Larisa McHugh, MA, MT-BC is Music Therapist and Internship Director at Bethany Village, a continuing care retirement community in Dayton, Ohio. In this AMTA.Pro symposium, she describes effective music therapy interventions and methods for fostering meaningful relationships with individuals diagnosed with Alzheimer’s disease or dementia living in memory supported care. She also shares some compelling stories highlighting the impact of music therapy on the quality of life of her friends in the Memory Support Center.

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Music Therapy in the Care of
Persons with Alzheimer’s Disease and Related Dementias

Larisa McHugh, MA, MT-BC

June, 2009
AMTA.Pro Symposium Script

Hello and welcome to AMTA.Pro, an on-line symposium for members of the American Music Therapy Association. My name is Larisa McHugh. I am a Board-Certified Music Therapist, a Certified Eden Associate, and an Advanced Trainee in the Bonny Method of Guided Imagery and Music. I work at Bethany Village, a division of Graceworks Lutheran Services, in Dayton, Ohio. My role at Bethany Village is to implement individual and group music therapy throughout the campus. I also serve as the Music Therapy Internship Director at Bethany Village.

I. Agency Description

Bethany Village is a nationally accredited continuing care community. The community includes 150 cottages for independent seniors, 230 apartments and suites, 30 villas, 60 rooms for assisted living, and 250 rooms devoted to providing multiple levels of nursing care, including Chronic Care Services, Sub-Acute Care, and Memory Support Services for individuals living with Alzheimer’s disease and related dementias.

The cornerstone of services at Bethany Village is an interdisciplinary approach to managing resident care. Treatment services include nursing services, rehabilitation services provided by physical therapists, occupational therapists, and speech therapists, social services, exercise physiology, and life enrichment services including pastoral services, nutritional services, and music therapy, an integrative therapy.

II. Music Therapy’s Role in the Agency Mission

The mission of Bethany Village is to help people experience dignity and wholeness in relationship with God, family, and community. We support and enhance that mission through the music therapy program, addressing dignity and wholeness as we work with individuals and their families. We encourage community development through group music therapy sessions, and we honor each person, helping enrich their lives and tell their stories through music. At Bethany Village, music therapy is considered an integrative therapy which addresses wholeness as it encompasses all aspects of a person – physical, cognitive, social, emotional, and spiritual.

III. Music Therapy Across Levels of Care

Music therapy is provided in all of the long-term care units and assisted living units each week. Although the schedule is challenging, those weekly contacts allow us to enrich lives through music and give the music therapy interns and I opportunities to establish and maintain long-term personal relationships. As the needs of the residents change, they may require a new level of care. Those established relationships can help decrease the trauma of moving. Recently a resident moved from a long-term care unit to the new Memory Support Center.  The resident was distraught because her room and the staff were unfamiliar. When I approached the resident to invite her to a music therapy group, she immediately replied “Hey, I know you!” She took my hand and walked with me to the group where I introduced her to the other group members and watched as friendships formed.

IV. Music Therapy in a Memory Support Center

A. Description of Center. The new Memory Support Center at Bethany Village is designed to enhance the quality of life of residents who have dementia or Alzheimer’s disease. The center is divided into four households with fourteen residents living in each. The first floor is dedicated to the care of persons in the early to mid-stages of dementia, while the second floor provides for those in advanced stages of the disease. The household design allows us to offer music therapy in small groups in comfortable, familiar places – the recreation room, living room, family room, or the Center’s relaxation room, an environment with little distraction where lights can be dimmed. We can also provide one-on-one music therapy in a resident’s room.

B. Challenges of Alzheimer’s disease and dementia. Residents diagnosed with a degenerative dementia in the early to mid-stages of the disease process may exhibit some deficit in memory of their personal history, display flattening affect, and may no longer be able to perform complex tasks. The residents may be disorientated to time or to place while retaining knowledge of major facts about themselves and others. Residents in the later stages of dementia usually retain some knowledge of their past and are sometimes able to recognize family and other familiar persons in their environment. They may experience changes in personality, mood, and eating and sleeping patterns. Eventually, as the disease progresses, verbal abilities and psychomotor skills diminish.  Music therapy is planned to meet the unique needs of each individual, and adaptations are made when necessary as the disease progresses.

C. Referrals to music therapy. Referrals are accepted from any member of the interdisciplinary team.  Guidelines on the music therapy referral forms assist the team in identifying needs and strengths that may be addressed through music therapy. The team might refer a person for music therapy for one or more of the following reasons: sleep disturbance, spiritual isolation, social isolation, speech barrier, difficulty coping with placement or illness, restlessness, signs of anxiousness or agitation, difficulty managing pain, excessive sadness, or a musical interest or skill that may assist in rehabilitation.

V. Music Therapy Interventions

A. Focus of music therapy. Music therapy is designed to provide structure, to trigger short and long term memory, to encourage reminiscing, to help maintain physical, verbal, and social skills, to provide sensory stimulation, to promote relaxation, and to meet religious needs of residents in the Memory Support Center.

B. Group music therapy. Depending on the needs of the residents, the pre-determined plan for a music therapy group may be altered or even abandoned. We load our music cart with various rhythm instruments, Orff instruments, a keyboard, and a guitar in order to be prepared for any circumstances we encounter. Each group or individual session starts with a song to welcome the participants to music and to capture their attention. If we haven’t already done so, we then check in with each individual, acknowledging their presence and giving them a chance to make a comment to the group. At the close of each session, we express appreciation to each individual for all they contributed on that day. We remind them when we will return, then end with a song. What happens in between the opening song and the closing song is dependent on the goals of the session and the needs of the residents at that particular moment in time. We recognize our residents are all unique individuals with different backgrounds, different strengths, and different needs. In an effort to reach everyone we utilize a variety of methods and interventions that fall into one of four categories: creative music, re-creative music, improvisation, and receptive music.

C. Creative Music. Song-writing promotes emotional gratification, allows for creative expression, and gives residents an opportunity to work together as they create something new. Possibilities for song-writing activities are endless. For example, a group of residents or one individual can “compose” an original song by writing the lyrics, selecting an existing melody or composing a new one, and working out the accompaniment.  Familiar tunes provide a more predictable structure, allowing residents to focus on rewriting the lyrics to tell a bit of their own stories or dreams. One group used the twelve bar blues as the basis of a parody on the mushy vegetables they ate at lunch. The exercise allowed them to express their frustration and feelings about the loss of ability to cook for themselves.

D.  Re-creative music. Music often helps to trigger memories of the past and helps us to tell our stories. The medial prefrontal cortex, one of the last sections of the brain affected by Alzheimer’s disease, is stimulated by familiar songs. Thus, re-creating music can promote reminiscing and memory recall or validate emotions being expressed during discussions. (Cuddy & Duffin, 2005).

Re-creating music might involve singing favorite songs, as a group or an individual solo. We also use tone chimes to re-create tunes. We might help residents to play the melody of their favorite song or a simple accompaniment pattern. Playing instruments impacts motor skills while at the same time capturing attention and encouraging concentration on the task. Over the years, I have been surprised how many residents pick out tunes on the xylophones, then begin talking about learning instruments during their youth.

We take the time to discover the resident’s preferred music, either by asking the individual or family members. Families can sometimes shed light on a person’s favorite radio stations and performers over the years, instruments they played, and their participation in choirs, bands, or other musical groups. Familiar music can provide a sense of security, and it may be the key to opening a new door.  For example, several years ago, a new resident came from the community to live in the Memory Support Center at Bethany Village. She was not very happy to be in a new place with new neighbors.  She was angry with her family for bringing her here, and she was angry that she could not remember how to get home. Anyone entering the unit could hear her yelling at the staff as they gently encouraged her to come out of her room. She declined every invitation to join music therapy groups. She spent most of each day sitting in a corner of her room with her arms folded and a scowl on her face. Eventually she loosened up a bit and came to the solarium when the music therapy group was gathering. She adopted her usual habit of sitting in a corner with her arms folded and a scowl on her face. As I was leaving the group one day, she stopped me and said, “Thank you.” Needless to say I was surprised. When I asked about her expressing appreciation, she replied, “When you are here, I remember.”

E. Improvisation. I am always amazed at the music that emerges when the residents in the Memory Support Center are introduced to new instruments. Most immediately begin exploring the instrument, improvising freely and with confidence. It is as if the words they cannot find to express themselves are suddenly found through the voice of an instrument.  Supporting and encouraging this organic improvisation encourages non-verbal communication (Bruscia, 1998) and increases self-esteem through successful participation in a music experience.

Group improvisation promotes peer interaction and can improve a person’s awareness and sensitivity to others (Bruscia, 1998). When designed appropriately, people can play without fear of making a mistake, and everyone finds a voice, contributing to the group conversation. I make every effort to be sensitive to the individual needs and preferences of group members, making a change if anyone is over-stimulated by the volume or pitch of the instruments being used. In an effort to make certain every voice is heard, I might highlight individuals and encourage solos, or I might stop the music and ask the group members to turn their attention to a specific individual as they play or sing a short segment. When appropriate, I ask the group to name their song. Interestingly, participants often select a title that captures the mood of the music or of the group that day.

F. Receptive music. We use music to encourage physical activity in music therapy groups. The rhythm of the music provides the structure for physical exercises or dance. The music, whether recorded or live, provides cues and predictable patterns to change movement. The music also helps to stimulate and engage the residents, making exercise a little more enjoyable.

Residents who are not able to get up and dance can participate in movement activities from a seated position.  At times we use soft, soothing recorded music for gentle stretching and slow movement. Other times we may march to a Sousa favorite while sitting in our chairs. We provide verbal and physical cues as needed. Live music has an advantage over recorded music because you can adapt the volume or tempo when necessary, and you can capture attention by singing verbal cues or inserting individual names in the lyrics. Last week I was singing and demonstrating with such enthusiasm that one of the residents was inspired to give some sage advice. The lady, a person who rarely speaks, looked up and said, “Shake it, but don’t break it, Honey!” Such wisdom!

Live and recorded music also help facilitate relaxation. I have discovered that the music for relaxation should not be too complex, and that it should be predictable and familiar to the group participants. I rely on the music to set a rhythmic structure for breathing. Predictable rhythms, patterns, and lyrics to increase focus and decrease internal dialogue. Again, it is important to be sensitive to the individuals in the group so they are not over-stimulated or surprised by any sudden changes in the music. Music-assisted relaxation can include scripts for simple imagery experiences, instructions for progressive muscle relaxation, or focus on the music itself.  Please note that as the muscles and the mind begin to relax, a person’s defenses also relax, sometimes causing an emotional response. I believe that accepting and supporting any response fosters closer relationships between group members and between the therapist and residents.

VI. Addressing Individual Needs

A. Transition to Memory Support Center. In spite of our best efforts, transition into the Memory Support Center can be a difficult process for the resident and for family members. When Mr. M moved from his home to the Center, he needed assistance with most activities of daily living and he rarely spoke.  His wife had tears in her eyes as they unpacked his belongings. I happened to walk by on my way to set up for group, so I invited them both to attend.  He willingly followed me to the group, but I noticed he shuffled his steps the entire way.  When his wife joined us after a bit, I asked if she could help identify any favorite tunes.  She replied, “I don’t know… anything from the 1930’s or so.” As I started singing “I Don’t Know Why (I Just Do),” Mr. M stood up, walked over to his wife, took her by the hand, and danced in the middle of the group. His steps were so smooth and he held her so gently in his arms. It looked like they were floating on a dance floor. As you can imagine, there wasn’t a dry eye by the end of the song. Mrs. M told us they went out dancing every Saturday night years ago. She said, “He hasn’t held me like that in ages!”

B. Sleep issues. At times, people with dementia may experience a disturbance in sleeping pattern. It is challenging to come up with an effective strategy to impact sleep since the music therapy interns and I are not usually around when the residents are sleeping. To address this need during the day, we use live music and techniques for relaxation techniques of deep breathing and gentle stretching in a one-on-one session. We use the same music and the same exercises every day so the process becomes familiar. Then we record the music and burn a CD for playing each night when doing relaxation exercises before going to bed.

The same intervention has been quite effective when addressing pain issues. We must be sensitive to the needs of the resident at that particular moment, and we must be careful not to over-stimulate the individual. We select music that matches the rhythm of a relaxed breathing pattern. A single voice singing with no accompaniment or instrumental music with no lyrics often works well for relaxation, sleep issues, and pain management.

C. Issues related to advancing dementia and Alzheimer’s disease. As dementia progresses and robs people of their ability to speak, it is important to have as much background information as possible and know their histories so that we can remind our residents of their stories. In doing so, we are able to connect with them personally and create a sense of the familiar, increasing their feeling of safety and belonging. I have had the privilege of working with some of our residents for several years, allowing me to know them personally and become an integral part of their life. Each person is special to me. From the professional perspective, knowing a person’s history also helps to determine what interventions might be most effective. For example, Ms. O loves the jazz standards and was quite a dancer in her formative years. While she has lost the ability to speak and to dance, she has not lost her love of the music. One day, in the middle of an improvisatory rhythm experience, I learned that her dance and her words had transformed into a something new – vocal improvisation. To our surprise, she can scat! The rest of the group and the staff now encourage her to continue expressing herself creatively whenever the opportunity arises. Her peers applaud her creative scat singing, and one commented on her friend “finding her voice.”

A resident I’ve known since I started working at Bethany as an intern was living in one of the assisted living units and was very active in campus life. She is now living in the Memory Support Center, and her life is impacted by late stage dementia. She is unable to speak, and relies on others for assistance with her activities of daily living. I use music to connect with her and to remind her that I know her. I sing Daisy Bell – a song also known as A Bicycle Built for Two – because I remember her telling me that her mother’s name was Daisy. The song also reminds both of us of her telling the hilarious story of learning to ride a bike. Because she had to borrow her brother’s bike, that silly bar in the middle made it hard to get on the bike. Finally she came up with the idea of leaning his bike up against a fence and climbing the fence to reach the seat. When I asked how she got off the bike, she replied, “Soft grass!”  Music allows us to reminisce about all those delightful stories from her past she told me over the years. She is not able to speak or to tell me the stories are still important to her today. When I sing and talk about the stories, her eyes widen and she smiles while reaching out her hand to hold mine.

D. Personal connection and interaction. Most of the residents on the Memory Support Center cannot remember my name, but what is important is that they remember who they are and that they feel as if they know me. One of the residents consistently introduces me as one of her best friends from high school. She is fifty years my senior, so we were not classmates. But we have made that connection through the music from her high school days. She knows me, and we have a meaningful relationship that has been established through that music.

I had another reminder of the importance of musical connections one day when Mrs. A suddenly sat down on the piano bench right next to me and opened a hymnal. As she leafed through the pages, I wondered what she was thinking and what she might be looking for. She held the book up a little closer, analyzing the page in front of her.  Then she placed the book on the piano and said, “Let’s try this one.” I played as requested, then waited as she selected another piece. This routine continued for some time. She closed her eyes and swayed to the music as I played, then she gave me a little pat on the leg before selecting the next hymn. I was so thankful for sight-reading skills! It seemed like she was finding the music she needed, and I was committed to providing it. I knew that music was important to her; she was a former piano teacher and church organist. Mrs. A’s husband was a pastor and I was certain that these hymns were a big part of their life together.  He lived on the unit, too, and he sat on the couch watching her as this all took place. During the last hymn she closed her eyes and bowed her head as if she was deep in thought or in prayer. As I played the last chord she patted me on the leg once again and said “Very nice, my dear. You can pay me next week.” It dawned on me that she was capturing her piano teaching days, so I thanked her for the lesson. As I helped her to the couch, Mrs. A winked at her husband and said, “She’s learning.” What wonderful teachers we have around us. If we are fully present and patient as moments unfold, if we ask them to tell us more and respond genuinely, residents will share their stories and make meaningful personal connections.

Conclusion

The music therapy program at Bethany Village evolves as we welcome new residents, as we work with new staff members and new interns, and as we learn more about our selves and our residents. The familiarity of the music and the music therapy experience, the predictability and structure that are inherent in the music, and the memories and associations tied to the music all lead to successful experiences for our residents. Our role is to be prepared for the unexpected, to take time to connect, and to accept each person, honoring them and recognizing their contributions to the community. Each music therapy session invites the resident to enter into a creative process, one in which they are free to express themselves, to be recognized and respected, and to connect with others. It is my hope that each moment of music therapy brings a feeling of fulfillment and contentment to each participant.

Thank you for participating in this AMTA.Pro discussion. Again, my name is Larisa McHugh. You can contact me at 6451 Far Hills Avenue, Dayton, Ohio 45459, by calling 937-433-2110 ext. 6274, or via email at [email protected]. Please feel free to comment on any aspect of this AMTA.Pro Symposium – just type your thoughts and ideas and questions in the Comments box below. We welcome your feedback. It is only through sharing that we learn and grow. Be well.

I’d like to thank the residents of Bethany Village for sharing their stories and for the constant inspiration to do the good work! A big thank you to Cathy Knoll for all the guidance she provided in development of this podcast.

References

Bruscia, K. (1998). Defining music therapy. Gilsum, NH: Barcelona Publishers

Cuddy, L. & Duffin, J. (2005). Music, memory and Alzheimer’s disease: is music recognition spared in dementia, and how can it be assessed? Medical Hypotheses, 64, 229-235.

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Bruscia, K. (1998). Defining music therapy. Gilsum, NH: Barcelona Publishers

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