Dementia is not a specific disease but is used to refer to a group of symptoms caused by brain disorders (Desai & Grossberg, 2011). It affects thinking and ability of the individual to solve problems or control their emotions bringing about personality change which is progressive. While dementia is very common, it is not part of normal aging process. It is one of the most common reasons for long term care facilities admissions. Cognitive problems for people with dementia have been the main focus of research in such of a cure and treatment (Desai & Grossberg, 2011). Today, some common non-cognitive symptoms have been recognized by researchers to be problematic not only to the individual with dementia and caregivers but also in healthcare professionals. Most common include agitation, aggression, mood disorders, psychosis and abnormal vocalizations which can be disruptive creating a challenging work environment. Unfortunately, pharmacological interventions which should be second line treatment have over the years become first line treatment in most facilities despite the calls for non-pharmacological treatment interventions to be utilized first. One of the reasons for this could be understaffing and/or increased cost for human labor and time which is needed to implement non-pharmacological interventions (Department of Veterans Affairs, 2011). In addition, healthcare facilities easily turn to psychotropics for behavioral management as it is quick and easier to administer pills and requires less personnel compared to implementing behavior modification interventions which require more training and personnel but can help manage some disruptive behaviors in patients with dementia. In March 2010, the Boston Globe highlighted research which showed that a significant number of nursing home residents in Massachusetts received powerful antipsychotics without having a psychiatric diagnosis to justify the use (Massachusetts Senior Care Foundation, 2013). The over use of psychotropics as the first line of treatment without attempting non-pharmacological interventions to manage disruptive behaviors issues in patients with dementia in Long term care prompted the Centers for Medicare & Medicaid Services (CMS) initiative announcing a government partnership with providers, caregivers and patients to improve dementia care in long term care facilities. Therefore the goal of this change proposal is to emphasize and encourage the use of active and passive music intervention; a non-pharmacological intervention as first line intervention in managing disruptive behaviors among patients with Dementia in long term care facilities. Review of LiteratureSearch results were found using Cumulative Index of Nursing and Allied Health Literature (CINAHL) with search words including: Non-pharmacologic, dementia and intervention, passive and active music intervention. In this article, the researchers used active and passive music therapy interventions on an individual basis. The music used was that which was likely to evoke special memories. The assessments of this research article indicated that anxiety and agitation were reduced after the music activity sessions (McDermott et al., 2014). The authors concluded that overall music intervention was effective in aiding control of disruptive behaviors especially agitation in patients with severe dementia. In addition, a non-pharmacological study which included active and passive music intervention to reduce common behaviors such as agitation and wandering in patients with dementia was found to be very effective. The researchers examined the use of active and passive music in patients with moderate to severe dementia in a long term care setting. The study indicated that music intervention is effective for patients with dementia. There were short term reductions in agitation during and after music therapy (Ridder et al,. 2013). The research revealed that 100% of nurses agree that music therapy can be effective in reducing agitation in an Alzheimer’s patient. There is no need for more education in music therapy but there is a need for more implementation in the facilities (Ridder et al., 2013). Agitation in dementia patients in long term care facilities leads to an increase in use of psychotropic medications to reduce this behavior. This study shows that music intervention significantly reduced primary disruptive behaviors in persons with dementias compared to standard care; in addition, music intervention led to a decrease in use of psychotropic medications as first line intervention for behavior management (Pedersen et al., 2017). The authors recommend active and passive music as a valid intervention to reduce disruptive behaviors in people with dementia. Agitation is a common problem in dementias patients. The researchers in this study included active music where people with dementia sing, dance and/or play instruments while others listened to live/recorded music without being actively engaged ( Särkämö et al.,2014). The researchers then evaluated the effectiveness of music intervention in management of disruptive behaviors in demented people. The study found that music therapy had a medium overall effect on agitation and other behaviors such as wandering, restlessness and aggressive behavior. However, the authors of this article recommend further research to determine when music intervention may be used effectively as disruptive behaviors and frequency were lower for morning sessions than afternoon sessions ( Särkämö et al.,2014) . The overall effect of this study suggests that passive and active music intervention can reduce disruptive behaviors especially agitation in patients with dementia. Theoretical FrameworkKurt Lewin born was born in Germany in 1890. He was a Humanitarian and Social Psychologist. The change theory was formulated in 1940s and is still in use today (Current Nursing, 2011). Kurt Lewin’s change theory will be the theoretical foundation for implementing the switch from using pharmacologic intervention as first line to non-pharmacologic intervention of Active and Passive music intervention in managing the behavioral components of dementia in long term care facilities. Kurt Lewin Lewin’s theory comprises of three stages: Unfreezing – Change – Refreeze, which requires prior learning to be rejected and replaced. Refreezing is important to prevent a return to the old norm. Lewin’s theory views behavior as a dynamic balance of forces working in opposite directions involving driving forces and restraining/opposing forces. Equilibrium is a state where driving and restraining forces equalize resulting in no change. Changes occurring between the driving and restraining forces either raise or lower equilibrium. While driving forces are towards change, restraining forces resist change (Current Nursing, 2011). Application of Lewin’s Theory to the change Proposal.In this change proposal with reference to Kurt Lewin’s theory of change, the first stage will be the unfreezing stage. Unfreezing stage involves recognizing and understanding that change is necessary and getting ready to move away from the comfort zone. (Current Nursing, 2011). It is therefore important to realize and Identify the need for change which in this case is the use of non-pharmacological interventions to manage disruptive behaviors. After identifying the need to change, the next step will involve setting up a team of stakeholders which includes: Administrator, Director of nurses, Activities director, dementia floor unit manager, nurses, CNAs, activities staff, staff developer and patients family members. These stakeholders are needed as they are the ones who come together to review and analyze the change proposal, weigh the benefits and discuss what was previously attempted, what failed and what worked. Finally, present the change proposal to the stake holders with clear guidelines which includes both short and long term goals. Goal setting is important for performance improvement. The second stage is the change stage. During this stage, people are unfrozen and moving towards a new way of being (Current Nursing , 2011). Change is difficult and is usually met with a certain degree of resistance. During this stage, the proposed change; use of active and passive music will be implemented using evidence based guidelines. Secondly, educate staff using evidence based practice on ways to implement the proposal, provide resources. Monitor and assess and for progress while addressing the driving and restraining forces. Ensure effective and timely communication with all stakeholders for successful implementation of the proposal. Finally, meet with stakeholders on a regular basis to identify and correct any limitations as needed. This will lead to a successful implementation of the activity. Refreezing is the third and final stage of Kurt Lewin’s theory of change. This stage involves maintenance of the implemented change. It is important to prevent going back to old ways . Refreezing is establishing the change as a new habit. Without refreezing, it is easy to go back to the old ways (Current Nursing, 2011). Regression will be maintained by creating a policy that includes the active and passive music intervention as first line intervention in management of disruptive behaviors. Carry out regular meetings with stakeholders for feedback; feedback is important for evaluation of the implemented change. Continue with staff education and trainings on a regular long -term basis through staff in service. Lastly, reward and celebrate change. Maintaining the change will ensure a safer, non-invasive way to reduce agitation in patients. ConclusionChange is a critical and long process that is usually met with resistance. Change requires systematic planning, organization, implementation and delegation to make it possible. With a diseases such as Dementia which widely prevalent and has no cure, behavior issues are always imminent . Unfortunately, most nurses in long term facilities tend to use pharmacological means to manage the behaviors . This practice does not help improve the patients quality of life nor does it maximize the patients capabilities. Nurses and healthcare providers with prescribing privileges need to be re-educated on the dangers of medication use to control behaviors as well as non-pharmacological dementia management such as music intervention which can make managing disruptive behaviors in dementia patients easier, more effective, less invasive and safer leading to a higher level of care in patients .This collaboration is important in reducing inconsistent care delivery which is characterized by unnecessary prescribing and changes in medication prescription especially psychotropics which may lead to adverse effects for these patients.Use of music as an intervention in demented patients is of great importance as music uses a number of interactive mechanisms, sensory, cognitive, affective, behavioral, spiritual and social. Music can access parts of the memory that are hard to reach in any other way (Moira, 2014). A study found that the effects of music lasts longer than the intervention (Pedersen et al., 2017). Music also enables human connection, provides purpose, order and enjoyment, music is nourishing and brings comfort in turn reducing disruptive behaviors. Music also develops relationships, fosters togetherness and can refresh lost memory (Olderog & Smith, 2015). ReferencesCenters for Medicare & Medicaid Services. (2012). Details for: CMS announces partnership to improve dementia care in nursing homes. Retrieved February 28, 2013, from http://www.cms.gov/apps/media/press/release.asp?Counter=4368&intNumPerPage=10& Current Nursing. (2011). Change Theory: Kurt Lewin. Retrieved March 8, 2013, from http://currentnursing.com/nursing_theory/change_theory.html Department of Veterans Affairs Health Services Research & Development Service. (2011). A Systematic Evidence Review of Non-pharmacological Interventions for Behavioral Symptoms ofDementia.Retrievedfromhttp://www.ncbi.nlm.nih.gov/books/NBK54971/pdfDesai, A. K., & Grossberg, G. T. (2011). Recognition and Management of Behavioral Disturbances in Dementia. Primary Care Companion to the Journal of Clinical Psychology, 3(3), 93-109. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC181170/Massachusetts Senior Care Foundation. (2013). Reducing antipsychotics in Massachusetts nursing homes using the OASIS curriculum (ECCLI special project). Retrieved from Mass Senior Care website:http://www.google.com/url? McDermott, O., Orrell, M., & Ridder, H. M. (2014). The importance of music for people with dementia: the perspectives of people with dementia, family carers, staff and music therapists. Aging & mental health, 18(6), 706-16.Moira, C. (2014). Soothing sounds: reducing agitation with music therapy. Nursing and Residential Care. 16. 217-221. 10.12968/nrec.2014.16.4.217Olderog K., and Smith M., (2015). The influence of group singing therapy on the behavior of Alzheimer’s disease patients. Journal of Music Therapy, 26, 58-70.Pedersen, S., Andersen, P. N., Lugo, R. G., Andreassen, M., & Sütterlin, S. (2017). Effects of Music on Agitation in Dementia: A Meta-Analysis. Frontiers in psychology, 8,742. doi:10.3389/fpsyg.2017.00742Ridder, H. M., Stige, B., Qvale, L. G., & Gold, C. (2013). Individual music therapy for agitation in dementia: an exploratory randomized controlled trial. Aging & mental health, 17(6), 667-78.Särkämö, T., Tervaniemi, M., Laitinen, S., Numminen, A., Kurki, M., Johnson, J.K., & Rantanen, P. (2014). Cognitive, emotional, and social benefits of regular musical activities in early dementia: randomized controlled study. The Gerontologist, 54 4, 634-50.
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