Engaging and connecting through music: enablement in practice

Kirsty Beilharz

Leading a program which makes music an integral part of relationship building and engagement for people with dementia by embedding it into the daily routine of residential life.

Music has been part of the culture of HammondCare’s residential care homes for many years – with visiting musicians, choirs, singing in the chapel, volunteers facilitating music listening and playing opportunities, excursions to concerts and seasonal festivities. However, the music engagement program specifically embeds music in everyday care, as part of relationship building and engagement with the individual, not merely as a peripheral activity or entertainment choice. With this program, we are aiming to bring about a paradigm shift that repositions music as a meaningful ‘in the moment’ experience for people living in aged care, rather than a form of ‘therapy’ provided every now and then or weekly by a visiting expert.

The music engagement program

It is important to acknowledge that there is no single approach to music engagement that is best. Alongside a consistently person-centred response, our program adopts a three-pronged approach:

1. Individualised music to leverage the benefits of deep emotional connection and tailored tastes. As part of this approach, we have developed music engagement in our residential care homes across NSW with the distribution of 750 iPods containing music that’s meaningful to each individual resident. Family members and staff work with residents to identify music and songs for their playlists. If we are unable to consult with an individual’s family or friends and the person is unable to verbally communicate, we try to get an idea of their musical tastes from their record collections, belongings, photographs and by observing which music on radio and TV they respond to. Sometimes we play through a variety of music with the person to see what sparks their interest and response. Most people will tap their fingers, smile, hum or acknowledge familiar songs with varying degrees of subtlety.
2. Group participatory music that fosters socialisation, belonging, integration and a sense of community. This includes singing groups or choir, singing along or clapping with visiting musicians, occasionally karaoke, and even the daily exercise to music that encourages group interaction.
3. Creative expressive music-making, including using bespoke musical instruments designed especially for people with dementia, which are playful, engaging and highly satisfying, without requiring long periods of concentration, practice or memory to produce a musically aesthetic result. This third angle gives ‘voice’ and expression to people who may not be able to speak up in conversation and nurtures enablement, creativity, choice and agency. The innovation of specifically designed instruments is to yield a more musically varied result than percussion, with the instruments looking and feeling like they are designed for adults, albeit adults having fun with movement, sound and control, enabling people to be inventive and adventurous. Other creative music-making includes drumming and playing harp.

Creating new musical instruments

These new musical instruments (or ‘interfaces’) are prototype designs developed with a group of UNSW Art and Design graduate Interaction Design students. It is a superb synergy in which students learn to design for a new user group and real clients (a privilege for design students), and create instruments that provide a dignified experience that is person-centred and highly satisfying, age-appropriate, motivating and engaging.

Tactile and kinetic controls on the instruments promote fun engagement, movement, and multisensory feedback. Students took a familiar set of gestures (after participating in occupational therapy groups with residents) and then embedded motion sensors inside the objects to control music production.

This collaboration was a response to the proliferation of percussion and elementary musical instruments sometimes used in aged care ‘music therapy’ or ‘activity’ sessions. At best, these instruments can provide a good experience for a short while, but at worst they can produce a musically barren (read ‘cacophonous’) or frustrating outcome; or equally concerning, they can infantilise people with dementia because the instruments are designed for children.

Embedded in everyday care

There is an increasing awareness of the potency and facilitation of music engagement for older people and people with dementia (of all ages), as shown by the proliferation of services and experts who can provide musical experiences in residential and community care. Our particular interest, however, has been in bringing knowledge from research and experimental settings into daily practice, developing methods for enabling care staff to make music available in a way that is flexible and responsive to the needs of residents at any time, in a tailored, individualised way, and by anyone (ie, not contingent upon specialist expertise, which immediately curtails flexibility and availability).

HammondCare sees music engagement as part of everyday life and care, not a peripheral, therapeutic or entertainment ‘add-on’. It is really not about the iPods (technology) or even about the music itself: it is all about the personal connection and relationships that develop through music engagement. It is about providing meaningful, engaging, enabling experiences ‘in the moment’ that affirm personhood, dignity and respect of the individual living with dementia.

It is also about facilitating connections between family, friends and carers with the person living with dementia, supporting their relationship through all stages of the dementia experience.

The research literature suggests the potential impact of music engagement is great. For example, we know that a person’s favourite music can be extremely beneficial in reducing agitation (Ashida 2000; Brotons & Pickett-Cooper 1996; Groene 1993; Gardiner 2000). Literature supports that music can be a successful intervention in relieving behaviours such as antisocial physical expression, persistent walking, vocalisations (calling out), teeth-grinding and feelings of stress associated with personal hygiene, bathing (Clark et al 1998; Thomas et al 1997) and mealtimes. Helping people to feel comfortable and receptive to assistance not only improves their quality of life, but also that of carers. Music is especially effective in calming agitation and engendering a more relaxed atmosphere.

However, you can only seriously hope to achieve that degree of efficacy if music is always available at the appropriate time. In order to provide timely relaxation and ameliorate agitation, care staff need to be able to intervene before a responsive behaviour or feeling of stress sets in. The triggers and timing are different for everyone. A visiting music therapist or entertainer simply cannot provide the same level of individual attentiveness and tailored timing as a regular carer.

Music engagement has been integrated effectively into HammondCare’s model of care because it is consistent with our values and mission: listening and relating; enabling choice; tailoring care; nurturing control, belonging, and a sense of ‘home’; partnering with family and friends in relating to people with dementia; nurturing the whole person – especially emotional, connection and spiritual needs; and communicating well.

For a music engagement program to be successfully implemented in residential aged care, music must be thought of as an integral part of caring for an individual and not as an entertainment activity. Organisations must already have a culture of tailoring care to the person, rather than being task orientated, and staff must be given the time to engage with residents. This needs to be part of the organisation’s ethos. Music engagement is chiefly about connecting, rather than communicating, and creating meaningful experiences rather than entertainment.

Personhood and positive expression

While there is great value in music therapy and specialist music programs, we deliberately use the term ‘music engagement’ to reflect the project’s essence as an experience and a vehicle for relating rather than a goal-oriented or curative model.

It is about emphasising personhood – individuality, worth, dignity and respect. Music can foster identity by triggering reminiscence, providing relevant stability and familiarity.

The choice of music on someone’s playlist (based on information provided by the person themselves or friends and family) provides insight into the tastes, era, style and events that have been important in their life, culture and nationality – clues for discovering the individual’s story, celebrating identity and diversity.

Music engagement is just one way of reinforcing and enabling a person’s capabilities and choice, and framing their life experience in a way that promotes and nurtures quality of life. Music is especially valuable during the later stages of dementia because the effect and touch of music reaches people emotionally, and is not contingent on speech or memory. Music appreciation is not affected by deterioration of any specific region of the brain and is not impeded by aphasia, amnesia or disinhibition common in many forms of dementia.

Some of the most profound impacts we have seen involving music are experiences of emotional connection and enlivenment in people with advanced dementia who are isolated, often immobile, and unable to speak, and therefore at risk of extreme isolation and loneliness. They have been emotionally roused by music and able to share moments of joy and feeling. When conversation deteriorates or people no longer recognise friends and family, music can provide a way to connect.

One of my colleagues in the Dementia Behaviour Management Advisory Services (DBMAS) recalls situations in which a person who has been constantly walking and not eating for days has finally been able to relax, sleep and regain energy thanks to the calming effect of listening to music; or instances where it has helped people in a communal cottage setting to interact more comfortably.

The experience of HammondCare resident Sandra* illustrates how music can aid engagement and relaxation:

Sandra, who had seemed reclusive, withdrawn, and did not speak, responded joyfully with upright, open posture and positive facial expressions when she listened to her favourite music. She tapped and hummed and opened her eyes. At the end of the song, she responded to my question, showing that she could both understand and speak, and that the music had stimulated her both cognitively and emotionally. Later on, Sandra was reluctant to open her mouth for a dental appointment. After listening to music, she became calm and participated willingly in the appointment. It is not uncommon for people with dementia to receive general anaesthetic for routine dental and medical procedures, with the associated risks and adverse effects that can accelerate cognitive deterioration. Music was a simple, painless and cost-free intervention that helped Sandra avoid the potentially exacerbating effects of general anaesthetic.

Another group of people who can easily be isolated in dementia care are those from diverse language and cultural backgrounds. Music can help staff and the person with dementia to connect in the absence of a shared language, restoring a feeling of belonging and meaning to people who are far from their home country, culture and communities, and allowing people to share emotions and joy irrespective of their background.

Ideh*, an Iranian lady, came into one of our care homes after a stroke. Care staff could not speak her language, Farsi, with her, however they experience emotions together and relate via her traditional Persian music. Her son told us that Ideh’s speech had been muddled and difficult to understand after the stroke, but her sentences and meaning became clearer after listening to music. He attributed this to the reinforcement of vocabulary and traditional language structures that she heard in her familiar songs.

Another group of people who can easily be isolated in dementia care are those from diverse language and cultural backgrounds. Music can help staff and the person with dementia to connect in the absence of a shared language, restoring a feeling of belonging and meaning to people who are far from their home country, culture and communities, and allowing people to share emotions and joy irrespective of their background.

Ideh*, an Iranian lady, came into one of our care homes after a stroke. Care staff could not speak her language, Farsi, with her, however they experience emotions together and relate via her traditional Persian music. Her son told us that Ideh’s speech had been muddled and difficult to understand after the stroke, but her sentences and meaning became clearer after listening to music. He attributed this to the reinforcement of vocabulary and traditional language structures that she heard in her familiar songs.

Sustainable implementation

From our 18-month program in residential care we have been learning how to implement a sustainable model of music engagement incorporating staff training, providing equipment and tailored music resources for a large number of staff and residents, maintaining engagement and educating staff about observing and remaining attentive to listeners’ responses.

Our learning has ranged from the routine – for example, iPod packaging, storage, charging and hygiene – to the ideological, such as how to integrate the music engagement program into the organisation’s existing model of care, staff ethos, documentation and evaluation processes.

We also have identified synergies between music and movement, use of outdoor spaces in the residences, improved mealtimes and the volunteer program. For example, music has been shown to reduce mealtime agitation. It also has the potential to improve the dining experience, food appreciation, and to enhance flavour (McHugh et al 2012). With HammondCare’s executive chef and food ambassador, Peter Morgan-Jones, we are developing research investigating and substantiating this interaction between music and food, especially in an older population, as most research to date focuses on the effect of music and sound in fine dining settings.

Just as Peter has devoted great attention to the aesthetics of texture, colour, aroma and presentation of food to enhance the quality and pleasure of the dining experience in aged care, music is an additional element that can flavour and intensify food appreciation for people living with dementia. As British chef Heston Blumenthal says: “Sound is one of the ingredients that the chef has at his/her disposal” (Spence et al 2011).

We are also looking at ways of translating and applying the findings of clinical research studies on the role of music in alleviating pain, reducing the need for antidepressant and antipsychotic medications, facilitating movement, balance and confidence to reduce falls (Gerdner 2010; Gill 2013), and providing a quality listening environment for residents.

Research studies identifying improvements to pain management; reduction in medication use, falls, agitation and anxiety; and cognitive and speech stimulation as a result of music engagement are invaluable for pioneering new ideas, but may not be readily available to care staff. We see our focus as refining how these research outcomes can be implemented in best care practice.

We are currently fine-tuning tools for assessing residents’ engagement, quality of life and emotional responses that can be used by care staff without the need to rely on costly and sporadic visits by expert consultants. We are using a combination of an adapted form of ERiC (Emotional Responses in Care) assessment (Fleming 2005); the MiDAS (Music in Dementia Assessment Scales) (McDermott et al 2014) and qualitative longitudinal case studies.

Music and pain management

In 2016, the program will branch out to include music engagement in palliative care (in collaboration with Professor Rod MacLeod) and pain management specifically for people with dementia (in collaboration with Professor Philip Siddall). Music can assist in reducing pain, and not merely by acting as a diversion. Personally relevant rousing music can also stimulate the release of dopamine in the brain, which reduces pain perception (Bradshaw et al 2012; Salimpoor et al 2011).

Providing high-quality pain management for people with dementia is notoriously challenging, not only because identifying and expressing pain can be difficult for people with dementia, but also because conventional medications can worsen confusion and traditional cognitive strategies such as Cognitive Behaviour Therapy (CBT), meditation and relaxation techniques are not helpful. Yet, unmet needs, including inadequately treated pain, underpin many behaviours that are effectively expressions or communication that something is wrong. Furthermore, music engagement to reduce pain is an inexpensive option without side effects or pharmacological interactions.

Sharing our experiences

HammondCare’s Dementia Centre is now providing music engagement training for residential care staff, visiting delegations of aged care providers from Singapore and Japan, and public workshops. In addition, Music Engagement in Dementia Care training will be available from 2016 as an online course through The Dementia Centre’s Hammond College (https://www.hammond.com.au/our-expertise/dementia-centre/dementia-education).

In 2016, music engagement will also be a theme of HammondCare’s International Dementia Conference, Grand Designs: “Are we there yet?” on 16-17 June (www.dementiaconference.com), where we will be presenting findings from our program evaluation.

We will also be launching a book at the conference about music engagement in dementia care suitable for anyone in a caring role (family and community carers, volunteers and professional care staff). It will provide information, implementation guidelines and individual stories from our experiences in developing the program.

Conclusion

The mental, spiritual, physiological and neurological benefits of music engagement are evident in medical, psychology, gerontology and music therapy research literature. We hope that HammondCare’s contribution will be of practical benefit to other aged care organisations and carers in the community seeking to implement music engagement in a workable, scalable and adaptable way.

It is essential to deliver lifestyle improvements well, not merely as a gesture, or a ‘nod’ to the latest transient ‘fad’. People can easily confuse music engagement with the technology that delivers it. However, without a cultural paradigm shift, music engagement cannot be sustainable.

Dr Kirsty Beilharz is the Director of Music Engagement at the Dementia Centre, HammondCare. Kirsty is a composer, performer, and former Professor of Music and Interaction Design (University of Sydney, and UTS). She is also a Visiting Fellow (Music) in the School of Health in Social Science, University of Edinburgh. To follow up on this article, please email kbeilharz@hammond.com.au.

Acknowledgment

HammondCare Music Engagement is generously supported by the Thomas Foundation, the Philip Bushell Foundation, Michael and Sarah Lawrence, Chris and Adrian McComb, the Aged Person’s Welfare Foundation, Dalwood-Wylie Foundation, and John and Karen Kightley.

* Pseudonyms have been used to protect the privacy of residents.