Improving Care of Assisted Living Residents with Alzheimer’s/Dementia Through Innovative Interventions Such As Music Therapy

Veranda K. Melton
Chamberlain College of Nursing

NR702: Project and Practicum I

August Session, 2016

Care of Assisted Living residents with Alzheimer’s/Dementia

            Alzheimer’s/Dementia has been noted as one of the most riveting problems of community health.These disorders frequently lead to a defined decline in cognitive and physical abilities in those who are affected and eventfully requires a large amount of care, assistance and patience.  Greater than ten percent of Alzheimer/s/Dementia disease victims experience major depression that often lead to distress. Individuals suffering from depression exhibit more severe behavioral signs and more severe vocally agitation thanindividuals without depression[AH1] . Anxiety is also prevalent amongst individuals with Alzheimer’s/dementia and is also associated with behavioral issues and limits in activities of daily living, in addition to decreased ability to function socially and diminished independence.

Specialty Care Assisted Living Facility (SCALF) is an assumed name for assisted living memory care institutions in Alabama serving elderly persons with Alzheimer’s /dementia.  The amenities offered by the facility include assistance with activities of daily living, medication administration and management, social, spiritual, physical, and intellectual stimulation via group and individual hands on contact.  [AH2] Innovative interventions such as music therapy during times of care may improve caregivers’ abilities to manage behavioral and emotional signs for assisted living caregivers thus providing optimal care for patients with Alzheimer’s/dementia. The determination of this doctor of nursing practice (DNP) project is to develop and implement music therapy during times of care and evaluate the behavior of residents pre and post study utilizing the Cornell scale for depression to improve the care of for depression to improve the care of Alzheimer’s/dementia residents and eventually improve the physical and social well-being of both the residents

Significance of the Practice Problem

            Greater than forty percent of the SCALF residents display behavioral signs during some point through the day.  Staff caring for SCALF residents report these inappropriate behaviors exhibited by residents poses chief challenges in providing care for their residents.  Reports further indicate the greatest prevalent behaviors causing the highest distress were: (1) refusal to allow staff to assist with activities of daily living, (2) “sundown” (amplified confusion and anxiety towards the end of the day), (3) agitation, (4) and, physical and verbal aggression towards other residents and staff.

            According to Spurlock (2005), staff difficulties in management of patients with behavioral symptoms and in SCALF is constant with findings in the available literature on Alzheimer’s/dementia. At this time, it is common for SCALF residents establishing inappropriate behavior such as anxiety, agitation, and depression have a doctor’s order for as-needed medication formanaging the above problems.  Pharmacologic administration has becomeacknowledged by the SCALF nursing staff as an effective answer for managing challenging behaviors; nevertheless, according to Jeste (2007), pharmacologic therapies have been confirmed to be clinically unsuccessful with substantialdanger of cardiac and vascular antagonistic effects, possibly resulting in death.

            The ideal innovative intervention for management inappropriate behaviors is non-pharmacological.  Music therapy programs have been shown to lead to a lessening of behavioral signs in individuals suffering with Alzheimer’s /dementia in addition to as reduced stress in staff providing care for this population[AH3] [AH4] 

PICOT Question[AH5] 

Does listening to music during times of care reduce anxiety levels compared to not listening to music in residents living in Assisted Living as measured on a Cornell Scale for Depression? The setting [AH6] that this question refers to is inappropriate behaviors exhibited by cognitive impair individuals residing in assisted living facilities. This is a vulnerable population and most behaviors are often unrecognized by the residents and can be very challenging for the staff who is attempting to provide care.Anxiety can have anundesirableoutcome on the resident’s welfare that can optimally become a safety concern. Application of innovative non-pharmacologic interventions such as music therapy have been recognized to improve outcomes in assisted living as well as resident quality of life and well-being (Mikkelsen, Ballard, & Arsland, 2010).

Pharmacologic administration is frequently used to aid resident’s inappropriate behaviors.  Yet a number of studies have been completed on nonpharmacological approaches to reduce depression/anxiety. One of these approaches is music therapy. Listening to music is aeasingmethod that can help reduce anxiety levels in cognitive impaired residents. Music is a cost-effective, relaxed innovative intervention that caneffortlessly be modified into many resident settings. The outcome for resident is an decreased incidence of depression and anxiety as evidenced by indicators such as corporation in tasks of daily living, smiling, and rating on depression scale in addition to a decrease in pharmacological interventions resulting in less side effects and secondary complications such as constipation, over-sedation, and possible increased agitation

 Theoretical Framework

Effectivetransformation of repetition behavior involves elimination of walls to change, delivery of managementprovision, and support for lastingrevision of the innovative practice.  The perceptions of Kurt Lewin’s (1947) change theory are notedverybeneficial for quality improvement resourcefulness to encourage transformation of practice (Rice, 2014; Zand &Sorensen, 1975).  Lewin’s theoretical framework suggests that change should happen in multiple stages: (1) unfreezing, (2) advancingto a new level, and (3) refreezing (Lewin, 1947), as visualized in (Appendix A)

Unfreezing requiresformulating individuals for change by making it possible for them to break old patterns and by removingwalls to change: giving information on the project and talking about their apprehensionsconcerning the project.  Unfreezing also includes providing awareness and acknowledgement of the need to change by provingindications that existing practice does not provide enhanced practice ideals. 

Advancing to a new level requires clear knowledge of recommended new concept(s) open dialogue, training[AH7] , supervision, and regular response between all parties involved.

Lastly, refreezing [AH8] requiressupporting this new concept or change in practice to encourage opportunities for this new concept to be sustainable through guidance and direction, creating the new design, and standards (Cummings & Huse, 1989).

            Lewin’s force field analysis as visualized in (Appendix B) confirm that the new standard of practice iseffective, maintainable, and discouragessetbacks (Lewin, 1947).  The use of this theoretical framework[AH9] , providespositive change that isattained by establishment of incentives to prefer change such as:  job gratification, and decreasing the limitinghindrances, which may include:uncertainties that come with change.  Change and force field analysis theories were useful in the development of music therapy being provided at times of care and will assistance to obtain knowledge of interventions that aid in behavioral problem solving that will promote alternatives to pharmological approaches seeking an optimal goal of reducing depression and anxiety in residents residing in assisted living facilities.

Synthesis of the Literature

Analysis of the available literature on the existing innovative interventions available to assist in care of residents with Alzheimer’s/Dementia.with depression and anxiety and included: rate of recurrence, financial obligations, conclusions, and efficiency interventions informed the development of this project. Google Scholar, Medline, andPubMedin addition toCINAHLdatabases were investigated for existingindication using the following keywords and phrases: dementia, innovative interventions, depression and anxiety, music therapy.

Care[AH10]  of Residents with Alzheimer’s/Dementia

According to the 2011 National Alzheimer’s Project Act (NAPA)The welfare and behavioral constancy of individuals with dementia is directly impacted by the well-being of their caregivers.Completecohesiveattention and quality enhancementcreativities must be clear and hands-on.[AH11] 

Dementia[AH12]  Care in Assisted Living facilities

  According to Kopetz, (2000) assisted living facilities (ALFs) are the primary option for residential care for individuals over the age of 65. National Center for Assisted Living (2013) states, ALFs are controlled by the state in which they function; leading rules and regulations to vary in from state to state.  Alabama is the state that this project will be implemented, admission requirements do allow for a diagnosis of dementia however the prospective individual must pass a medication awareness test, not be an elopement risk and actively participate in their daily care needs in addition to medical exam with a plan of care, andprovide proof they are free of communicable diseases. The state of Alabama does not require that a licensed nurse be present for ALFs but does requires that each resident be capable of managing his/her own medications. SCALF facilities are required to have a licensed nurse at times of medication passes in addition to a register nurse to assess and assess each cognitive impaired resident as least monthly.                                  Alabama[AH13]  also does not specify staff-toresident ratios for ALFs however does have specific guidelines for SCALFs. It is required that each facility be able to meet the needs of each resident in addition to being able to safety evacuate in case of emergency. Alabama Category I (ALF) administrators are required to complete a minimum 20-hour classroom training for initial certification and pass section A of the administrator licensure exam on the Rules of the Alabama Department of Public Health, for Assisted Living.  Category II (SCALF) administrators are required to complete a minimum 30-hour classroom training.Administrators are required to present 24 continuing education hours with a minimum of 8 hours being Dementia specific and pass section A and B of administrator licensure exam.

Cost/Incidence of Treating Depression And Anxiety[AH14] 

Over sixty percent of individuals suffering with Alzheimer’s/dementia remain home with family serving as caregivers. Depression and anxiety exist resulting from the challenges involved in dealing with these disorders.Cost-effectiveness of anemotional intervention have been developed in an effort to combat these complications. Cost of caring to individuals with Alzheimer’s/dementia is said to be greater than six billion dollars per year globally. These costs include medical, and community care. According to Hermann (2006), patients suffering from Alzheimer’s/Dementia with Behavioral and psychological symptoms of dementia (BPSD) in a community setting was over $16,000 yearly per patient opposed to managing care for those who do not have BPSD at a considerable lower rate of $7,000 yearly per patient.

Burden of Care

Kales, Gitlin, & Lyketsos (2014) note that those managing the care of individuals with dementia face a higher level of burden than those managing the care of other chronic disease with much of the increase in burden is due to managing behavioral issues[AH15] . 

Antipsychotics[AH16] and Dementia Patients

 Non-medicationapproaches to address behavioral signs in individuals suffering from Alzheimer’s/Dementia have not been approved and have been linked to increased risk of death for the elderly population being administrated these drugs however over fifty percent of patients are still receiving pharmacologic interventions. [AH17] 

Managing[AH18]  Behaviors in Patients with Alzheimer’s/Dementia

Researchreveals the use of nonpharmacologic methods as the primarybeneficial intervention for behavioral symptoms have been successful and supports non-pharmacologic behavioral interventions as a best practice approach.Inappropriate behaviorsrequire knowledge of behaviors and the primary causes, which is vital in the appropriatefollow up of behavioral symptoms (Tripathi & Vibha, 2010).    Behavioral symptoms[AH19] can be addressed through non-pharmacologic approaches, such as music therapy.

Music Therapy Strategies[AH20] 

An analysis of the literature revealed current and reasonable behavioral interventions strategies to improve staff assistances in management challenging behaviors of assisted living residents with dementia. [AH21] Music therapy will make important contributions to management for decreasing behavioral symptoms and has had modest effects on anxiety and behavioral symptom[AH22] s. Music therapy undoubtedly assists as a valuable service positively influencing the behavior of elderly patients with dementia and those caring for them.Applicable literature exists observing the benefits and how important to value of music therapy programs can be for the elderly, especially for those diagnosis of Alzheimer’s/dementia.[AH23] 

Nonpharmacological treatments such as music therapy are frequently suggested in caring for residents with noted neuropsychiatric symptoms (NPS) secondary to their diagnosis of dementia in long term care (LTC); yet, limited data is available as to the viability of interventions, given the availability of resources [AH24] in typical LTC environments.Forty investigations were appropriate for measures. Forty percent of these studies described substantial outcomes favorable of interventions options other than pharmological on more than one review of NPS. Interventions involved staff training in NPS managingapproaches, mental health evaluations and action plans, workouts,entertaining[AH25] activities, and music therapy and other sensory motivation. A number of studies had procedurallimits that posedprobable risk of bias. Record interventions (75%, n = 30) depend upon valid means from assistance apart from LTC or substantialtime assurances from LTC nursing staff for application[AH26] [AH27] .

Ethical[AH28]  Considerations

It is the desire that this quality improvement project be accepted by the DNP committee as exempt from Institutional Review Board approval by the University of University of Alabama Committee on Human Research.  Development, reflections associated with respect for beneficence, justice, persons and up-to-date consent will be evaluated.  The participants in the project will be consenting adultstaff who manage the care of residents on a SCALF facility and are employee with the University of Alabama.  No problems of confidentiality or privacy for subjects have been noted, noapprehensionsconcerning the confidentiality of namelessly collected quality improvement data.  Involvement in this DNP project will not reflect in the participant’s job performance evaluation.  Additionally, residents[AH29] in the facility will be observed for changes in behavior while music therapy is included during times of care with a pre and post Cornell depression scale being completed.

 Beneficiaries of this project implementation will be both direct and indirect.

1.      Direct- Residents who reside in Assisted Living facilities suffering from Alzheimer’s/Dementia who have secondary complications such as depression and anxiety who are challenging to care for without interventions.

2.      Indirect - Staff managing the care of residents suffering from Alzheimer’s/Dementia who exhibit signs of inappropriate behavior and present as challenging to meet their daily needs[AH30] .

Association to Other Evidence[AH31] 

There is an inadequate consideration[AH32] for obtainable printed literature regarding music therapy during times of care as an intervention to manage behaviors such as depression and anxiety in Assisted Living facilities.According to Day, Carreon, & Stump (2000), a large number of the studies for non-pharmacological behavioral and music therapy were conducted in long term care facilities or group homes settings[AH33] . Review studies not only provide understanding of efficient interventions, specifically in investigating behavior issues in caring for individuals with dementia, in addition close several gaps in understanding component care methods require advanced research.

Practice Recommendations

Based on review the literature, the intent of the project is to implement a music therapy program at times of care that will request change in practice.  The hypothesis, as Lewin (1947) implied, persons who take part in activity often are resistant to change.  In an effort to reduce incidents of resistance, this practice improvement project is being developed with second opinion of staff members who are challenged by inappropriate behaviors, Medical Director, Unit Coordinator, Care Plan Coordinator, and the Music department for the University of Alabama. The decision to develop a music therapy program project results from staff seeking alternatives in managinginappropriatebehaviors in SCALF facilities to pharmological interventions which cause additional issues such as over sedation, increased agitation, and delay in pharmological intervention changing behavior.   This project isintended to give a reasonablethought of inadequate resources with consideration to funding and time constrains. This project is being developed with the following thought processes:

1.      Frontline staff voiced their concerns and requests for alternatives that they could implement in managing the care of residents who are resistant to care due to inappropriate behavior.

2.      These individuals identified issues that make their task of providing care difficult and why alternative methods should be considered that included the time it takes for medications to work, the noted change when they sing of incorporate music into activities of daily living in addition to the problems that arise from medications currently being given with the chief complaint being increase drowsiness. 

3.      Accessibility of available interventions was of great concern as many spoke of the license nurse having to intervene causing a delay in opportunities to provide care.

As identified from the interviews, and direct observation of the staff caring for this population, the implementer this project has determined challenges do exist related to caring during times where resident exhibit inappropriate behavior[AH34] [AH35] . The particular findings are in line with research previously completed (Sloane, Zimmerman, & Ory, 2001)[AH36] 

            The primary approach for the planned improvement/change will involve the development of a music therapy program that will be individualize according to each resident need and preference daily during times of care in addition to the previously scheduled weekly group music therapy sessions with pre and post evaluations that will indicate levels of depression and anxiety.

Project Setting

The project setting is a 16-bed specialty assisted living secured dementia facility in Tuscaloosa, Alabama.  This facility is a part of a continuing care community owned and operated by the University of Alabama (UA) and is location on the UA campus. This facility assists in the care to include activities of daily living for individuals who are diagnosis with Alzheimer’s/Dementia and other disorders causing cognitive impairment.    The facility is a 100% occupancy with a waitlist and 100% of the current residents have a diagnosis Alzheimer’s or other forms of dementia.  Over 50% of the current residents exhibit inappropriate behavior at least one time throughout the day. Of the residents, 100% are actively involved in music therapy on a group bases at least once a week with no incidents of inappropriate behavior noted during music therapy.  Staffing ratio is 4 to 1 resident-to-caregiver with 98% of residents being able to ambulateand no residents are bedbound. Staff have daily assignments that include provision of all activities of daily living (ADLs), laundry, escorting to doctor appointments and outings in addition to charting.Current procedure indicates that resident care aides report all inappropriate behavior to the license nurse who at that time follows up according to problem that is existing and may include medication, redirection, and/or distraction. All sixteen residents will have the opportunity to participate in the implementation of music therapy however if at any time resident(s) appear unwilling to participate either verbally or non-verbally, the will be removed immediately with opportunity for re-evaluation as necessary. Staff working in any shift to will be trained and able to assist residents with music as needed.  However key staff will be assisting in pre and post screening, evaluation of the project throughout in addition to participating in providing music at times of care as well.   Currently all staff completes training based upon the state required DETA(Dementia Education and Training Act) immediately upon being hired and prior to any contact with residents.  In addition the staff complete up to 40 hours of training on  facility policy/procedures, shift orientation and care of dementia which include managing inappropriate behaviors.

SWOT Analysis

                       The SWOT analysis (Appendix C) illustrates the need for innovative

interventions related topresent separationamong best practice and existing practice in managing inappropriate behaviors in caring for dementia residents.  The recognized SWOT essentials will direct the writer in development and helpplanapproaches to implement in the facility.  Strengths (S) for this project consist of:

1.      Alabama requires that all staff be trained on DETA when working on a SCALF unit and this training includes how to manage care of residents who exhibits inappropriate behaviors.

2.      The University of Alabama music department supports this project and has offered to assist in any way they can

3.      This project has received the endorsement of the facility medical director

4.      Music therapy program that will be implemented individually during times of care as well as within groups setting

5.      This intervention can be implemented by any care staff member and will allow for immediate change in behavior.

 Weaknesses (W) of this project may include:

1.      Not enough data to support practice change

2.      Music therapy may not be effective on a regular continuous bases

3.      Inability to utilize this intervention due to limitations in hearing.

4.      Staff non-adherence to practice change

Opportunities(O) for this project:

1.      Caregivers will be able to provide non- pharmacological interventions for Alzheimer’s disease and Dementia thereby decreasing the current delay in providing care.

2.      Reduction of sedatives and reducing unwanted side effects

3.      Decrease in inappropriate behavior such as agitation, and anxiety.

Threats (T) to this project:

1.      Undesired behavior resulting from introduction of music therapy during times of care

Project Vision, Mission, and Objectives

The vision of this project is to provide an innovative intervention that will assist in the reduction of anxiety at times of care for residents who suffer with Alzheimer’s/Dementia residing in Assisted Living and Long term care facilities. This vision was created based uponevaluation of residents being over sedated and inappropriately addressed by staff.  Additionally, the staff noted frustrations in attempting to handle inappropriate behavior or having to wait for medication to take effect prior to assisting resident which causes increase agitation for all parties involved. Music therapy currently exist [AH37] within this setting and is noted to change moods upon listening had staff asking for more. Many began to sing to residents as they attempted to shower them and it appeared to calm most. This began research on music therapy as an innovative intervention.

 The mission statement is providing leading retirement living in an atmosphere that promotes dignity and respect. Search for enhancement in physical, emotional, cultural and spiritual well-being of residents, calling upon the resources of a caring professional staff and a cohesive relationship with The University of Alabama[AH38] .

Project Plan[AH39] 

Understanding that this intervention will add to the existing busy schedule of staff who are very task oriented.  , I [AH40] plan to invest in key staff members to assistance in the introduction of this change in practice. This staff include our Unit Coordinator, Care Plan Coordinator, Activity Coordinator, Medical Director, and Lead Resident Aide. The Activity Coordinator and I have [AH41] met with the Music Department at the UA and they will continue to provide weekly music therapy session as residents are very routine and I did not [AH42] want to confuse them with eliminating one type of music for another and feel the addition of individual music selection will enhance the program currently in place. The UA will assist the Activity Coordinator make personal selections for each resident and will help to coordinate music tones and what is to start and end as well as songs that will best fit when behavior is inappropriate based upon their involvement with the residents and previous history. The Care Plan Coordinator had been trained on the use of the Cornell depression scale to include how to score residents which was noted as straight forwarded and user friendly. This assessment was selected due to not having to touch the resident and the ability to observe and score. IT has built this assessment into our system with an automatic scoring based upon the answer/observation given. All 16 residents will receive a baseline assessment/score and will be re-assessed on at least 3 different occasions throughout this project. 

I invested in 6 iPods [AH43] [AH44] with cordless earphonesat a cost of $1500.00.  The iPods will be shared between residents therefore a policy and procedure was created for cleaning between use. The Activity Coordinator has been taking small groups to the “quiet room” and introducing them to this new manner in which to listen to music. The residents were accustomed to hearing music live through instruments such as drums, guitars, and flutes in group settings or through IPhones through speakers. We have noted no resistance to the iPods and continue to allow for adjustments. We have introduced the concept of this program to care staff in the July meeting with positive feedback, with time constrains being the number concerns. We discussed the logistics of getting the IPod for the secured location which is not on the unit and then allowing the resident to “warm up to the new concept of listening to music via earphones. The majority of the staff voiced that this would be “new” every time however identifying that they would actually place them on prior to the resident getting up in the morning for am care, and would be consist in how they apply them it would become routine quickly. Several staff members were excited and stated that they currently sing to the residents to get them up and feel this would be easier on their ears so the feedback was very positive. After the discussion, a decision was made to place the ipods on the unit and keep them in a locked cabinet that the leads residents aides on each shift will dispense to staff at the beginning of each shift and will take them up at the last round on evening shift, at that time the nurses will dispense them as needed for residents who are toileted every 2 hours throughout the night and/or who have a tendency to exhibit inappropriate behaviors. It was also discussed that they will be an attempt to provide music through the ipods at times when staff is aware that residents become more anxious such as at shift change, time to get up or go to bed and several suggested that the ipods be placed on prior to 5pm for those that are known to show signs “sundown”. The music department is in discussion as to what is considered “too much” music throughout the day and I continue to research this aspect as well. I am also working with my preceptor who is our past medical director and our current medical director on recommendations for number of hours listening to music in via ipods is appropriate.

I plan to provide incentives for the staff that will include gift cards, lunch for the shift who provides the most music interventions in one month, recognition at staff meetings in addition to personal shows of gratitude. I will also be looking for mentors in this project that can help other staff member who may not feel comfortable with implementation, the use of the ipods, or knowledge of when to and not to include to music therapy in addition to guest speakers including family members who can give first account of the experience and noted changes in personalities, behaviors, and physical appearance.

Doctors will be notified of the progress of music therapy in their residents who are not current patients of our past or present medical director in an effort to show that non-pharmological choices can be an alternative to managing behaviors and hopefully they can also communicate this information to their patients who are being managed in home care settings and Long term care facilities. 

There will be procedure for individualize music therapy developed and placed in the resident aide shift book in addition to in the nurses’ work room that will provide clear guideline that need to followed on each occasion of music therapy during times of care. There will also be a section in the currently charting regimen that will include a space to document when and why music therapy was initialed and the resident and will be simple to include effective (resident calm) or ineffective (resident remain anxious) however will prompt them to complete next task with is report to nurse for further intervention. I have informed all family members who appear excited about this new intervention and plan to update them within 5 weeks of starting this program as to any changes and ask for in sight as to their visits since implementing music therapy during times of care. I will continue to gather and analyze the data. I plan to meet with nurses prior to the implementation of the program and instruct them to use music therapy in case where the resident is showing signs of inappropriate behavior and to document incidence where this was done as opposed to offering medications and include the results and any further intervention. I have asked that the Activity Coordinator provide instruction class on how to get to a specific selection on the IPod for staff in anticipation of a resident showing preference to a particular song and also helping to come up with a strategy in case the preference is on a IPod being used by another resident in light of the fact that only 6 were initially purchased. 

It is of concern that lack of staff oversight may cause inconsistencies in provision of music therapy and this could prove detrimental to the resident. In an effort to avoid this from occurring, the flow sheet will be check off by the nurse on duty and any absent of therapy will immediately be address hopefully preventing future incidents. 

I am creating a folder that will be based on the ABC model (Appendix D) and will include policy and procedures, behavior intervention flow sheet, music therapy suggestion times, quick reference on use of IPod in addition to family/staff comment sheet.

Project Evaluation Plan[AH45] 

This innovative intervention project consists of:

1.      problem exist in caring for cognitive impaired individuals in Assisted Living facilities who exhibit inappropriate behavior

2.      investigation of indications that could lead to resolving the problem

3.      Developing an innovative intervention created on evidence-based research that could provide best practice.

4.      Development the application and assessment of the intervention: in this case, music therapy during time of care

5.      Documenting the findings

The methods observed normal project development, implementation, and evaluation protocols:

1.      Recognition of concern/problem

2.      Developing strategic approach

3.      Implementing of strategic approach

4.      Assessment of implementation

The successful implementation of music therapy during times of care will be evident by a documented reduction of inappropriate behavior in residents noted by a decrease in medication and increase in smiling, allowing staff to provide care. Staff will have an opportunity to provide feedback and reflect the benefits in how they are able to manage care noted by a post implementation satisfaction/comment   It is the hopes that the implementation of the f music therapy at during times of care will show useful in the reduction of inappropriate behavior such as anxiety and depression. The optimal goal would be for Assisted Living across the globe to have this implementation available for their communities and that this will begin the discussion of other non-pharmological interventions in care of the elderly suffering from Alzheimer’s/Dementia.

Pre-screening for this project will help to identify those at risk for inappropriate behaviors and will be compared to behavior scales during the project and at the completion. It is hopeful that the finding will show improvement for those who were predisposed to inappropriate behaviors while providing those who were low risk with no additional stressor that could cause unwanted behaviors.

During implementation the residents will receive monthly assessments of behavior, weight, and vitals to ensure that they are not being comprised by the project and due to their possible limitations in communicating unwillingness to participate, the above mentioned tools can serve as a guideline as to how the residents are managing during with this new concept. The above mentioned assessments are currently completed monthly and will in no way place the residents at any risk or undue hardship. The data will be observed for different indicators and the information complied to support the success of failure of the project. Any resident noted verbally or non-verbally to not want to receive music therapy via IPod will have the option of traditional listening to music via radio with a CD of common music types for the era in which residents most identify and will continue to be a part of the project as the methods remain intact. Family members will be encouraged to participate and offer music if they note residents becoming anxious of showing signs of agitation, there will a flow sheets at the bedside of each resident participating in the project and staff will be able to assist with equipment and explaining recommended times for each session. I will present this project at our annual family night the end of this month and will be available to address questions and discuss one on one for those who are interested in volunteering or assisting with getting music selections for their loved ones based on past preferences.

I will attend monthly and as needed meetings with my supervisor to discuss the staff and resident reaction to the project, I do not anticipate any overtime nor do I foresee any need to use additional equipment or tools from the facility.

Plans for Dissemination

        For the internal dissemination of this project, there will be a formal invitation sent to our Executive Director, The Head of the Music Department, my mentor and preceptor, my medical director, our staff of nurses, activity coordinator and resident aides, and the families of our residents.I plan to present my findings to the above in a 20-25 presentation through a power point presentation that will be scheduled a time that fits the needs of the group. For the online Chamberlain project presentation, I plan to invite my DNP mentor, and preceptor. This presentation will take place online via live stream. 

             External Dissemination I am hopeful to submit my manuscript to the Journal of the Alzheimer’s Association. I have recently become a member of the Alzheimer’s Association however have been involved in several projects over the years to include “A walk to end Alzheimer’s” which is held yearly in over 500 communities worldwide, this is the largest event to raise awareness and monies for Alzheimer’s care, research, and support.  and would like to contribute my research to the field. Abstract submission for 2017 opens in November. I also am planning to attend the Alzheimer’s Association International Conference July 2017 and converse with professionals who are seeking non-pharmacological methods to address behaviors in individuals who are cognitively impaired and will submit my abstract to them in November as well if polished by the deadline.  The Alzheimer's Association founded and launched Alzheimer's & Dementia^®: The Journal of the Alzheimer's Association in 2005, providing a single publication for the global scientific community to share diverse knowledge about Alzheimer's science. This bimonthly publication is an influential journal in the field of Alzheimer's and dementia research and is indexed by MEDLINE.[AH46] 

Conclusion

This evidence-based change practice project intends to enhance care of individuals residing in Assisted Living facility who suffer from Alzheimer’s/Dementia by employing a music therapy program during times of care that can reduce inappropriate behaviors and as an alternative to pharmological methods of managing inappropriate behaviors.This project will also assess the effectiveness and feasibility of placing this program into practice globally as little to no literature currently exist. It i[AH47] s the hope to lessen challenges to implement the individualized music therapy programs, and offering a non pharmological intervention to reduction of inappropriate behavior in those suffering from Alzheimer’s/Dementia.

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Table 1

Budget

Figure 1

Appendix A

NOTE: Order these appendices in the order in which they were referred to in the paper.

Summary of Primary Research Evidence (this table may be single space[AH51] )

Appendix B

Summary of Systematic Reviews (SR) (this table may be single space[AH52] )

Legend:

Appendix C[AH53] 

Project Schedule