CHALLENGING BEHAVIOUR-(CB- SUMMATIVE ASSIGNMENT)

INTRODUCTION- (200 WORDS)

In my assignment, I will be looking at the music therapy intervention and how effective it is in people with dementia where agitation/anxiety are the common features creating a challenging impact on the wellbeing.

Dementia has globally become a concern and the world health organization has estimated that approximately around 50 million people have dementia and nearly 10 million new cases every year is said to be identified. This number will totally rise to 82 million by 2030 and to 152 in 2050 due to people living on low or middle income therefore there is a need to further research into finding the cure. WHO (2019).

Dementia is a term used to describe a wide range of cognitive impairment and has a massive impact on people as they get old. It is a degenerative cognitive condition usually occurring in older age but not always so and is characterised by the appearance of behavioural disturbances. (Goodall & Etters, 2005).

According to NHS (choices) behavioural and psychological disturbances are characterised by the following; agitation, anxiety, aggression which are as a result of an individual being distressed. Behaviour can be described as challenging when it creates intensity or frequency that will threaten the quality of life or the physical safety of the individual or others and it is likely to lead to responses that are restrictive, aversive or result in exclusion. Royal College of Psychiatrists (2007).

Challenging behaviour on the other hand is defined as behaviours which involve significant risks to people’s wellbeing or an act that will markedly reduce their access to community settings. Emerson (2001).

Behaviours like Agitation and anxiety have a significant impact on the people with dementia and the caregivers therefore it is important that all health professionals to provide a holistic/person centred approach care to support the Individual’s and enable them to have a better quality of life.

Different interventions have been used in research to explore the best understanding of individuals with dementia using scientific evidence to propose interventions that can be used for long to create effective outcomes.

MAIN BODY (WORS -2100) CRITICAL ANALYSIS (PRIMARY RESEARCH PAPER-3)

Dementia symptoms have been treated predominately by pharmacological and physical interventions according to Robinson et al (2007). However the pharmacological agents have side effects and on the ethical side physical restraints are a concern Hughes (2002).

In light of all this non-pharmacological options should be the first line of treatment used as the best practice intervention approach. (Nice guidelines 2018). Music therapy is a non-pharmacological intervention that aims to increase emotional wellbeing through cognitive stimulation and social interaction.NursingTimes (2014).

The American music therapy association (AMTA) defines music therapy as ‘’the clinical evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credential professional who has completed an approved music therapy program’’ American Music Therapy Association (2006).

A study was carried using meta-analysis to investigate the effects of music on agitation in dementia and different database was used to search for key terms for 5months (October 2015-february 2016). 57 articles where identified, 45 did not meet the inclusion criteria and the remaining 12 articles where used in the meta-analysis. 658paticipants were involved in the included 12 studies and further divided into subgroups where each of the studies used different practitioners to carry out the interventions. The interventions used included; singing, stretching and clapping (active music intervention) and music through headphones, CD players or live performance (passive interventions)

The study used original research following inclusion criteria like; randomised study design, population study which consisted exclusively the  elderly individuals diagnosed using the Diagnostic and statistical Manual of Mental Disorder. Other clinical tools used were; the Global Deterioration Scale (GDS) to examine Alzheimer’s disease (Reisberg et al, 1982), Clinical Dementia Rating (CDR) and Mini- Mental State Examination (MMSE). Music intervention was used with aim to reduce agitation. Agitation was assessed by validated and reliable scales. To measure agitation Cohen-Mansfield Agitation Inventory was used to assess agitated behaviours and their frequencies (CMAI; Cohen-Mansfield et al., 1989), another inventory used was the Neuropsychiatric Inventory (NPI) to obtain information about the patient’s psychopathology in particular agitation.

Clinical judgment and research results suggest music therapy to be an intervention that considerably has positive health outcomes (MacDonald, 2013).The National Institute for Health and Care Excellence (NICE) guidelines for treating people with dementia who have Comorbid agitation recommends a range of sensory stimulation interventions and these include; music intervention, aromatherapy etc.(National Institute for Clinical Excellences, 2006.

Active music intervention acts as a powerful stimulus that encourages socialization involvement with the environment and awareness (Raglio et al 2008, 2010; Sakamoto et al, 2013. This  intervention also helps to reduce stress and apathy and negative behaviours such as aggressiveness and agitation (Sakamto et al 2013 it also helps the patient to create meaningful activities (Svansdottir and Snaedal 2006).Passive music listening also is reported to have a beneficial effect on agitated behaviour by elicting repressed feelings (Lin et al 2011. Music based on the patient’s preferences has been argued to have a good effect on agitation in dementia (Sung et al 2006b). Furthermore in this design the authors conclude that there was a high probability of positive effects on cognitive abilities, quality of life and agitation but conceded that the methodological shortcomings and inconsistencies in the published work available by 2004 reduced the robustness and comparability of the reported findings and this limited any conclusions that could have been drawn in relation to the robust effects of the music intervention (Vink et al 2004.

The meta-analysis of the music intervention provides evidences for effectiveness of music intervention in the treatment of agitation in people dementia. Furthermore the analysis validates that non-pharmacological approach should be used in detrimental symptom like agitation and interventions should be tailored to the individual’s preferences if positive outcome are to be achieved.

In another research paper a randomized controlled trial was used where forty-seven (47) individuals with mild to moderate dementia were recruited from two (2) care facilities in the Queensland area of Australia. (Access economics 2009b). The researchers used this design to explore the effect of music on agitated behaviours and anxiety in older people with dementia. The prevalence of agitation in the individuals varied from 15% to 95% (Lyketsos et al (2002) in anxiety from 10% to 70% (Teri et al 1999).Cohen-Mansfield Agitation Inventory (short form (CMAI-SF) and the rating Anxiety in Dementia Scale (RAID) (shankar et al 1999) was used to access the participants. In the study it is reported that agitation and anxiety from the people with dementia created a great impact to the caregivers where the mangers from the care facilities (Long term care facilities) found it very difficult to admit people with challenging behaviours (Hogan 2004). The study used the randomized cross-over design with a music intervention and a reading control group for a period of 6months (October 2008 to march 2009).

Individual studies into the efficacy of music for managing dementia have been reported to be successful in the intervention of reducing the symptoms of agitation and anxiety. Studies in relation to agitation, have found that music played during mealtimes significantly reduced agitation in nursing home residents with dementia (Hicks-Moore 2005) and regular music sessions had also significantly positive impact to reduce agitation (Choi, Lee, Cheong, & Lee, 2009).

The methodology of using the randomised design has some advantages like, it ensured that both groups received a good level of equal opportunities to the two treatments offered (Polit, Beck, & Hungler, 2001), the participants were not denied to take part in the study and were also allowed an examination over a six months period to see the effects.

Further more studies have highlighted that another third group of the participants should be added in the study as this may also help to contextualize the results of the music and the reading groups in light of a normal pattern of change of agitation and anxiety levels without intervention over the same period. Secondly the findings may also support the importance of individualizing interventions and not providing one-treatment-suits all approach (Cohen-Mansfield & Werner 1997).

The non-significant findings also highlight the possible need to try and conduct future research when the symptoms under investigation are most prevalent so as to maximize the chances of detecting a significant effect.

In another research article a randomised controlled design was conducted to explore the effect of the music therapy and compared it with the general activities in reducing agitation in people with dementia residing in the nursing home facilities. 94 people with dementia where allocated to the music therapy or recreational activities and the data were analysed for 77 residents where 43 randomised were allocated to the music therapy and 34 to the recreational activities. The groups both received sessions twice weekly for the duration of 4months and the researcher used a mixed model analysis to evaluate the effectiveness of music therapy and compared it with general activities. The music therapist uses music parameters like the tempo and mode to activate or relax the individual and also stimulate the social and emotional well-being in order to reduce the individuals anxiety…………………………………..

The effects of music when applied can bring psychological symptoms and the behaviours in people with dementia by affecting the physiological parameters like the autonomic nervous system for example the heart rate variability and the plasma cytokine and catcholaine levels.(Raglio et al 2010)  and Okada et al 2009. In an active control condition it was seen that those residents who received a comparable level of attention with the specific effect of the therapy had reduced levels of agitation identified……………….. There was a greater decrease of agitation to those who received the music than the ones who took on the recreational activities

The study also had several limitations and these complicated the study outcomes and findings; although the residents where located to the group by randomisation unfortunately the ones in the general activities groups, they had a higher GDS score than those in the music group indicating a severe dementia stage. The second limitation of the study was that a modified version of the CMAI was used to assess the presence of agitated behaviour which lacked the sensitivity of the full version of the Cohen-Mansfield agitated inventory (CMAI). Another limitation of the study was that a complete blinding could not be guaranteed because the nurse carers who rated the Cohen-Mansfield inventory score were also responsible for taking the residents to either the activity or the music therapy room. However they were kept unaware of the exact study purposes which may have prevented them from being positive biased towards music therapy.

CONCLUSION-(200 WORDS)

In conclusion using the music therapy mode of intervention on people with dementia is suggested in all the different studies as the most effective intervention even when compared with other activities. Music helps the individuals to improve in different ways such as their active involvement, social emotional and cognitive skills hence reducing their behavioural problems.

There should be further more in depth assessments of the participants in order to be able to detect discrepancies in the other interventions.

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