As a geriatrician, a friend and colleague of Music and Memory founder Dan Cohen, and an alumnus of the Alive Inside documentary on the subject, I can enthusiastically attest to the value of personalized music in improving the well-being of people living with dementia in all environments. There are countless examples, not only of improved engagement, but also improvements in memory and communication during and after the use of such music, and I have seen it myself many times.
The largest study of this approach, conducted by researchers at Brown University was just published in the American Journal of Geriatric Psychiatry (http://www.ajgponline.org/article/S1064-7481(17)30285-3/pdf). In this 6-month study, comparing the residents of nearly 100 US nursing homes that had instituted the M&M approach, compared with a similar sample of homes that had not done so, some positive results were seen.
The homes that participated in M&M showed a greater discontinuation rate of antipsychotics (increasing from a discontinuation rate if 17.6% to 20.1% during the study) than the control homes (15.9% to 15.2%). The discontinuation rate of anti-anxiety drugs went from 23.5% to 24.4%), while the control homes showed a drop in the rate from 24.8% to 20.0% over the same 6-month period (there are a lot of double negatives here, so a higher number over time is better).
The M&M homes saw an increased rate of reduction of “behavioral problems” from 50.9% to 59.5%; the control homes remained level, from 55.8% to 55.9%. There was no significant improvement in depressed mood seen with the program.
So there was some benefit shown, though it appears to be quite modest, and perhaps somewhat disappointing to those of us who have seen some amazing changes in people. Why did such a large study not show more impressive results? I think we need to put all of this into some context.
It’s been 20 years since Tom Kitwood spearheaded the “person-centered care” movement, but many of his visionary words have still not penetrated the deeper cultural ether. In 1997, Kitwood wrote that it is very hard to study a multifactorial approach to dementia with traditional methodology. As I wrote in Dementia Beyond Drugs;
“… The experiential approach requires a wide range of transformative interventions happening concurrently. It would be futile to try to break them into separate parts for study because that is not the way the model is intended to operate.
“Again, Kitwood supports this argument: ‘A better research strategy, I suggest, involves assessing the consequences of a pattern of care practice taken as a whole, without attempting to subdivide it minutely into separate variables.’ He goes on to say that even a ‘discrete’ intervention, like music therapy, ‘involves many different types of interaction’ (1997, p. 100).”
So what Kitwood was trying to tell us is that an approach like Music and Memory can be an important and valuable tool for engagement for people living with dementia; but too often we apply it incorrectly, and study it incorrectly as well.
Using the Eden Alternative Domains of Well-Being as a framework (identity, connectedness, security, autonomy, meaning, growth, and joy, as I have applied to dementia in my book Dementia Beyond Disease), one can see that personalized music feeds into many of those aspects of well-being at once, which is why it is so powerful. Unfortunately, it is easy to be seduced by the “awakenings” we see and not understand the larger context.
In our long-term care system, which still remains stubbornly task-focused, there is too often a tendency to grab onto Music and Memory as an “intervention” (a) without adequate attention to the larger framework of care, and (b) without taking advantage of the benefits that this increased engagement creates. Let’s look at each of these:
The “intervention” mindset continues to use such approaches like pills—i.e., applied at regular intervals or else in response to an episode of distress. But what else is being done for the person’s overall well-being? If you are supplied with a personalized playlist, but you have no choice or input into your daily life, it will fall short of sustained success. If your carers are rotating, causing you to be supported by relative strangers whom you do not know well (and vice versa), it will fall short of success. If you have improved ability to communicate, but those supporting you do not improve their communication and understanding skills, it will fall short. If your carers have all the best intentions, but work in an inflexible system that doesn’t enable them to engage the person as she needs, it will fall short.
You get the idea.
The second point is one that I have made repeatedly, ever since doing a talkback for the film at our local theater. Here’s my usual comment: “What I would hate to see is people getting an iPod and headphones put on their heads and being left in a corner of their room all day, thinking it’s going to improve their lives. If the use of personalized music improves people’s memory retrieval and their ability to communicate and engage, this is a magic moment that should not be ignored. Use these periods of heightened ability—to converse, find out more about the person, understand her needs, and cultivate your relationship. Once music opens that door to improved engagement, you have to use it!”
By now, the drawbacks of our typical research methodology should also be clear. A controlled, single-intervention trial across large populations of homes that may or may not be employing these deeper approaches along with the music will likely give less impressive results than we would like to see; and more importantly, such research starts with a premise that reinforces this overly simplistic and uni-dimensional view of dementia and aged care.
I know you are all crying out for more “evidence,” but we have to accept that there are a lot of reasons why traditional research approaches cannot provide this. (I’ll have another post on issues around “evidence-based research” coming soon.)
So to summarize, Music and Memory is a great tool for engagement for people living with dementia (and everyone), within the context of a deeper transformational approach to support and care. It is not a magic bullet, and we need to stop expecting to find a magic bullet. There is no substitute for relationships, meaningful engagement in all aspects of life, and shifting our systems to support different ways of living and caring.