Touch Therapy and Music Therapy for Nursing Home Residents with Severe Dementia; a Crossover Study

by Nanette Kramer, Ph.D, and Michael Smith, Ph.D. 

We recently completed a study which grew out of several intersecting interests. We were interested first in exploring interventions for nursing home residents with severe dementia; most interventions developed for dementia have focused on those with mild or moderate dementia, while those with severe dementia have been relatively neglected. Specifically, we were interested in seeing whether music therapy, an auditory intervention, and touch therapy, a tactile intervention, might be effective in evoking positive responses and contributing to improved quality of life. We also had a continuing interest in recognizing and enhancing the importance of nursing assistants in caring for people with dementia, and wanted to develop interventions which they could deliver. Finally, we wanted to expand the intervention delivery role to include family members as well. 

In assessing the impact of interventions for people with severe dementia, the question of what constitutes a meaningful outcome is important. We felt that it was realistic to expect that our interventions might have an immediate positive emotional impact on the participants in our study, but we were uncertain whether there would be any longer-term effect. Given the historical neglect of interventions for people with severe dementia, we felt that even just an immediate short-term effect would be a meaningful contribution to improved quality of life.

Method

The subjects in our study were 54 nursing home residents with severe dementia (mean Mini-Mental State Exam score = 1.1). Each resident was paired with a caregiver; 35 of the caregivers were nursing assistants and 19 were family members. The resident-caregiver pairs were randomly assigned to one of three intervention conditions — 16 to a music therapy condition, 19 to a touch therapy condition, and 19 to a no-intervention control.

The caregivers received training in the intervention appropriate to their condition. Music therapy and touch therapy caregivers received structured training consisting of introductory group sessions followed by a number of individual sessions with their resident and a trainer. The individual (usually 30-minute) sessions continued until caregivers were judged by the trainer to have reached a mastery criterion. Typically, caregivers needed about 8 sessions, spread over about 7 to 8 weeks to achieve mastery, in both the music therapy and touch therapy conditions. Control caregivers received no training.

Music therapy training taught caregivers to use a range of techniques, including singing, humming, playing recordings of familiar music, moving rhythmically, and playing instruments, to interact with residents. Touch therapy training taught caregivers to apply a specific hand massage technique to residents.

Residents were assessed before and after the training period on an outcome battery which included, among other measures, the Cohen-Mansfield Agitation Inventory (Cohen-Mansfield, Werner, and Marx, 1990) and the Cornell Scale for Depression in Dementia (Alexopoulos, Abrams, Young, and Shamoian, 1988). In addition, after the training was completed, caregiver-resident interactions were observed and the residents were rated using several instruments, including a modified version of the Affect Rating Scale (Lawton, Van Haitsma, and Klapper, 1996). During these observation sessions, the music therapy and touch therapy caregivers applied the techniques they had learned, while the control caregivers were asked to interact in whatever way they thought would be positive and enjoyable for the residents. At the end of the sessions, caregivers were asked to rate the impact that their interactions had just had on the residents.

Results

First, we found that the music and touch therapy interventions both had an immediate emotional impact on the residents but that, interestingly, the nature of the impact was different for the two interventions. On the modified Affect Rating Scale, the residents experiencing music therapy tended to show increased interest and decreased sleep compared to the control residents; for the residents receiving touch therapy, the pattern was the opposite — a tendency toward decreased interest and increased sleep compared to the controls. In addition, both the music and touch therapy residents tended to show decreased sadness compared to the controls. (One-way ANOVAs comparing the three conditions yielded significant results on these three dimensions of the modified ARS: interest, F = 3.97, df = 2,50, p = .03; sleep, F = 4.23, df = 2, 50, p = .02; sadness, F = 3.15, df = 2, 50, p = .05.)

Because these intervention effects occurred relative to the control group, it was interesting to note how the control caregivers interacted with their residents. We observed that they engaged in a wide variety of both verbal and nonverbal activities, and typically engaged in more than one in a given session. The activities included speaking with the resident (this was the most common activity observed, occurring in over 75% of the sessions), touching the resident (kissing, stroking, holding hands), feeding the resident, grooming the resident, watching TV with the resident, and others. Our overall impression was that, regardless of their specific nature, the activities the control caregivers engaged in tended to be relatively brief and unsustained.

At the conclusion of the interaction sessions, the caregivers in the music and touch conditions felt that they had had more emotional effect on their residents than did the control caregivers (F = 4.25, df = 2, 49, p = .02).

Finally, there were also indications of some longer-lasting effects, beyond the immediate reactions to the interaction sessions. On the nursing units, the residents in both the music and touch therapy conditions showed decreased levels of agitation from pre- to post-intervention while the control residents did not (for the CMAI scores, the condition X time interaction was significant: F = 3.13, df = 2, 51, p = .05).

Discussion

The results of our study provide evidence that nursing home residents with severe dementia can be appropriately and differentially responsive to music and touch therapy interventions, and that these interventions can evoke positive responses which can enhance residents' quality of life. Further, the study demonstrated that both nursing assistants and residents' family members can be trained to apply these interventions effectively.

We are currently preparing a full report of this study, and are also preparing training manuals, suitable for both nursing home staff and family members, to teach the music and touch therapy interventions developed for the study. Readers interested in any of these materials are welcome to contact us.
Nanette Kramer is a psychologist at Cobble Hill Health Center, and on the faculty at Teachers College, Columbia University in New York City. Michael Smith is a psychologist in private practice in New York City. Dr. Kramer can be contacted at nk105@columbia.edu. 

References

Alexopoulos, G.S., Abrams, R.C., Young, R.C., & Shamoian, C.A. (1988). Cornell scale for depression in dementia. Biological Psychiatry, 23, 271-284.

Cohen-Mansfield, J., Werner, P., & Marx, M. (1990). An observational study of agitation in agitated nursing home residents. International Psychogeriatrics, 1, 153-165.

Lawton, M.P., Van Haitsma, K.V., & Klapper, J. (1996). Observed affect in nursing home residents with Alzheimer's disease. Journal of Gerontology: Psychological Sciences, 51B, P3-P14.

(This article originally appeared in Psychologists in Long Term Care Newsletter, Vol. 12, No. 4, Winter 1999 and is posted with the authors' permission.

The active phase of the research project took place at Cobble Hill Health Center in Brooklyn, NY from June 1996 to April 1997, and was funded by the New York State Department of Health. Massage Therapy Program graduate Barbara Goldschmidt, L.M.T. created the touch therapy protocol and worked with graduate of the Massage Therapy and Acupuncture Programs Megan Haungs, L.Ac., L.M.T. to teach and supervise participants.)

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