOWS clapping STOPS Clapping STOPS clapping (pause) QUICKER clapping REACHES Lucy Like my work with Mary Geraldine showed signs of responding to musics' structure. I used a blues style to encourage interaction. Using this table you can see how Geraldines responses seemed to be in line with the structure of the music. Most notably, Geraldines movements on the 7th chord were the same each repetition of the chord progression. I apologise, I am not a gifted blues player!

2.5mins – needs a little tidying up
1 2 3 4 5 6 7 8 BEGINS clapping REACHES therapist + QUICKER clapping SLOWS clapping STOPS Clapping STOPS clapping (pause) QUICKER clapping REACHES Lucy 2.5mins – needs a little tidying up

7 CLIP 3 – BLUES Geraldine interacting on a structural level
1 2 3 4 5 6 7 8 BEGINS clapping REACHES therapist + QUICKER clapping SLOWS clapping STOPS Clapping STOPS clapping (pause) QUICKER clapping REACHES Lucy I think this is an area that could be researched further.

OUTCOMES LINKED TO GERALDINES CASE STUDY
Geraldine remained 'in the moment during music therapy' Similar to Magee (2007) OUTCOMES RELATED TO GERALDINE Geraldine responded to the music therapist, her music and events that happened in music therapy. This is similar to a study by Magee who also found clients became more responsive in and shortly after MT.

Geraldine retained structural information Geraldine remained 'in the moment during music therapy' Magee (2007) Geraldine responded to musics structural aspects.

Geraldine recalled members of her family Geraldine remained 'in the moment during music therapy' Magee (2007) Geraldine retained structural information Geraldine recalled family members whilst in music therapy.

Music therapy enable Geraldine to interact with me, and others in the room Geraldine remained 'in the moment during music therapy' Magee (2007) Geraldine retained structural information Geraldine recalled members of her family Similar to Powell (2006; Brotons and Koger (2000); Knaefsey (1997) Through music Geraldine was able to make eye contact, talk to me and touch me. She often clapped and responded vocally to me. This is in line with Powell and Knaefsey et al's literature reviews, which showed positive responses to MT. Brotons also found that language functioning increased in and after MT.

Resulting from Geraldine's responses to music therapy staff now use music to settle down at night Geraldine remained 'in the moment during music therapy' Magee (2007) Geraldine retained structural information Geraldine recalled members of her family Music therapy enable Geraldine to interact with me, and others in the room Powell (2006; Brotons and Koger (2000); Knaefsey (1997) Similar to Svansdottir and Snaedal (2006) and Suzuki et al (2007) Staff told me that as music therapy had had the affect of making Geraldine very sleepy they used music to get Geraldine ready for going to bed. Carers also used the piano to calm her if she was anxious, they said the sound of it seemed to be soothing. This outcome is in line with Svansdottir and Snaedal (SOUNDS LIKE?) s project saw reduction in activity distrubance, reduction in aggression and anxiety. It may be that Geraldine was feeling less stressed as Suzuki et al reported reduction in THE STRESS hormoneS present in saliva and reported a reduction in stress after MT.

Geraldine received less anti-psychotic medication during the trial Geraldine remained 'in the moment during music therapy' Magee (2007) Geraldine retained structural information Geraldine recalled members of her family Music therapy enable Geraldine to interact with me, and others in the room Similar to Powell (2006); Brotons and Koger (2000); Knaefsey (1997) Geraldine's staff team use music at night to aid transition to bed time Lastly, the manager of the service, a nurse, who was interviewed after the project told me that Geraldine had received less antipsychotic medication during this time. I'd like to stress the importance of this. As anything that can reduce the amount of medication given to this population can only be a good thing.

REDUCING ANTI-PSYCHOTIC MEDICATION
NHS audit on use of anti-psychotics says 80% are inappropriately prescribed Anti psychotics can lead to reduced mobility, increasing fall risk, lack of attention, makes people tired In fact, anti psychotics increase the risk of many of the adverse symptoms associated with dementias. Nursing homes urged to reduce Anti psychotic use At present, there are little alternatives New research on psychotherapy An NHS audit of the use of APSY says 80% are inapp.ly prescribed. Anti psychotics can lead to reduced mobility, increasing fall risk, lack of attention, makes people tired In fact, anti psychotics increase the risk of many of the adverse symptoms of associated with dementias. Nursing homes urged to reduce Anti psychotic use Currently no alternatives given..... New research on psychotherapy My phd idea

Report PROJECT AIMS Is music therapy of benefit to those with late-stage dementia? Is the rating scale 'How the client is...' relevant for use with those in late-stage dementia? What are the perceived benefits of the intervention of music therapy by an observer? To revisit the project aims from earlier on - Is mt of benefit to those with LSD? This research shows that music therapy can benefit some adults with late stage dementia some of the time. This study is inconclusive as it is not generalizable due to sample size. Benefits commented on by the therapist in process notes included – increased alertness, increased interaction, more eye contact, remaining in the here and now, showing enthusiasm, increased participation in activities, improved emotional expression, alleviating anxiety, and memory recall.

Report PROJECT AIMS Is music therapy of benefit to those with late-stage dementia? Is the rating scale 'How the client is...' relevant for use with those in late-stage dementia? What are the perceived benefits of the intervention of music therapy by an observer? Is the rating scale 'how the client is' relevant for those in LSD? The rating scales were useful in gauging ‘How the client is’. The scales described each activity and aided the therapist in assessing the efficacy of the music therapy intervention. The quantitative figures gained from adding a numerical value to each activity allowed the therapist to gauge alertness on any given day. Further research is needed.

Report PROJECT AIMS Is music therapy of benefit to those with late-stage dementia? Is the rating scale 'How the client is...' relevant for use with those in late-stage dementia? What are the perceived benefits of the intervention of music therapy by an observer? What are the perceived benefits of the intervention of mt by an observer? Lucy and the MOS agreed that music therapy is beneficial to this client group. The setting has also commented on ways they have begun to change their professional practice. The setting now uses music more often in the day to day care of the residents. They have also employed the researcher as a musician. In addition music therapy reduced the need for anti psychotic medication. FINALLY, as always, more research is needed.

Case study of the dissertation
That's all folks THANKS FOR LISTENING Melanie Burton MSc Music Therapy Case study of the dissertation “What is the benefit of music therapy to those with late-stage dementia” questions

REFERENCES Aldridge, A Music Therapy In Dementia Care. London and Philadelphia: Jessica Kinglsey Publishers. Belgrave, M The effect of expressive and instrumental touch on the behaviour states of older adults with Late-stage dementia of the Alzheimer's Type and on Music Therapist's Perceived Rapport. Journal of music therapy XLVI (2) Brotons, M and Koger, S, M The Impact of Music Therapy on Language Functioning in Dementia. Journal of music therapy XXXVII (3) Groß W., Linden. U, and Ostermann T Effects of music therapy in the treatment of children with delayed speech development – results of a pilot study. BMC Complementary and Alternative Medicine 1-:39. Knaefsey, R The therapeutic use of music in a care of the elderly setting: a literature review. Journal of nursing care 6 Ledger and Baker, An Investigation of Long Term Effects of group music therapy on agitation levels of people with Alzheimer's disease. Ageing and Mental Health 11 (3) Magee, W A Comparison Between the Use of Songs and Improvisation in Music Therapy with Adults Living with Acquired and Chronic Illness. Australian Journal of Music Therapy 18 Mahoney. J. F Interrater Agreement on the Nordoff-Robbins Evaluation Scale 1: Client-Therapist Relationsip in Musical Activity. Sage Publications NHS National Dementia and Antipsychotic Prescribing Audit. NHS Information Centre 2012 Nordoff, P. and Robbins, C Creative music therapy: a guide to fostering clinical musicianship. 2nd ed. USA: Barcelona Publishers. Pavlicevic, M Music therapy in context: music, meaning and relationship. London: Jessica Kingsley Publishers. Powell, H The voice of experience: evaluation of music therapy with older people, including those with dementia, in community locations. British Journal of Music Therapy, 20 (2). Pp Suzuki, M., Kanamori, M., Nagasawa, S., Tokiko, I. and Takayuki, S Music therapy-induced changes in behavioural evaluations, and saliva chromogranin A and immunoglobulin A concentrations in elderly patients with senile dementia. Geriatric and Gerontology International 7(1). Pp. 61–71. Svansdottir, H. B. and Snaedal, J Music therapy in moderate and severe dementia of Alzheimer’s type: a case-control study. International Psychogeriatrics, 18 (4). Pp Robertson, J How The Client Is.. adapted rating scale. QMU. Vink, A. C., Bruinsma, M. S. and Scholten, R. J. P. M Music therapy for people with dementia. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD DOI: / CD pub2.

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