Music and other strategies in the care of agitated individuals with dementia. A nursing perspective

Abstract: Agitation is an overarching term commonly used to describe the behaviour of elderly restless patients with dementia. The concept includes behaviour such as tension, aggression, aimless wandering, pacing, cursing, screaming, and fighting. The overall purpose of this study was to expand nursing knowledge of how to improve the psycho -social environment for agitated patients with dementia. The aims of these studies were to study, from a nursing perspective, probable reasons for expressed agitation in patients with dementia, to elucidate how integration of cognitively intact and agitated cognitively impaired patients effects perceived quality of care, to explain agitation from the nursing staff's point of view, and to investigate how dinner music and individualised music and other strategies can be used to manage agitation in these patients. The findings were applied to the progressive lowered stress threshold (PLST) model. The model suggests that anxious behaviour occurs when an individual with dementia feels stress. When the perceived stress exceeds the individual stress threshold agitation occurs. Data were collected using systematic observations of video recordings, weighing of helpings, questionnaires, interviews and rating scales. The most probable reasons for expressed agitation were need for assistance related to discomfort, a wish to meet a need immediately, reactions to environmental noise, conflicts between a patient and other individuals, and invasion of personal space. Nursing staff from hospital wards, nursing home wards, and residential homes identified integration of lucid residents and cognitively impaired agitated residents as a specific problem. Many lucid residents become annoyed at or fearful of the behaviours exhibited by cognitively impaired patients. This in turn could lead to an exacerbation of a behaviour in the residents who were already agitated. Many of the staff on two nursing home wards reported agitated patients' behaviour imposed mental strain on them. Experienced nurses suggested music, a slow pace, establishment of close contact with the patients, and avoidance of uncontrolled sounds as strategies to manage agitation in patients with dementia. During the dinner music periods, the patients ate more and became less irritated, anxious, and depressed compared to a control period. The staff members were probably also influenced by the music, as they served larger helpings when music was played. Five agitated patients were further analysed by video observations. Four of those patients spent more time over dinner when music was played. Two of them became unusually calm when dinner music was played. In an individualised case study, the music seemed to affect all four patients. Two patients became distinctly calmer during some of the music sessions. For the two other patients the noticeable effect of the music was minimal. Agitation can be seen as a stress-related form of communication related to dementia patients' diminished power to communicate. Integration of cognitively impaired person with agitated behaviours with lucid residents should, if possible, be avoided. A calm atmosphere with a slow pace on the ward is an important way to reduce the stress level on a care unit. Prerecorded music can affect individuals who suffer from dementia and can therefore be used to soothe agitated patients. Dinner music, particularly soothing music, can reduce agitation in patients with dementia. Playing prerecorded music is a simple means to alter the psychosocial environment in a care unit. If the nursing staff succeed in finding the individual's music preferences, individualised music may be a good nursing intervention to mitigate anxiety and agitation for some patients.

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