LIVE WIND MUSIC WITHIN AN ACUTE WARD FOR PEOPLE WITH DEMENTIA
(Accepted for publication Journal of Applied Arts and Health)
Geoffrey Richardson, Amy Clare, Sally Stapleton, Lawrence Wintergold

ABSTRACT

This project sought to examine the effects of live music as an intervention to improve the well-being of people with dementia who had been admitted to an acute dementia assessment ward following severe psychological and behavioral distress. The literature search revealed little research into the use of a group of musicians, none using a wind quintet ( flute, oboe, clarinet, bassoon and horn ) and few studies involving a group of wind musicians and people with dementia experiencing severe distress. Measurements were undertaken using Dementia Care Mapping (DCM) and the Bradford well-being and ill-being profiles. Data collected from individuals with dementia, carers, staff and players, provided evidence to show that as an intervention using live group music the experience had a positive effect upon individuals’ well-being. The number of participants was restricted to twelve – the capacity of the assessment unit – and there was no control group. This pilot study could lead to a larger, controlled research study.

The interesting findings were observations of well-being in favour of ill-being in responses to the live music interventions. The precise mechanisms responsible for these affects appear complex, relating to both the musical and socially therapeutic dimensions of the intervention. An important secondary finding related to the positive effect of the whole process on musicians’ development in person-centred skills appropriate for working with people with severe dementia. The project also extended ward staff’s facilitation skills encouraging individuals’ participation in a new situation with a group of players on the ward.

BACKGROUND

New Harmonie is a small charity that aims to support professional wind musicians using live music in health and social care settings (www.newharmonie.org.uk). Successful grant applications in collaboration with Sussex Partnership NHS Foundation Trust were made to Lankelly Chase and the Friends of Horsham Hospital. Funding was to provide ten consecutive music activity workshops for people admitted to the dementia assessment ward at Horsham Hospital.

The ward assesses people with dementia who have complex needs and who are unable to be treated in their usual care or home setting. The project was discussed with the Trust’s Research and Development Department and, as it was not deemed to be a research study, the project did not require ethical approval. The project started on September 26th 2012.

New Harmonie players are not trained music therapists but before this project started, players had experience running over 70 music activity workshops in 25 Sussex residential/day care centres with older people many with dementia. The Hospital staff supporting the workshops and undertaking observations as to the effectiveness of the musical interventions included members of the occupational therapy, clinical psychology and nursing team.

KEY QUESTIONS

1. Can live music performed regularly by a wind ensemble reduce severe psychological and behavioral distress experienced by people with dementia?

2. Would there be a difference in well-being in individuals with dementia before, during and after the intervention?

3. Can a multi-method qualitative and quantitative approach to the evaluation enhance an understanding of impact?

4. What would the data collected during the hour long sessions show about the impact of the live music on well-being and ill-being?

LITERATURE

A literature search was undertaken to look for similar studies that have been undertaken and outcomes measured using regular live wind music with individuals in the later stages of dementia. The literature review did not reveal any other examples of where a wind quintet or wind instruments in general had been used. Vink et al. (2003) found 354 references for music therapy and dementia. Most were excluded from their report because they did not refer to a research study, were anecdotal or were reports of case studies. Of those studies that were considered as ‘active group music therapy’ none used groups of ‘live musicians.’ Recorded music was used with singing, movement, dance and patients playing along with simple children’s instruments.

A recently published extensive report (Gould 2012) described 17 London4Arts Challenge projects with people in the early stages of dementia. Two projects involved music (singing and using a stringed instrument). Measurement was through the use of filming and questionnaires. Sarker (2012) as part of the Arts4Dementia project describes how South Asian dance can be used as a tool with carers and people with dementia to improve fitness and restore well-being. Aldridge (2000) looked at the approach of music therapists in dementia care reporting that classical music was most commonly used and that specific instruments are more suitable than others. Behrens and Green 1993 found that violin and singing were more suitable to express sadness and that rhythm is ‘the key to the integrative process underlying both musical perception and physiological coherence’. There appears to be no literature measuring the impact of live wind instruments. The National Institute for Clinical Excellence (NICE) (2006) undertook a comprehensive literature review about the psycho-social interventions that might improve the behaviour and well-being of people with dementia. The study found little research evidence regarding music-based approaches but referred to Groene (1993) suggesting that music therapy can reduce the incidence of “wandering”. NICE (2006) also suggests that music and dancing can be effectively used for people with all types and severities of dementia who have comorbid agitation.

Brotons et al. (1997) is a useful review of the literature at that time and Cutler (2009) is a more up to date review of arts groups working in UK with the elderly including those with a dementia. Of the 120 case studies 19 are musical and most use choral singing. Those using instruments can range from large concert events to small workshops. Aims include creating a relaxed atmosphere and combating isolation but little evidence that there has been measurement of the effect of such large scale interventions. Publications from the Sidney de Haan Centre for Arts and Health focus mainly upon the positive benefits of choral singing on the health and well-being of participants. Clift and Hancox 2010 looked at the causal relationships between singing and well-being. They suggested six ways in which music may impact; positive effect, focussed attention, deep breathing, social support, cognitive stimulation and regular commitment. Three of these focussed on people with mental ill-health and other work Livesey et al. (2012) concluded that choral singing could be used to promote mental health and treat mental illness.

Gregory (2002) found higher measures of attentional ability in adults with cognitive impairments following weekly recorded music sessions. Gotell et al. (2002) observed increased verbal comprehension amongst people with a dementia exposed to singing especially in one-to-one situations with carers. Clark et al. (1998) et al using recorded, preferred music during bathing periods for residents exhibiting severe cognitive impairment found a significant reduction in aggressive behaviours and greater co-operation in bathing. Myska and Lindbaek (2000) reviewed studies that showed that music can improve function and alleviate symptoms in various forms of dementia. Ragneskog et al. (2001) showed how individualised music (if nursing staff can identify it) may be an effective intervention to mitigate anxiety and agitation for some people with dementia.

Schweitzer and Bruce 2008l used regular group sessions with adults with dementia and their carers helping to remember life before dementia. Art based stimuli (including music) are used and having carers/family there helped bonding and filling in memory gaps.

From these studies several themes emerged which informed the structure of this service evaluation project.

THE PROJECT

An important difference between this and other studies is that the group of participants were not in the early stages of dementia. All individuals in this study had been admitted to the ward following severe psychological or behavioural distress. Data were collected before, during and after the interventions.

The format of the sessions was based on elements that are highlighted in the literature search. For example, the literature supports regular sessions, use of all kinds of music including classical, the importance of rhythm, possibly dance, individualised and preferred music so far as possible in a group, singing and the presence of carers. The structure was also informed by elements of cognitive stimulation therapy sessions (Spector et al 2003) and sensory integration theory
(Ross et al 1981;)

The New Harmonie quintet had already run workshops in the Falls Unit of Horsham Hospital. A member of staff suggested the group approach the dementia care ward to see if staff would be willing to partner New Harmonie in a similar project. The ward staff were keen to take forward the opportunity of working with a group of musicians and evaluating the impact on people with dementia. This particular combination of wind instruments was chosen because New Harmonie’s previous experience had shown that the diversity of sounds (flute, oboe, clarinet, bassoon and horn) provided a powerful mix of tones, vibrations, interest and repertoire to engage people with dementia.

People being assessed on the ward would normally be there for an average length of stay between a few weeks to several months. They would not all have moved into the ward at the same time. The ward provides services for younger and older people with dementia, the majority being over the age of 70. The number of females far out-numbered males.
The structure of the project for each of the ten weeks is set out below:

  • Players sitting by individuals, talking and assembling instruments.
  • An introductory rhythmic signature tune (e.g. Liberty Bell) to gain attention.
  • Chair-based exercises
  • Solo instruments – one per week - to allow players to get closer interaction with individuals and playing melodies particular individuals might prefer
  • Singing ‘down memory lane’ songs from the 1930s,40s and 50s with word sheets for individuals and staff and action songs (e.g. ‘I’m forever blowing bubbles’ )
  • A dancing section for those who felt able.
  • Rousing marches with individuals accompanying on percussive instruments.
  • A quite/calming period with appropriate more gentle music
  • A concluding piece of music accompanied by a physical activity using a parachute with a balloon on top. All participants were encouraged to hold the parachute and lift it up and down in time with the music.
  • Tea with individuals, carers and staff, evaluations/reflections.

Clair (1996) working one to one with participants in the later stages of dementia, found that singing produced the most alert responses though in the one to one situation, responses to singing were not contingent upon instrumental accompaniment. She also found that participants who were relatively non-responsive in initial sessions might grow in responsiveness over time, supporting a series of sessions rather than a one off. Clair and Ebberts 1997 working with groups of people in the later stages of dementia twice weekly for 4 weeks (50 minutes sessions) involving conversation, group singing, ballroom dancing, and participation in rhythm playing using paddle drums. Examining (a) participating in music, (b) initiating touch, and (c) responding to touch, caregivers' engagements in participations were higher in music applications when compared with conversation. The greatest participation occurred during rhythm playing, followed by singing and dancing, respectively.

Gizzi and Dallow (c2002) studied the benefits of live music (not defined) in a nursing home for residents with a dementia. They tracked the number of falls, number of times sedating medication was given and the quality of life (using the Quality of Life in Dementia (QOLID) scale). They tested participants before and after two live music performances given six weeks apart. QOLID scores increased significantly following each performance. They noted a trend for the use of sedating medications and the number of falls to decrease in the two week period following each performance though these results were not statistically significant.

DATA COLLECTION

Data were collected throughout this project by hospital staff and players.

Observational data were provided by a clinical psychologist observing individuals with dementia before, during and after four of the sessions using Dementia Care Mapping (British Standards Institution (BSI), 2010). DCM is a recognised observational tool which has been used in clinical practice and research. DCM records each person’s behaviour, mood and engagement every five minutes. It also records interactions that are likely to support or undermine an individual’s psychological needs.

Further data were obtained by staff using well-being/ill-being scales. These are based on the well and ill-being indicators identified by Kitwood and Bredin (1992) which have been used within clinical practice. Permission was given by the Research and Development Department of Sussex Partnership NHS Foundation Trust for the project to use a collated group set of anonymous data, which included no individual personal data. Ward Staff met after each session to share and collate this information. For the purposes of the project, they used Bradford Dementia Group’s (2008) terminology: ‘well-being’ where individuals are ‘engaging with the world around them and experiencing positive feelings’; ‘ill-being’ where individuals are ‘withdrawing or disengaging from the world around them and experiencing negative feelings’.

Data were also collected from individuals with dementia, carers, staff and players through the use of open ended questions asked at the end of each session. The qualitative data consisted of feedback from individuals with dementia, staff, carers and players. It was collected using a variety of methods. These included (a) a questionnaire for staff members (b) a questionnaire used by players to talk to individuals after each session (using closed questions or facial expression cards); (c) discussions with carers and (d) detailed evaluations from players themselves after each session. This process produced a large quantity of qualitative data.

The number of hospital staff present each week during the sessions averaged 5.4. This was a higher number of staff than would normally support a group session on the Ward (usually two to three) An Occupational Therapist was present for all sessions. She had an important role in creating the appropriate environment, supporting and facilitating engagement (with carers present), leading the chair-based exercises and providing the percussive instruments for individuals to use.

Nursing staff present joined in the activities and supported engagement. Most weeks a clinical psychologist or trainee clinical psychologist was also present, although on four occasions the clinical Psychologist had an observing rather than participatory role due to her undertaking DCM to evaluate the group. Each staff member was asked to write his/her weekly comments on a questionnaire with the guidance:- ‘We are particularly interested in the effect/advantage for individuals of (i) live music (ii) single instrument v group (iii) exercise sessions (iv) singing (v) dancing (vi) reminiscing (vii) individuals joining in (viii) relaxation’.

Players used simple questionnaires to talk to individuals with dementia after each session. Between 7 and 11 individuals attended each week. Some individuals were able to respond to ‘Did you enjoy yourself’, ‘Did you like the music’ but many were not. Facial expression cards were used to help gain feedback. Players were able to talk to Carers (usually three attended each week) who proved very willing to offer feedback. After each session, players wrote their own detailed evaluations focussing upon their observed reactions of individuals to the music, suggestions of pieces that might be more effective than ones played and ways to improve New Harmonie’s performance. Each week this feedback was shared between staff and players so that informed reflection could take place and modifications as necessary included in the following week.

RESULTS

1.DEMENTIA CARE MAPPING DCM observations were carried out by the Clinical Psychologist who sat in one corner of the room before, during and after the musical activities, including following individuals, carers, and players into the tea room after the group. A maximum of six participants were observed on each occasion. With one person undertaking this, six was considered the maximum number that could be effectively monitored and scored using DCM. Eight participants is considered the maximum (BSI, 2010) However, as group participants changed across the sessions, the same individuals were not consistently observed at all-time points. On Sessions 8 and 9 no data were recorded after the session due to the Clinical Psychologist giving feedback to one of the players and a family member wishing to speak with her.

In order to calculate an accurate well-being/ill-being (WIB) score, four hours of continuous data are needed. The observation periods were less than this (for example the group was an hour session). However, the WIB scores (average levels of mood and engagement) were still calculated to give an average of individuals’ mood and engagement, before, during and after each group. Statistical analyses were not possible due to the participants within each group changing from session to session and the small numbers of participants involved. However, the results are reported below to give an indication of trends.


Table 1. Summary of the group average levels of mood and engagement

An average WIB score of +1.5 and above indicates that an individual is experiencing more periods of well-being than ill-being. During three of the four sessions, well-being was equal to or above +1.5. For the week that well-being was below this level (session 8) there were less ward staff supporting individuals to engage with the group (only 2 compared to the average of 5.4 across all the sessions). It was felt by the ward team staff that this affected individuals’ engagement with the group and led to the lower well-being score. Carers and players also felt a contributory factor was the impending sickness that was to close the ward for several days soon after this visit.

For two of the four sessions, individuals were observed before, during and after the live music activity sessions. From the DCM observational data, slightly higher scores were observed during the intervention than prior to the intervention. However, following the intervention, scores decreased after one session and increased after another. Therefore it was not possible to get a consistent picture of before, during and after the sessions.

Looking in more detail, the results of the DCM suggested that individuals participated in different activities and behaviours before, during and after the group. The behaviours and activities recorded immediately before, during and after the group are listed in the table below in order of frequency. Behaviours and activities recorded for more than 10% of the time are highlighted in bold. Of particular interest was ‘social interaction’ which was more commonly associated with high well-being scores. Social interaction included interactions with members of New Harmonie. For players this drew heavily on their experience working in many care homes and their ability to empathise. It was noted that expectations were raised and supported prior to the session by staff commenting that ‘the musicians are coming’. As the group progressed, it was noticed that nursing staff began to play music on the CD player prior to the group. After the group, the players joined individuals and carers for tea, which was associated with the observation of further social interaction.


Table 2. Summary of the most frequently observed behaviours and activities (bold indicates recordings that were made for more than 10% of the time)

The Dementia Care Mapping was also used to identify occasions when staff interactions (ward staff and players) led to individuals’ psychological needs being met (personal enhancers) or undermined (personal detractions). Across all weeks, there were more occasions when individuals’ psychological needs were met (41 occasions) rather than undermined (11 occasions). The most personal enhancers were observed during session 2. The higher number of personal enhancers was partly associated with highly skilled support given to a lady who became distressed during the session. Personal detractions were observed only on Sessions 2 and 6. These were all associated with well-intentioned feedback given to the group (individuals and staff) suggesting that the singing was perhaps not quite good enough. The Clinical Psychologist encouraged reflective discussion after group 6 to consider the impact of these comments on people with dementia. It was interesting to reflect on the different types of feedback that are used in different types of singing and music groups. It was agreed that the focus for this group was about supporting and encouraging engagement rather than the ‘performance’ aspects. Following this reflective discussion, there were no other occasions when individuals’ psychological needs were observed to be undermined. The players reported that the use of DCM was an important factor in improving their skills in interacting with people with dementia. The Clinical Psychologist noted that the players were extremely open to feedback on their interactions with people with dementia and were able to reflect on the feedback and use it to inform their interactions in future sessions. This meant that during the last two observed sessions, interactions (staff and players) were all supportive of individuals’ psychological needs, which is an extremely important outcome in terms of enhancing the experience of the individuals with dementia.


Table 3. Summary of personal enhancers and personal detractions (DCM)

2. BRADFORD WELL-BEING/ILL-BEING PROFILES

Directly after each session the clinicians involved met together to complete the well-being and ill-being profiles based on their observations. The group of clinicians primarily consisted of members of the Occupational Therapy and Clinical Psychology team and the Ward Manager (nurse). Three of the staff were present for most of the 10 weeks, giving a degree of consistency to the process. The individual results were collated as anonymous group scores by the Trainee Clinical Psychologist. As the group participants changed during the 10 sessions, the data are presented as a whole for all participants across all groups. This scale is used to provide an overall impression of ill-being and well-being for each individual. There are no normative data associated with this measure. It is used in clinical assessments and service evaluations


Table 4. Summary of the well and ill-being profile data for the group as a whole across all sessions

3.FEEDBACK FROM PEOPLE WITH DEMENTIA, CARERS, STAFF AND PLAYERS

The feedback data from the open-ended questions asked at the end of each session, were analyzed using thematic analysis. In this case inductive analysis was used because this form of thematic analysis is data driven rather than driven by a theoretical interest with a pre-existing coding frame (Braun & Clarke, 2006) The collated data were examined as a whole (outside the categories listed above) to generate initial codes and these codes were then analyzed at the broader level of ‘themes’. Once potential themes had been generated they were shared with a senior hospital colleague. The data was then re-examined by taking all the feedback and physically separating each comment and ensuring that each one fell into one of the generated themes. This ensured consensus and credibility of the themes.

Throughout this process of analysis, most of the data came under an overarching theme about the impact of the whole group process on a variety of different areas. Within this overarching label of ‘the impact’ several themes emerged each containing further subthemes. A secondary theme was also identified which we have termed perspectives.

THEME 1; THE IMPACT ON THE INDIVIDUAL WITH DEMENTIA. Feedback within this theme fell into three subthemes;

  • The impact on mood. For example; Carers said ‘My husband is often very agitated and distracted but he relaxes and enjoys the music’
  • Staff said ‘Lifting mood and helping patients, therapeutic, entertaining’. ‘Relaxed mood flowed well’. ‘Lifting moods and relaxing patients. Brings joy’ ‘one patient missed session for a week - there was deterioration in her well-being.’ ‘I think patients enjoyed the group. Being a group is substantial with many different people, instruments to look at’ ‘… the effect on the patients was wonderful to watch’.
  • Players said ‘The demeanor of a lady in a wheelchair, who had been agitated and distracted when we arrived, changed almost instantly when the music started, focusing her attention forward instead of sideways…’ ‘… one elderly patient who was confused most of the time, really loved 'You are my Sunshine' and volunteered straight after we finished the song that it had made her happy…’ ‘Our patient ex drummer responded not only to changing tempo, but also mood and dynamics with his gestures’.

The impact on memory. For example; Staff said ‘Patients getting used to sessions, looking forward to sessions, recognizing musicians’ ‘Week on week patients expect and look forward to sessions’.

Players said ‘Most patients had been to previous weeks…smiles from many as we arrived, indicating a degree of recognition’ ‘Three of the four patients who were already in the 'lounge' as we arrived showed clear signs of recognising us, greeting us with smiles and handshakes. Whilst none were sure what we would be doing with them they all seemed to be looking forward to it as if they remembered/associated us with something nice (emotional memory)’ ‘Some of them though, seemed to be anticipating the music with more interest than in previous weeks as it becomes more familiar to them’ ‘They definitely recognized us and I felt a very genuine affection towards us from some of the patients. We had become familiar faces that they were glad to see which made the project seem extremely worthwhile’.

The impact on interaction (including communication). For example; Carers said ‘One patient spends much of her day wandering sadly round but when the music begins she smiles, joins in, remembers the words and moves in time to the melody’ ‘One patient was immediately captured by the music and I was able to get him to tell me that he had been a drummer in a jazz band’.

Staff said ‘positive engagement from several usually withdrawn patients’ ‘Patients responded very positively to music – laughing, gesticulating and singing along’ ‘A mix today – some patients very engaged and participating well, others distracted – one very negative in her comments’ ‘A patient who doesn’t participate during the performance but listens to the music, got up afterwards when most people had left and did the Lambeth Walk with two of the musicians. She was singing and laughing and said she would do it next week…’.

Players said ‘One man's eyes lit up during the entire time we were there, got up spontaneously to dance and tapped his foot and clapped his hands’ ‘The youngest patient said how much she loved the Beatles’ ‘Yesterday’ ‘On several occasions one of the patients got up from his chair and came close to us to sing and clap in time to the music. He danced and laughed (almost contagiously at one point) – he absolutely loved the session’.

THEME 2; THE IMPACT ON THE SOCIAL AND PHYSICAL ENVIRONMENT
(In this case the environment means the world around the individual with dementia including the ward as a whole and those people around the individual). For example;

  • Carers said ‘The effect of your music is transforming. The difference
    among the residents during your sessions and other times when I visit is
    huge. The atmosphere is much more cheerful and positive. It is lovely to see
    people smile who don’t usually smile’ ‘I am a frequent visitor and am very
    grateful for the visits of the quintet. There is a significant lifting of the spirits
    on Wednesdays’ ‘I look forward to visiting so much more than on other days
    – the music makes it so much less stressful’ ‘I absolutely loved it. For me
    it is the best afternoon of the week’.
  • Staff said ‘Missed you last week – it’s the highlight of the week’.
  • Players said ‘There was also more interaction with each other as well as with
    staff, and they were literally spreading the joy around the room which gave a
    tremendous sense of community, family almost ‘ ‘ … we didn't really need to
    ask if they had enjoyed themselves, as it was self-evident’ ‘The new lady
    who led much of the dancing really helped to lift the atmosphere and I noticed
    several patients smiling during this’ ‘The atmosphere was calm, and, for the
    most part, happy and alert when we arrived, with plenty of smiles and eye
    contact, even from some who have previously found this difficult’.

THEME 3; PERSPECTIVES ON THE PRACTICAL ELEMENTS
(including the practicalities of running the sessions and suggestions for improvements). There were two sub themes;

  • The staff perspectives. For example; ‘Upbeat and participatory music used to good effect’ ‘Dynamics easier to manage if 1:1 support available…much of patient involvement was facilitated – it was apparent this week the difference a higher level of support makes’ ‘..…the marching songs worked well as did the use of (percussive) instruments’ ‘Be aware of patients especially sitting or standing in front of (you). Be careful of what music will evoke feelings of sadness memories of what was/may have been, patients do have insight, upbeat jolly music. Music for our patients is a wonderful experience but needs to be chosen with care’.
  • The players’ perspectives For example; ‘It was noticeable to staff, facilitation led to higher well-being and enabled active rather than passive engagement. Less staff members today had an impact especially on individuals who can become withdrawn if not facilitated by staff’ ‘Patients don’t react so well to ‘evergreen’ standards numbers Fascinatin’Rhythm, Chattanooga, St Louis Blues, Mamma Mia contrary to our expectations or slow rhythm– so just listening for any length of time (more than two minutes) seems unproductive. Patients participating in music activity is key’ ‘the biggest success was the Lambeth Walk dance which seems to get more popular every week’ ‘we need to be flexible and change or cut pieces when the staff are running the exercises, but during the rest of the programme we should try to stick to previously agreed orders of music so that there isn’t indecision, breaking the pace’ ‘the workshop had pace and more singing than in previous weeks which really helped to hold attention and promote involvement. There were no pieces which did not work. The use of real bubbles when we played ’I’m Forever Blowing Bubbles’ was a great idea from one of the staff’.

DISCUSSION

The data collected tentatively suggests a positive impact of live music performed by a wind quintet on the psychological and behavioral distress experienced by people with dementia. The DCM data despite the small numbers involved observations ‘before’, during and ‘after’ the intervention and suggested a trend towards higher well-being during the intervention. The well-being and ill-being scales suggested that individuals experienced higher levels of well-being than ill-being during the intervention. In addition, comments by carers and staff in particular suggested that they had noticed a reduction in the psychological and behavioral distress of certain individuals.

From the DCM observational data, it was possible to look at the types of behaviours in which individuals were engaging. As anticipated ‘creative self-expression’ was only observed during the actual music session. However, ‘social interaction’ was observed before, during and after the session. When the musicians arrived, there was a lot of social interaction and interest watching the players set up their music stands and instruments, prior to the actual music session ‘starting’. Then following the music session when there was also social interaction between the players and individuals as players sought feedback and sat down together for tea. Therefore ‘before’ and ‘after’ the session, the players (including staff preparing for and talking about the players anticipated arrival) were still having an impact on the well-being of individuals.

Although DCM was used to help evaluate the intervention, another use of DCM was to further develop the person-centred therapeutic skills of the players and staff. The DCM data as well as the feedback from individuals with dementia, carers, staff and players was reflected upon and helped to shape the format of the next session, including certain types of facilitation. Examples of this were the use of ‘blowing bubbles’ during the song ‘I’m forever blowing bubbles’ and the use of percussion instruments to accompany particular songs. Staff who came for just one or two sessions had little preparation time. Further thought about how to prepare the whole ward staff team should be given in any future project.

It was also noticeable that involvement of family carers had a positive impact on individuals. Some individuals were observed to be supported by a family member who also helped facilitate their engagement, in a similar role to the facilitators. It is difficult to know if the presence of staff facilitators who were able to model ‘facilitating’ types of support assisted with this.

SUGGESTIONS FOR FUTURE STUDY

1. This was an initial service evaluation, rather than a research study. It is suggested that any future study uses a formal research methodology to enable firmer conclusions to be made.
It is recommended that in any similar future groups, this model be used involving ongoing feedback, reflection and planning from various sources, in order to tailor the group to the needs of the participants.
2. Assessment units in hospital tend to be small so trying to replicate this study with a larger group suffering the same levels of distress would be difficult. However, New Harmonie has for several years worked in residential units with larger numbers of participants though it is not easy to find venues where staff have skills in DCM and using the Bradford scales. There would need to be pre-training costed and built into any project.
3. Future projects might look at the selection of music to be used measuring the impact on the generation most likely to be experiencing dementia over the next few decades. Music from the 1940s and even 1950’s will increasingly not be relevant in the repertoire. Another area for study is whether the nature of the group of instruments – strings, brass or woodwind makes any significant difference. A comparison could also be made with virtually the same structure and music – using a pre-prepared disc and then a week later using a group of live musicians. There is also a cost issue and further work could look at how costs could be met by using a smaller group of musicians (though there are issues here about available repertoire) and how volunteers or carers could help reduce NHS staffing costs in a workshop.
4. The structure of each session and work done by staff to engage individuals with dementia prior to the music starting may have had an impact on the well-being of those individuals. This may have positively influenced the well-being scores prior to the players arriving and it may have been useful to have had a well-being score for individuals when there was not a structured activity being offered. Thus, DCM could begin say half an hour before players arrive and then players simply walking in and playing. Another possible area for further thought and study would be to compare the changes in well-being for another sensory intervention (such as baking) or non-sensory intervention (such as reminiscing) using the same resource and structure though language reminiscence is less common that multi-sensory reminiscence.
5. Over the duration of the sessions there were opportunities for the musicians and clinicians to reflect on the sessions which led to refinements in content, structure and communication styles. This was felt to be a valuable and important component of the intervention that enabled the musicians to develop their knowledge and awareness of the impact of communication and their music on the well-being of people with severe dementia. Clinical staff also learned from the experience. How to adapt and relate to a group of unfamiliar players (not music therapists) joining their ward. For those not musically trained, how to make the most use of the different sounds, vibrations, tones, rhythms in supporting individuals with dementia. How to familiarize themselves with songs and words from individuals’ distant memories? For the occasional staff participant how to clarifying what their role is e.g. helping to facilitate particularly those staff/students who just came in for one or two visits. How to ensure that any staff member taking part is fully briefed about what will happen in a session.

 ACKNOWLEDGEMENTS

Thanks to Lankelly Chase and the Friends of Horsham Hospital for providing the funding to make this project possible. We should also like to thank all individuals with dementia and their carers who took part. We owe a debt of gratitude to the Ward staff and especially Karen Diamond (Ward Manager), Fiona Waters (OT) and Janice Bond (OT). Thanks to Gemima Fitzgerald (Trainee Clinical Psychologist) for her tireless work in collating the data and Phil Martin (Trainee Clinical Psychologist) for his valuable help with analyzing the qualitative data. Our thanks to the other players who took part alongside Geoffrey Richardson ( clarinet), Rachel Sherlock (flute), Liz Burtenshaw (flute),Sarah Williams ( oboe), Sue Bellamy (bassoon) and Annie Barnard ( French horn).

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DR GEOFFREY RICHARDSON former College Principal of The Queen’s College Glasgow offering Higher Education particularly in Health Studies; currently Secretary and Treasurer of ‘New Harmonie’ which uses music as an intervention in Dementia Care, Palliative Care and for Sussex children with Special needs.
AMY CLARE is an Honorary Assistant Psychologist working within Dementia Services. Amy also works as a Speech and Language Therapist within Learning Disability Services
SALLY STAPLETON, Clinical Psychologist works with people with dementia, families, carers and staff teams within inpatient Services. Sally is a Licensed Dementia Care Mapping Trainer with the University of Bradford. She is particularly interested in working therapeutically with people with dementia and has a keen interest in supporting organisations in becoming more person-centred
LAWRENCE WINTERGOLD is Professional Lead Occupational Therapist, Sussex Partnership NHS Foundation Trust and Dementia Forum Lead for the College of Occupational Therapists. He has twenty two years post graduate experience of working in health and social care services for people with dementia.