2 Introduction to the guide
3 People in geriatric settings
3.1 The patient
3.1.1 The dementia patient
3.1.2 The depressive patient
3.1.3 The Parkinson patient
3.1.4 The stroke patient
3.2 The relative
3.3 The carer
3.4 Other qualified personnel: physicians, psychologists, social workers, occupational therapists and physical therapists
4 Scientific perspectives on music therapy with elderly people
4.1 Music therapy research and the evidence base
4.1.1 Discussion on evidence and on music therapy
4.1.2 Is music therapy practice evidence based?
4.2 Current developments in music therapy with elderly people
4.3 Singing as therapy
4.4 Effect factors in music therapy
4.4.1 Factor A – attention modulation
4.4.2 Factor B – behaviour modulation
4.4.3 Factor E – emotion modulation
4.4.4 Factor C- cognition modulation
4.4.5 Factor I – interpersonal communication modulation
4.4.6 Concluding remark on the heuristic effect factors
5 The music therapist
5.1 Training and professional standards
5.2 Basic therapist and relationship behaviour
5.2.1 Therapeutic stance for encounters
5.2.2 Basic discussion techniques
5.2.3 Basic music therapy stances and skills
5.2.4 Music therapy techniques
5.3 Music theory, instrumental and vocal skills
5.4 Special features of working with the elderly
5.4.1 Helpful “inner stances”
5.4.2 Confused and sundowning people
5.4.3 “Whenever I hear music, I think of … “
5.4.4 “Where people sing, they settle down …”
6 Music therapy intervention catalogue
6.1 Milieu-oriented music therapy on the ward
6.1.1 Corridor music
6.1.2 Background music (in everyday care)
6.2 Music therapy in the patient’s room
6.2.1 Individual music therapy
6.2.2 Singing in the room
6.2.3 Music and movement
6.2.4 Songs in everyday care
6.3 Music therapy in a separate room
6.3.1 Group music therapy
6.3.2 Singing in the group
6.3.3 Music and movement
6.3.4 Relatives in the group
6.4 Music therapy as a leisure activity
7 Evaluation of the intervention catalogue
7.1 Qualitative perspective on the effectiveness of individual music therapy modules
7.2 Quantitative perspective on the effectiveness of music therapy interventions
7.3 Summary of evaluation results
8 Summary and outlook
By Lutz Neugebauer
In recent decades, music as therapy has proven to be an innovative approach for people with special needs. This approach to treatment shows its strengths where words reach their limits. Examples include work with people who have intellectual or linguistic limitations originating from congenital or acquired disabilities or that develop due to degenerative processes, neurological disorders or age-related limitations. Even in cases where people have experienced unspeakable suffering, traumatisation through war, fleeing unsafe environments, violence or abuse, music therapy offers plausible and simple approaches.
The group of patients referenced in this book will include people in the last phase of their lives, when verbal approaches reach their limits. Sometimes these individuals no longer understand what the others are saying, they can no longer articulate themselves, perhaps they no longer share the same reality as us. Music – which we know from experience and can prove through research – can reach these people; beyond both the word and rational understanding.
This broadens our view once again. It draws our attention to the fact that, in our description of those being cared for, we also describe our limits; and the increasing desire to understand and overcome these limits – at least for the moment. Music is capable of this.
Richard von Weizsäcker (1994) says, in an essay on music, that it does not adhere to boundaries. Perhaps that is exactly why music is suitable as therapy. The forgotten can become present, the unsaid audible, the inaccessible recognisable. Loneliness can be overcome through shared activities.
Music is created from two elements, impression and expression. In contrast to verbal interaction, which is always reciprocal, i. e. alternating, ideally related to each other and running one after the other, music offers the possibility of synchronous and simultaneous communication. Impression and expression merge when the people acting together meet in the music. It wants to communicate nothing, nothing but itself. It always unfolds temporally and thus offers possibilities (e. g. to give temporally non-oriented people a frame of reference that makes orientation possible again).
However, music only becomes part of music therapy when it is related to a diagnosis, enabling new insights or showing ways of alleviating, overcoming or avoiding suffering. In order to move from meaningful leisure activities or cultural participation to music therapy, there is a requirement of good and relevant training, cooperation within institutions and recognition that music therapy is a special approach to helping special people. There is also a need for recognition on the part of underwriting agencies and institutions providing care, and, not least of all a legal safeguarding of the profession.
The results of the Music Therapy 360 ° project (hereby referred to as Musiktherapie 360 °), which form the basis of this book, can contribute to this need for recognition and safeguarding. Many colleagues will recognise themselves and their daily practice in the scenarios described here.
Witten, December 2019
Prof. Dr. Lutz Neugebauer
2 Introduction to the guide
By Thomas K. Hillecke & Alexander F. Wormit
This practice guide is a result of the project Musiktherapie 360 ° – Innovative Concept for the Establishment of Modularised Music Therapeutic Interventions for the Enhancement of the Quality of Life of Patients, Relatives and Nursing Staff within the framework of the funding line Social Innovations for Quality of Life in Old Age (Soziale Innovationen für Lebensqualität im Alter – SILQUA-FH) funded by the Federal Ministry of Education and Research (BMBF Programme SILQUA FH 2015).
There is no need to underline the fact that the quality of life of older populations is one of the most pressing challenges in our ageing societies. It is noteworthy that music therapy receives special attention through the funding of the BMBF. This may come as a surprise from the point of view of those music therapists all over the world who are comprehensively involved in providing care for the elderly. At times, this commitment is not truly perceived by the outside world, by the elderly themselves, their relatives, the gerontological disciplines or the health care system. The aim of this project was therefore to systematically record the internationally available findings and to develop them further for practical use. This process resulted in the creation of functional Modules that music therapists can utilise in their practices, thus providing a music therapy system from which older people, their relatives and the nursing staff working in this field can benefit. In addition, it was necessary to create transparency regarding the potential of music therapy.
No other study has investigated the integration of music therapy interventions and their implementation in institutions for the care of the elderly as systematically as the Musiktherapie 360 ° project. This project thus enriches the research landscape with its specific approach to module development and its attempt to compile an adequate description of possible music therapy interventions (which other sources often described inaccurately and heterogeneously) for practice, from which patients, relatives and nursing staff can benefit.
The reader can explore individual chapters in the sense of professional articles, or allow themselves to be guided systematically by their own interests. These options resulted in the following logic for the structure:
Chapter 3 describes the groups of people found in geriatric settings.
Chapter 4 addresses the scientific perspectives of music therapy with elderly people. The more recent evidence as well as possible general and effect factors of music therapy are discussed.
Chapter 5 focuses on the music therapist. What training prerequisites, basic music therapy stances, musical and practical therapy skills and knowledge must be available in order to work successfully as a music therapist in the field of geriatrics?
Chapter 6 presents the music therapy intervention module catalogue. This was derived from literature as part of the project Musiktherapie 360 ° in which music therapy services were systematically summarised, modularly conceived and partly tested in practice at cooperating institutions, depending on requirements.
Chapter 7 systematically summarises the quantitative and qualitative empirical evaluative results of the project Musiktherapie 360 ° and discusses conclusions regarding music therapy with the elderly, while taking into account the perspectives of patients, relatives and nursing staff.
Chapter 8 summarises the book chapters and provides an outlook.
The project and author team hope that music therapists and other gerontological specialists will benefit from the practice guidelines and that they will be able to create transparency regarding the potential of music therapy, especially with older people and their relatives. We also hope that our practice guide will be considered by funding agencies, institutions and administrations for the care of the elderly, so that music therapy can be a more strongly implemented practice in the future.
Finally, we would like to express our sincere thanks to all those involved, the patients and nursing home residents, their relatives, the nursing staff, the management of the facilities, the SRH University of Applied Sciences Heidelberg and, last but not least, the Federal Ministry of Education and Research (BMBF) for their support.
For reasons of clarity, the male form was chosen in the text. Nevertheless, the information refers to members of all possible genders. The authors also opted for a uniform use of the term patient. This always includes residents in residential homes and nursing homes. Finally, as music is an integral part of music therapy, all song examples will remain in the original German. Music used as part of the Musiktherapie 360 ° project consisted of traditional folk music, popular music from the early 1900s and hymns.
3 People in geriatric settings
By Dorothee von Moreau & Michael Keßler
The geriatric setting in residential homes and nursing homes, senior citizens’ day care facilities, specialist hospitals and rehabilitation clinics includes senior citizens with illnesses and illness-related limitations, specialist staff such as nurses and specialist therapists, social workers, pastoral workers, doctors, and also the relatives of the patients, volunteers, everyday companions and housekeepers. Some of these groups of people will be described in more detail below with their respective individual challenges and needs and the possibilities for interdisciplinary cooperation.
3.1 The patient
The patient is typically 70 years and older. Because of the higher life expectancy of women, the proportion of female residents is often considerably higher. From the age of 80 onwards, seniors are particularly vulnerable to the onset of illness due to the risk of complications and their resulting conditions, the risk of chronic illness, and the increased risk of loss of both autonomy and of the ability to engage in self-help practices (Neubart, et al., 2015).
However, according to the German Society of Geriatrics, the German Society of Gerontology and Geriatrics and the Geriatrics Association (BV Geriatrics), geriatric-related multimorbidity is more important than biological age. This stage is reached as soon as at least three relevant diseases such as hypertension, fat metabolism disorders, stroke, pneumonia, osteoporosis, bone fractures, atrial fibrillation, Parkinson’s disease, delirium, dementia, incontinence, sleep disorders or certain tumour diseases (Neubart, 2015) present simultaneously.
Frequently, those affected believe that the consequences of the disease compromise their quality of life to a greater extent than the disease itself does. The International Classification of Impairments, Disabilities and Handicaps (ICIDH) describes here a so-called cascade model: a disease (e. g. brain tumour) causes damage (e. g. paralysis), which leads to disruptions in everyday abilities (e. g. inability to walk) resulting in a participation disorder (e. g. no possibility to attend a social afternoon for senior citizens). Neubart (2015) cites disruptions in mobility, daily activities and communication as well as problems in the processing of disease as capability disruptions, which can have a particularly limiting effect on the quality of life of geriatric patients. Preserving or improving quality of life is currently an important criterion for the evaluation of therapeutic interventions in geriatrics, as many chronic diseases cannot be cured or treated as aggressively in old age (Dichter et al., 2011; Dröes et al., 2006).
The following sections describe the most common age-related diseases and their effects on those affected in more detail.
Figure 3.1: In old age, maintaining quality of life is of great importance.
3.1.1 The dementia patient
Dementia (F00-F03) is manifested by disorders of cortical functions in memory, thinking, orientation, perception, arithmetic, learning, language and judgment. Cognitive deficits can also affect emotional regulation, social behaviour and motivation. Dementia can occur in neurodegenerative diseases such as Alzheimer’s disease, cerebrovascular disorders (e. g. vascular dementia), as well as other primary or secondary brain diseases. Tumours, hematomas or other spatial events can also be associated with dementia (DIMDI, 2018). Mixed forms are not uncommon. Depending on the type of dementia, there are different presentations of dementia. The classification into severity levels has therefore proven to be valid across the various forms of progression (Möller et al., 2015).
Progression forms and degrees of severity
Mild dementia (phase I of Alzheimer’s dementia): This phase is characterised by mild memory loss with weak memory of recent events, impaired judgement, impaired visual-spatial orientation (especially in a foreign environment), and disorders of word finding. Those affected can no longer store new information, items are misplaced, the way to well-known places is no longer found as quickly, everyday activities are forgotten or neglected and not infrequently those affected put themselves at risk (e. g. forgetting to switch off the stove). Many sufferers perceive the loss of their skills clearly and painfully and try to conceal it from themselves or compensate for these loses in front of their relatives and friends. Feelings of fear or shame, depression, indifference or restlessness can occur. Social withdrawal is often the result and goes hand in hand with this mild form. At the same time, a loss of control over affects is reported, which is why affected people often react differently (aggressively, irritably dismissively, exuberantly …) when they are moved on an emotional level. This is often perceived as alienating and irritating by those in the shared environment as well as by the person affected.
Moderate dementia (phase II of Alzheimer’s dementia): This stage is characterised by profound memory disorders: not only recent events, but also earlier memories are lost, sometimes including the recognition of relatives or familiar environments. This disorientation in everyday life and the inability to plan and carry out actions necessitates guidance or accompaniment in almost all areas of life. Linguistic communication becomes increasingly difficult due to impediments in speech comprehension and linguistic expression (e. g. word confusion, syllable twisting). The ability to judge is more severely impaired. There is no difference between then and today, no before and now. The person concerned is completely at the mercy of the current situation. The loss of one’s own control is no longer perceived and therefore no longer denied, covered up or fended off. Emerging memories cannot be classified as past events, but are experienced unfiltered in all their intensity in the here and now. In addition, those affected are often unsettled by sensory illusions (their own mirror image is perceived as an alien person); delusions are also reported (although it is often unclear whether the experience is distorted in a delusional manner or whether an unclear biographical memory dominates the momentary experience). The loss of autonomy, control, self-determination, orientation and understanding is often difficult to bear for those affected and is accompanied by fear and a feeling of isolation. Restless wandering, strong affective fluctuations, sometimes also aggression present relatives or carers with great challenges. A well-intentioned redirection of the affect (if it does not recognise and validate the existing affect) can intensify the confusing feeling in the person concerned, making him feel that he is not understood, has offended or is even wrong.
The symptoms of the disease can often no longer be addressed or compensated for in the home environment. It is not uncommon for them to lead to emotional overload on the part of those affected and their relatives. In addition, for the relatives the experience of being misjudged or no longer recognised is a shock and is frequently experienced as an insult that cannot be understood or accepted. The loss of the self also alienates the affected person from their relatives (and vice versa). In view of the changed experience of those affected, everyday communication is difficult or becomes impossible depending on the situation. Day care or relocation to a nursing home becomes inevitable.
Severe dementia (phase III of Alzheimer’s dementia): This stage manifests itself in the most severe memory disorders, especially with the loss of procedural memory. Even the simplest of procedures that have been automated in the course of life (e. g. eating and hygiene) are lost, so that even basic functions are no longer controllable. This can lead to walking disorders, insecure standing, swallowing disorders, incontinence and even result in the patient becoming bed-ridden. The simplest processes, such as drinking, are forgotten, so that the affected person is dependent on help without being able to understand their necessity. Care can become a great challenge here because it appears to be an attack or an assault. Often it comes with the loss of one’s own language as self-expression and with the loss of understanding language. Verbal expressions have a meaningless character (e. g. echolalia, palilalia). Individual impulses of affects and also the need for exchange of affects seem to recede. The person concerned can neither adequately express his own feelings nor his own needs, even if he is still capable of verbal expression. Similarly, verbal offerings from others often run into emptiness. Relatives cannot understand that the person concerned can no longer classify words. The person suffering from dementia can no longer be reached in this phase via spoken words. On the other hand, the atmosphere of helplessness that intensifies the retreat of the affected person is conveyed in the failed encounter. The experience of the affected person is described as dream-like or surreal, whereby the demarcation between sleep or dream and alertness becomes blurred. There are no reactions to aid or assistance. Muthesius et al. (2010) speak of a “disappearing self” at this stage. Here, when words are nothing more than sound and no longer convey meaning, it is important to provide the person concerned with an atmosphere of protection, security, safety and loving care.
At the nursing home, I visit Mrs Müller for an individual music therapy session. She is sitting at the table in her room. I know from the nursing staff that she has been sitting over her breakfast for two hours. She remembers my face and smiles at me. She asks me how my children are and if everything is all right at home. Like every week, I remind her of her son with my manner and appearance and she engages with me in that familiar way. Because of the distance, he can only visit his mother in the nursing home once a month. I do not point out her confusion and answer that everything is fine at home, but that the much more important question is how she feels. She tells me that her husband Richard hasn’t contacted her for a long time but will be home from work tonight – her husband passed away eight years ago. She continues to complain about the many strangers who walk around in “her house” (the nursing home). She is still able to clean and do the laundry herself! I direct the conversation back to the topic of her husband and remind her how much they loved to sing together. I take out my guitar and we sing our welcome song “Kein schöner Land in dieser Zeit” …
3.1.2 The depressive patient
Depressive disorders are among the most common mental disorders, even at an advanced age, and occur more frequently in geriatric patients. In particular, there appears to be high co-morbidity with coronary heart disease and diabetes mellitus. Furthermore, it is often observed that a stroke or heart attack is followed by depression. Since the symptoms of dementia partly overlap with those of depressive disorders, it is often difficult to make a clear distinction (Robert Koch-Institut, 2010).
Symptoms of a depressive episode (F32.-) include a depressed mood, and a reduction in: drive, activity, appetite, interest, concentration and the ability to experience pleasure. Fatigue can occur even after small efforts. Sleep disruption typically occurs (e. g. drifting in and out of sleep, waking early), and almost always an impairment of self-esteem and self-confidence. Those affected are not able to easily resonate with the affects of those around them and sometimes show themselves to be agitated (DIMDI, 2018).
One of the defining features of so-called old-age depression is that, in older people, health-related problems are often at the forefront of the affected person’s experience, causing physical complaints to be superimposed on the depressive symptoms. Non-specific symptoms such as dizziness, headaches or back pain predominate, the changes in mood take place gradually in the background, and are misjudged as a result of the physical complaints. Speech and thought inhibitions that appear more clearly in old age are often anxiously fended off or concealed by those affected as the first sign of late-onset dementia. Due to their socialisation, older people also find it more difficult to perceive and accept mental illnesses as independent illnesses (e. g. to talk about them). Older people have the added complication of memories and experiences from a time of National Socialism when mentally ill people were labelled as “not worthy of life”, sterilised or murdered, and the topic anxiously tabooed. Thus, depression can often remain undetected and untreated.
The psychological changes only become clearer over the course of time: activities or contacts that were previously enjoyed become less important, the mood becomes depressed over a longer period of time, the usual possibilities of cheering people up fail, the affected people withdraw further and no longer want to leave their own four walls. In men, depressive symptoms often manifest themselves through increased irritability, aggressiveness, anger or rage, increased addiction, hostility and rejection, even towards loved ones. Social withdrawal is justified by physical complaints, one’s own perceived uselessness and personal experience of loss. This in turn intensifies negative thought loops, which favour insomnia due to lack of activity and the feeling of one’s own worthlessness. A lack of drive and listlessness, indifference towards people and their surroundings, emotional numbness and thinking about death are often misinterpreted in the social environment as changes typical of older age (“that is just how it is in old age”).
The danger of suicide is problematic in depressive illnesses. The number of suicides also rises with increasing age: 42 % of all suicides are committed by people over 65 years of age as reported by the German Federal Statistical Office (Statistisches Bundesamt, 2017), whereby the “silent” or “concealed” suicides (e. g. by refusing to eat or refraining from taking necessary medication) contribute to a high number of unreported cases.
Mr Gustav sits alone at his table in the nursing home’s common room. Here and there, the odd resident sits at a table in the room. Nobody speaks. I am looking forward to the upcoming singing group in the lounge and take a seat next to Mr Gustav. Since the death of his wife three years ago, he prefers to stay alone and avoid social interaction. He has been living in the institution for four weeks. He cannot understand the decision of his children. He feels that he has literally been deported to this nursing home. His children’s hope that their father’s liveliness and happiness will return has not yet ...