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Annals of Physical and Rehabilitation Medicine xxx (2018) xxx–xxx

Available online at

ScienceDirect
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1
2 Letter to the editor

3 Effects of standardized musical intervention on refusal broadcasting variety music from the 1960s to the 1990s. This 52
4 of care and aggression during toileting in people with was not chosen at random, but because it was the radio station 53
5 institutionalized neurocognitive disorders closest to the preferred music of the patients included in the study 54
given their generation, and a third was carried out using the MUSIC 55
6 Dear Editor, CARE application. The order in which the soundscapes were
C 56
delivered was random. 57
7 Care management for people with Alzheimer’s disease or a A technique based on the principles of receptive music therapy 58
8 related dementia is difficult on a daily basis for their relatives or was standardized and evaluated: the ‘‘U’’ sequence. Based on the 59
9 professional caregivers who are often confronted with various principles of hypnoanalgesia, the musical sequence is divided into 60
10 refusals and/or behavioural disorders. Pharmacological approa- several phases that gradually leads the patient to relaxation 61
11 ches to improve behavioural disorders in these diseases have not according to the U-shaped sequence (Fig. 1) [4,6]. Original musical 62
12 been shown to be effective [1]. Several studies have shown that works were adapted to the patients’ tastes (classical, jazz, world, 63
13 musical intervention can help to manage behavioural disorders in modern, etc.). The trained caregivers a digital tablet have at their 64
14 institutionalized patients with neurocognitive disorders [2–7]. The disposal with a varied choice of sessions available through the 65
15 use of a digital application allows a caregiver to easily implement MUSIC CARE application. Caregivers can select a 20-minute
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16 sessions based on therapeutic music listening. It offers personal- session based on patients’ tastes in music expressed through a 67
17 ized music listening based on the patient’s preferences and choices, questionnaire. 68
18 Q3 and on the standardized principle of the ‘‘U’’ sequence (Figs. 1–3) Immediately after the end of the toileting session, the 69
19 Q4 [7,8]. This digital application has proven its effectiveness in many investigator met the caregiver who performed the washing and 70
20 medical situations such as anxiety or depression, or even pain, in asked them to enter a numerical verbal scale of the resident’s level 71
21 many healthcare settings (geriatrics, intensive care, and rheuma- of aggressiveness during the toileting (0 to 10) and the level of 72
22 tology). refusal/opposition to the resident’s care during the washing (0 to 73
23 Given its interesting effects on pain in other settings, we 10). Finally, he asked the caregiver to indicate the total duration of 74
24 hypothesized that the use of a digital application could reduce the the timed spent washing up using a watch. 75
25 aggressiveness associated with care in Alzheimer patients living in Then the investigator asked the resident to fill out a numerical 76
26 geriatric institutions and to facilitate care. verbal scale concerning his level of pain during the washing up 77
27 The main aim of this study was to compare the intensity of (0 to 10), as well as a numerical verbal scale to describe his level of 78
28 residents’ aggressiveness during toileting with or without a satisfaction with the progress of the care (0 to 10), and this was 79
29 standardized musical intervention. done without the presence of the caregiver. 80
30 This was a prospective observational study evaluating the level In the absence of published data on the same topic, it was not 81
31 of aggressiveness during toileting under three musical conditions. possible to calculate the number of subjects to include for the trial. 82
32 It focused on residents living in residential care facilities for Also, this is a preliminary study and the sample size was 83
33 dependent elderly people (EHPAD) (Korian les Jardins d’Alésia -
34 Paris) suffering from Alzheimer’s disease or other diseases
35 responsible for cognitive disorders and receiving assistance from
36 the facility’s caregivers for the morning toileting. To be eligible,
37 patients had to be able to communicate, have moderate or mild
38 cognitive impairment (defined by a MMSE score > 15), and have a
39 moderate or mild level of dependence for daily living routine
40 (defined by a GIR group of 3 or higher on the AGGIR scale).
41 Residents benefiting from end-of-life care were not considered for
42 the study. Eligible patients were included if they and/or their
43 primary caregiver gave their agreement not to object to partici-
44 pate. The study was carried out in accordance with the principles of
45 the Helsinki Declaration and in accordance with the rules of good
46 clinical practices.
47 Each participant was studied during the morning toileting
48 sessions three times (on 3 different consecutive days) by the same
49 caregiver. Three caregivers participated in this study. One of the
50 toiletings was done with no musical atmosphere; another was
51 done using the music from a French national radio station Fig. 1. The ‘‘U’’ sequence: music therapy technique used.

https://doi.org/10.1016/j.rehab.2018.09.001
1877-0657/ C 2018 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Loko A, et al. Effects of standardized musical intervention on refusal of care and aggression during
toileting in people with institutionalized neurocognitive disorders. Ann Phys Rehabil Med (2018), https://doi.org/10.1016/
j.rehab.2018.09.001
 G Model
REHAB 1216 1–3

2 Letter to the editor / Annals of Physical and Rehabilitation Medicine xxx (2018) xxx–xxx

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102 2015. It involved 21 residents (7 males and 14 females) aged
120 86.6  7.0 years (range: 68 to 96 years). Six residents (28%) had a
121 level of mild dependence (GIR 5 or 6) and 15 (72%) had a level of
122 moderate dependence (GIR 3 or 4). The median MMSE score was
123 19. Seven patients (33%) had an MMSE greater than 23. The
124 neurocognitive diseases concerned were: Alzheimer’s disease in
125 12 cases (57%), dementia associated with Parkinson’s disease in
126 3 cases (14%), vascular dementia in 1 case (5%), and unspecified
127 etiology in 5 cases (24%). Twenty of the residents (95%) expressed a
128 musical preference, including 9 (43%) for classical music, 5 (24%) for
129 world music and 7 (33%) for contemporary variety music.
130 We have focused on significant differences between the
131 3 musical conditions. The indications provided by the caregivers
132 showed a significant decrease in the Refusal of Care scale score in
133 the MUSIC CARE situation compared to the control situation
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134 without music (Table 1). The duration of the toileting was reduced
135 by 6 minutes on average (reduction of 33%) in the MUSIC CARE C

136 situation compared to the situation without music (P = 0.00263).

137 The information provided by the residents showed a decrease in
138 the pain score and greater satisfaction with the care under MUSIC
139 CARE conditions. In contrast, in the musical atmosphere situation
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140 of French radio, no difference was found compared to the situation

141 without a musical atmosphere (Table 1).
142 Fig. 2. Flow chart. This observational study showed that the personalized musical
143 intervention by the digital application MUSIC CARE decreased the
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144 determined empirically, taking into account the available means refusal of care and aggressiveness of patients with major
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145 and feasibility of the study. neurocognitive disorders living in institution during the washing
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146 The treatment durations as well as for each of the 4 numerical up. This musical intervention was associated with reduced pain
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147 verbal scales, the scores obtained in the three experimental and increased resident satisfaction. In addition, this intervention
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148 conditions were compared by Friedman’s non-parametric test. The shortened the duration of this care and made it easier.
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149 presence of a refusal of care, aggressiveness or pain during care These main results are similar to those observed in the
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150 (defined by a score > 0 on the corresponding scale) was compared international scientific literature [3]. Koger et al. [9] conducted a
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151 in the 3 groups by the Chi-square test. A value of P < 0.05 was the literature review that included 69 published articles. This analysis
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152 significance threshold. All included patients meeting the eligibility provides a favourable response to music therapy and musical
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153 criteria were included in the intent to treat (ITT) population that interventions on agitation and behaviour in Alzheimer patients.
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154 was analyzed. Gerdner, in several studies have shown that musical interventions
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155 The study was conducted between October and December have a significant effect on Modified Cohen-Mansfield Agitation

Fig. 3.

Please cite this article in press as: Loko A, et al. Effects of standardized musical intervention on refusal of care and aggression during
toileting in people with institutionalized neurocognitive disorders. Ann Phys Rehabil Med (2018), https://doi.org/10.1016/
j.rehab.2018.09.001
 G Model
REHAB 1216 1–3

Letter to the editor / Annals of Physical and Rehabilitation Medicine xxx (2018) xxx–xxx 3

Table 1 neurocognitive disorders. Further studies could confirm these 192

Refusal of care, Aggressiveness, Pain and Satisfaction as regards care and duration of
preliminary results. This type of intervention should be studied in a 193
the care.
broader population that includes people with severe dementia in 194
Variables No music Music Controlled MUSIC CARE P C
whom agitation and aggressiveness are frequent and severe 195
Refusal of care disorders. 196
Score (0–10) 5 (0–7) 5 (0–6) 0 (0–0) < 0.001
Patients with score > 0 15 (71%) 13 (62%) 4 (19%) 0.001
Aggressivity (0–10)
Disclosure of interest 197
Score (0–10) 0 (0–1) 0 (0–0) 0 (0–0) 0.130
Patients with score > 0 5 (24%) 5 (24%) 2 (9%) 0.448
Pain (0–10) Stéphane Guétin is the founder of MUSIC CARE1, his role was to 198
Score (0–10) 0 (0–2) 0 (0–4) 0 (0–0) 0.045 train the healthcare team on the technique before the study was 199
Patients with score > 0 7 (33%) 8 (38%) 1 (5%) 0.027
set up and before any intervention on patients. The other authors 200
Satisfaction score (0–10) 8 (7–8.5) 8.2 (7–9) 9 (9–10) < 0.001
Care duration (mins) 18 (15–20) 20 (15–22) 12 (10–15) 0.026 declare that they have no competing interest. 201

Results are expressed in median (IQR) for scores on the corresponding scales and
duration of care, and in number (percentage) for patients with refusal of care,
aggressiveness or pain during care. References 202

[1] Amieva H, Robert PH, Grandoulier AS, et al. Group and individual cognitive 203
156 Inventory. This symptomatic effect was maintained until one hour therapies in Alzheimer’s disease: the ETNA3 randomized trial. Int Psychogeria- 204
157 after the sessions were stopped [4,5]. trics 2016;28:707–17. 205
[2] Ray KD, Mittelman MS. Music therapy: a nonpharmacological approach to the 206
158 In our study, the musical intervention was accompanied by a care of agitation and depressive symptoms for nursing home residents with 207
159 decrease in the pain score, which may have reduced agitation and dementia. Dementia 2017;16:689–710. 208
160 aggressiveness and thus improved cooperation with the care, and [3] Van der Steen JT, van Soest-Poortvliet MC, van der Wouden JC, et al. Music- 209
161 decreased toileting time. It is also possible that the musical based therapeutic interventions for people with dementia. Cochrane Database 210
Syst Rev 2017;5:CD003477. 211
162 intervention may have had a positive effect on the caregiver, which [4] Gerdner LA, Buckwalter KC, Clarification:. Research and associated evidence- 212
163 may have contributed to the good results observed. The fact that no based protocol for individualized music in persons with dementia. Am J Geriatr 213
164 significant effect was observed under standard music compared to no Psychiatry 2017;25:1289–91. 214
[5] Gerdner L. Effects of individualized versus classical ‘‘relaxation’’ music on the 215
165 music could be explained by the discontinuity of the music. In fact, frequency of agitation with Alzheimer’s disease and related disorders. Int 216
166 the announcer can talk, insert advertising spots that can interrupt the Psychogeriatr 2000;12:49–65. 217
167 effect of the music. In addition, patients know the music they have [6] Zatorre R, McGill J. Music, the food of neuroscience? Nature 2005;17:312–5. 218
[7] Guétin S, Portet F, Picot MC, et al. Effect of music therapy on anxiety and 219
168 already heard. This is not the case with the ‘‘U’’ sequence since these depression in patients with Alzheimer’s type dementia: randomised, controlled 220
169 are original compositions of entirely new instrumental pieces never study. Dement Geriatr Cogn Disord 2009;28:36–46. 221
170 heard by patients, and broadcast without interruption. [8] Guétin S, Coudeyre E, Picot MC, et al. Effect of music therapy among hospitalized 222
patients with chronic low back pain: a controlled, randomized trial. Ann 223
171 Our study has several limitations. First of all, it was not done in a Readapt Med Phys 2005;48:217–24. 224
172 blind manner. This could have been done using video recordings [9] Koger SM, Brotons M. Music therapy for dementia symptoms. Cochrane Data- 225
173 without sound, which were subsequently analyzed by a neuro- base Syst Rev 2000;CD001121. 226
174 psychologist independent from the study. Knowledge of experi-
175 mental conditions may have influenced data collection. Then, the Auguste Lokoa, Emmanuel Coudeyreb, Stéphane Guétinc, Q1227
176 evaluation of aggressiveness and refusal of care was done using Witold Jarzebowskia, Joël Belmina,* 228
a
177 non-validated scales. This was done by caregivers who were not Université Paris 6, Pierre et Marie-Curie (UPMC), 75006 Paris, France 229
b
178 qualified and trained to perform complex tests. For the sake of Service de médecine physique et réadaptation, CHU de Clermont- 230
179 feasibility and simplicity, VAS was used. In addition, as this was a Ferrand, INRA, université Clermont-Auvergne, 63000 Clermont-Ferrand, 231
180 pilot study, a user-friendly tool was chosen. A next step would be France 232
c
181 to consider additional studies based on validated scales. Clinical psychology and psychopathology laboratory (EA4056), Q2233
182 As this was a pilot study, it has only been set up in one center, it university Paris 5-René Descartes, France 234
183 would be interesting to carry out a similar multi-centre study.
184 For almost all patients, except for 3, the duration of care under *Corresponding author. LivingLab Pratiques de soin dans le grand âge 235
185 the ‘‘U’’ sequence was less than 20 minutes. The ‘‘U’’ shaped music et service de gériatrie, hôpital Charles Foix, 7, avenue de la 236
186 sequence was therefore not listened to in its entirety for these République, 94200 Ivry-sur-Seine, France 237
187 patients. It may be interesting to consider another study and E-mail address: j.belmin@aphp.fr (J. Belmin). 238
188 evaluate a treatment over a longer period of time in order to
189 evaluate the effectiveness of the entire ‘‘U’’ shaped music. Received 28 February 2018 239
190 This study opens interesting avenues to improve the behaviour, Accepted 2 September 2018 240
191 adherence to care and pain of institutionalized patients with Available online xxx 241

Please cite this article in press as: Loko A, et al. Effects of standardized musical intervention on refusal of care and aggression during
toileting in people with institutionalized neurocognitive disorders. Ann Phys Rehabil Med (2018), https://doi.org/10.1016/
j.rehab.2018.09.001