The Effects of a Single Session of Music Therapy on the Agitated Behaviors of Patients Receiving Hospice Care

Abstract

Background:

Research suggests that agitation is a common symptom for hospice patients, but while studies have examined the outcomes of music therapy on the agitated behaviors of patients in other settings, none have addressed this symptom in patients with terminal illnesses.

Objective:

The study objective was to determine whether a single session of music therapy provided by a board certified music therapist and using the entrainment principle would decrease agitation in hospice patients.

Design:

This pilot study was a single-blind, pretest/posttest design. Music therapists used the principle of entrainment with live music during the treatment session.

Setting/subjects:

Subjects included in the study were 77 patients at a large hospice in south Florida with documented agitation.

Measurements:

Agitation was measured using the Overt Agitation Severity Scale (OASS) for 5 minutes prior to and 5 minutes following a 20 minute music therapy intervention.

Results:

Results from 73 participants were analyzed with a mean difference of −5.77 points from pretest to posttest. Results indicating a decrease in agitation were statistically significant (p < 0.001) for the entire sample. Age, gender, location, and diagnosis were found to have no significant effects on the results.

Conclusions:

Results indicate that a single session of music therapy using the entrainment principle may be an effective treatment for hospice patients experiencing agitation.

Introduction

Agitation is a common symptom for patients nearing the end of life. Although the prevalence of agitation among hospice patients has not been exactly defined, some studies indicate that up to 50% of hospice patients may experience agitation.^1,2 The use of music therapy in hospice and palliative care for enhanced physical and psychosocial outcomes has been well documented;^3–6 however, no studies have specifically examined the use of music therapy in the treatment of hospice patients' agitation.

Studies of related populations found that the use of active music making interventions resulted in a decrease in agitation for participants with dementia or Alzheimer's Disease.^7–16 Studies examining the effect of passive music listening on agitated behaviors of patients with dementia found a decrease in agitated behaviors particularly during bathing and meal time.^17–21 Some of these studies used recorded music provided by other health care disciplines; however, live music provided by music therapists has been found more effective than recorded music for reducing the pain perception of hospice patients²² and reducing anxiety of hospitalized cancer patients.²³

One live music intervention commonly used by music therapists is based on the principle of entrainment, which is defined in the Gale Encyclopedia of Medicine as “the patterning of body processes and movements to the rhythm of music.”²⁴ Entrainment with music has been studied to treat pain^25–27 and respiratory distress^28–30 but has not been studied to address agitation. The aim of this pilot study was to quantify the effects of music therapy treatment using entrainment on agitation experienced by hospice patients.

Methods

Research participants and ethics

Participants for study were selected from the patient census of a large hospice in south Florida. Participants were referred for music therapy, had agitation documented in the medical record by the interdisciplinary care team, and were receiving standard treatment for agitation. Patients under 18 or those with hearing loss too severe to allow them to hear the music were excluded. This study was a quality improvement initiative for the hospice. Therefore additional consents beyond those obtained for hospice services at the time of admission—which cover the provision of music therapy—were not collected; nor did the hospice's administration believe additional institutional review board oversight was necessary. The study procedure did not deviate from standard music therapy services, and data were presented in aggregate form.

Measurement tool

The researchers used the Overt Agitation Severity Scale (OASS)³¹ created by Yudofsky, Kopecky, Kunik, Silver, and Endicott to assess agitation. The OASS is a 16-item test that measures observable behaviors of agitation. The researchers used the OASS as a pretest and posttest. The original OASS stipulated a 15 minute observation period; however, the observation time was reduced to 5 minutes so that the procedure would not differ noticeably from normal music therapy treatment.

Procedure

Nine board-certified music therapists provided the music therapy sessions and collected data. Before beginning data collection, the music therapists practiced using the OASS to increase inter-rater reliability. The music therapist observed the participant for 5 minutes and collected pretest data using the OASS. Treatment consisted of selecting a standardized song list that best fit the participant's musical preference (see Table 1). The music on each list was arranged so that faster, more musically complex songs were first on the list, and each progressive song was intended to be slower in tempo and less complex to aid in facilitation of the entrainment principle. Each list consisted of approximately 20 minutes of music, which was provided by the therapist using acoustic guitar and voice. The music therapist matched the rhythm and tempo of the music to the participant's breathing or movements and then gradually slowed the tempo of the music over the session. After the intervention, the participant was observed for 5 minutes, and posttest data were recorded using the OASS.

Table 1.

Music Therapy Intervention Song Lists ^a

Christian	Jewish
In the Garden C. Austin Miles Amazing Grace John Newton	Bei Mir Bist du Schon Jacob Jacobs & Sholom Secunda
How Great Thou Art Stuart K. Hine	Hatikvah traditional
Peace Like a River traditional	Me Shaberach Mi Shebeirach traditional
Michael Row the Boat Ashore traditional	Sabbath Prayer Jerry Bock & Sheldon Harnick
	Shabot Shalom traditional
1930s–1950s standards	Americana/folk
Fly Me to the Moon Bart Howard	500 Miles traditional
Sentimental Journey Les Brown & Ben Homer	Beautiful Dreamer Stephen Foster
Over the Rainbow Howard Arlen	Shenandoah traditional
Blue Skies Irving Berlin	Water Is Wide traditional
Summertime George Gershwin	All Through the Night traditional
1960s–1990s popular	Spanish
Sweet Baby James James Taylor	Cielito Lindo Quirino Mendoza y Cortés
Peaceful Easy Feeling The Eagles	Eres Tu Juan Carlos Calderón
Let It Be John Lennon & Paul McCartney	Solamente Una Vez Agustín Lara
When You Say Nothing at All Paul Overstreet & John Schlitz	Amapola Joseph LaCalle
Sunshine on My Shoulders John Denver	Paz Como un Rio traditional

One standardized song list was chosen based on the participant's preference to be performed during the music therapy intervention.

Data analysis

A power analysis conducted using G*Power 3.1.7 (Franz Faul, Universität Kiel, Germany) indicated a minimum of 45 participants were needed to elicit an effect size of d = 0.5 with an alpha of 0.05 and 95% confidence. Data analysis was performed using statistical software SAS (SAS version 9.3, SAS Institute, Inc., Cary, NC). Descriptive statistics were used to summarize demographic information and results of the OASS assessments. The null hypothesis was adopted, and the alpha level was set to 0.05. A paired sample t-test was used to detect differences between pretest and posttest OASS scores. Additional analysis using factorial analysis of variance was performed to detect differences in the effectiveness of the music therapy intervention based on age, gender, diagnosis, and location. Effect size (Cohen's d) was calculated using the mean difference between pretest and posttest scores and the standard deviation of the difference scores.

Results

Data were collected on 77 participants and results were analyzed for 73 participants. Data from 4 participants was excluded because of significant interruptions, including medication administration, during the session. Participants' ages ranged from 46–100, with a mean age of 83.6 (SD = 11.3). Demographics of participants are summarized in Table 2.

Table 2.

Demographics of Study Participants ^a

Gender		Diagnosis
Male	23	Dementia	25
Female	50	Cancer	13
Age		Cardiopulmonary	6
<60	5	Adult failure to thrive	15
61–70	4	Neurological	2
71–80	13	CVA	4
81–90	34	Other	8
91–100	17	Song list used
Race		’30s–’50s standards	41
Black	5	’60s–’90s popular	4
Caucasian	66	Christian	15
Hispanic	2	Jewish	2
Asian	0	Americana/folk	4
Location		Spanish	2
Home	5	List not used	5
Assisted living	11
Skilled nursing	23
Inpatient unit	34

n = 73.

CVA, cerebrovascular accident.

Fifty-two participants experienced a decrease in agitation, 15 participants experienced no change in agitation, and 6 participants experienced an increase in agitation following the music therapy intervention. The mean OASS pretest score was 12.34 (SD = 12.30; Med = 10; CI₉₅ = 9.47–15.21); and the mean OASS posttest score was 6.58 (SD = 8.23; Med = 3; CI₉₅ = 4.65–8.49), indicating a 5.77-point decrease from pretest to posttest.

The null hypothesis was rejected, with a statistically significant difference between pretest and posttest scores on the OASS—t(72) = 7.34, p < 0.0001, d = 0.74. The effect size (d = 0.74) was found to exceed Cohen's³² convention for a medium effect (d = 0.50) but fell slightly short of a large effect (d = 0.80).

Results of the factorial ANOVA are presented in Table 3. No statistically significant differences in main effects or interactions were found based on age, gender, diagnosis, or location.

Table 3.

Results of Factorial ANOVA: Effectiveness of MT Intervention Based on Participant Variables ^a

Source	DF	Type III SS	Mean square	F value	Pr > F
Diagnosis	4	0.68775975	0.17193994	0.36	0.8319
Gender	1	0.05231748	0.05231748	0.11	0.7412
Diagnosis ^* Gender	2	0.47457501	0.23728750	0.50	0.6092
Age	1	0.44893955	0.44893955	0.95	0.3365
Age ^* Diagnosis	4	0.76067118	0.19016780	0.40	0.8048
Age ^* Gender	1	0.08359753	0.08359753	0.18	0.6765
Age ^* Diagnosis ^* Gender	2	0.93377557	0.46688779	0.99	0.3826
Location	3	0.16322267	0.05440756	0.12	0.9504
Diagnosis ^* Location	4	0.89343942	0.22335986	0.47	0.7546
Age ^* Location	3	0.17665077	0.05888359	0.12	0.9447
Age ^* Diagnosis ^* Location	4	0.80675614	0.20168903	0.43	0.7874

Results indicate no significant differences in the effectiveness of the MT intervention based on participants' age, gender, diagnosis, or location at the time of treatment.

ANOVA, analysis of variance; DF, degrees of freedom; MT, music therapy; Pr, probability; SS, sum of squares.

Discussion

The results of this study indicate that one music therapy session of live music using entrainment is effective in decreasing agitated behaviors. These findings are both statistically and clinically significant. Seventy-one percent of participants experienced a decrease in agitation, a noteworthy finding given how difficult agitation can be to treat in hospice patients. Agitation decreased by an average of 47% and a medium effect size was detected.

One of the most clinically pertinent findings is that music therapy appears to be beneficial for adult patients with agitation regardless of age, gender, diagnosis, and location. A positive implication of this research is that hospice clinicians may have another modality to turn to when traditional treatment is not completely effective at reducing agitation. Music therapy is a noninvasive therapy that can be used to complement the services and treatments provided by the other members of the interdisciplinary team to reduce agitation.

This research may also help address the notion some have that using music to alleviate symptoms of agitation is counterintuitive. It is often thought that to reduce agitation one must eliminate extraneous sensory stimulation from the environment, including sound. However, music, when used appropriately, appears to have a positive effect and may even serve to mask the noise common in a hospital or long-term care facility.

While the results of this study are favorable, there were some limitations. Practical considerations prevented the researchers from being able to include a control group, have third-party observers perform the OASS assessments, or track medications.

Though no studies have examined music therapy to treat agitation in hospice patients, the results of this study are consistent with studies that have examined music therapy for agitation in patients with dementia. The inclusion of a control group in a larger randomized clinical trial is recommended in order to further support the conclusions of this pilot study. Future studies could examine the cost-benefit of music therapy in the hospice setting, whether medications alter the effect of music therapy, the long-term effects of music therapy on agitation in the hours after treatment, or whether more than one session of music therapy can be more effective on agitation. The results of this study may serve to inform future patient care and increase the use of music therapy to treat agitation in hospice patients.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

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