nicheprogram.org • 2016 Annual NICHE Conference • Care ...Listening+for... · Synthesizer Selection #1 Comfort Zone Steven Halpern ... Piano Gigi #3 Nadia’s Theme Roger Williams

nicheprogram.org • 2016 Annual NICHE Conference • Care Across the Continuum1

Music Intervention to Prevent Delirium Among Older

Patients Admitted to a Trauma Intensive Care Unit and a

Trauma Orthopedic Unit

Kari Johnson

PhD, RN, ACNS-BC, Hartford Scholar

Introduction

• Delirium is a neurobehavioral syndrome characterized by

alterations in consciousness, attention, cognition, and

perception.1,2

• Hospitalized older adults have the highest rate of delirium.3

• Age related changes in the brain that contribute to delirium:

o Neurotransmitter imbalance

o Inflammation

o Physiologic stressors.4,5

Significance

• Neurotransmitter Imbalance

o Age related changes in the brain alter neurotransmission.

o Neurotransmitters serotonin (5HT), dopamine (DA),

norepinephrine (NE), acetylcholine (ACh), and gamma

aminobutyric Acid (GABA) are involved in delirium.7

o Iatrogenic factors with medications (sedatives, hypnotics,

anticholinergics) contribute to delirium.4


Significance

• Inflammationo Age related changes:

o Low grade inflammation with chronic neurodegenerative

changes in the brain.7

oCauses a more severe CNS response increasing

pro-inflammatory cytokines at areas of existing

inflammation, resulting in delirium.9

Significance

• Stressor

o Stress hormones are released due to a stress response

from surgery, pain, trauma, and systemic inflammation,

causing and prolonging delirium.7, 10,11

o Hospitalized older adults experience acute stress from

sensory impairment, medications, immobilization, physical

restraints, noise stimuli, and sleep deprivation.6

Significance• Music:

o A non-pharmacologic approach for delirium prevention.

o Addresses pathophysiologic mechanisms that contribute to

delirium.4

o Music can regulate stress and emotions through reflexive

brainstem responses caused by slow tempo, low pitch, and

simple repetitive rhythms.13

o Reflexive brainstem responses found to alter physiological

responses include decreased systolic blood pressure (SBP),

heart rate (HR), and respiratory rate (RR).13-16


Purpose

• Evaluate the feasibility of a music intervention for

delirium prevention among older adults in a Trauma

Intensive Care Unit (TICU) and a Trauma Orthopedic

Unit (TOU).

Specific Aim 1

• Specific Aim 1: Examine acceptability, demand, and

implementation of a music intervention among older patients in a

TICU and TOU setting.

o 1a. Acceptability: Participant evaluation of intervention

protocol and delivery mechanisms.

o 1b. Demand: Participant attrition rates and dose of music

intervention sessions.

o 1c. Implementation: Index of Procedural Consistency.

Specific Aim 2

• Specific Aim 2: Evaluate effects of a music intervention in

decreasing physiologic parameters (SBP, DBP, HR, RR), and

delirium prevention among older patients.

o 2a. Music listening (ML) group will demonstrate a decrease

in SBP,DBP,HR, and RR compared with usual care (UC)

group.

o 2b. ML group will demonstrate less delirium post-admission

compared with UC group.


Environmental

Stimuli

Focal

Contextual

Management

of stimuli17

Coping

Process

Regulator

Cognator

Modes of

Adaptation

Physiologic

Mode

Roy Adaptation Model

Intervention Components of a Music InterventionTheory

of the Problem

Critical

Inputs

Process

Variables

Expected

Outcomes

Extraneous

Factors

Implementation

Issues

Neuro-

Transmitter

Imbalance

Inflammation

Physiologic

Stressor

Regulator:

ML

(1) Slow

tempo

(2) Simple

repetitive

rhythm

Cognator:

(1) Self

selected

music

Adaptive

Physiologic

Response to

Focal

Stimuli:

(1) SBP

(2) DBP

(3) HR

(4) RR

Adaptive

response:

Prevent

delirium

Noise

Stimuli

Bright

lights

Interruption

from care

ICU setting

intervention

Delivery

intervener

Research Design and Methods

• Design

o Randomized

o Sample

o N = 40 older adults

oML group (n = 20)

o UC group (n = 20)

• Setting

o TICU: 22 bed trauma intensive care unit

o TOU: 37 bed trauma orthopedic unit


Sample • Inclusion criteria:

o 55 years and older

o Oriented on admission

o Confusion Assessment Method (CAM-ICU)

negative on admission

o Hearing intact

o Provide consent

o Not intubated

Methods: Music Intervention Protocol

• Self-selection of music

o Slow tempo – 60-80 beats per minute

o Simple repetitive rhythm

• Delivered with iPod and headphones

• Dose: 60 minutes twice a day (2 p.m. and 8 p.m.)x 3

days

Music SelectionsStyle Selection Tape or CD Artist

Synthesizer Selection #1 Comfort Zone Steven Halpern

Harp Gnossienne #2 Fresh Impression Georgia Kelly

Piano Gigi #3 Nadia’s Theme Roger Williams

Orchestra Symphony #4 Beethoven Cleveland

Orchestra

Jazz When Joanna

Loved Me #5

Easy Living Paul Desmond


Variables and Measurement• Acceptability

o Intervention of Acceptability Questionnaire

• Demand

o Study attendance/Attrition rates

• Implementation

o Index of Procedural Consistency

• Physiologic Parameters

o SBP, DBP, HR, RR

• CAM-ICU score

Data Management and Analysis

• Specific Aim 1

o Means and SD for continuous variables

o Frequencies and percentages

• Specific Aim 2

o Descriptive statistics

o Repeated Measures ANOVA

o Post Hoc Analysis

o Pairwise Comparisons

Demographic Characteristics UC Group (n=20) ML Group (n=20) Total

Age : Range 58-87 58-86 58-87

Race: White Caucasian 16(80%) 18(90%) 34(85%)

Gender: Female 17(85%) 17(85%) 34(85%)

Widowed 8(40%) 9(45%) 17(42%)

Married 6(30%) 7(35%) 13(32%)

Adm. Dx. Respiratory 5(25%) 5(25%) 10(25%)

Adm. Dx. Gastro- intestinal 4(20%) 6(30%) 10(25%)

Adm. Dx. Cardiovascular 4(20%) 4(20%) 8(20%)

Adm. Dx. Bone 5(25%) 3(15%) 8(20%)

Medication: Analgesic 14(70%) 15(75%) 29(72.5%)

Medication: Cardiovascular 11(55%) 12(60%) 23(57.5%)


Results: Intervention of Acceptability Questionnaire

Variable n % Variable n % Variable n %

Overall ML was

helpful

ML helped with anxious

thoughts

Satisfied with number &

length of sessions

Strongly Agree 3 15 Strongly Agree 2 10 Agree 7 35

Agree 17 85 Agree 8 40 Disagree 11 55

ML helped me relax Would recommend ML

to others

Wearing headphones

was comfortable

Strongly Agree 2 10 Agree 14 74 Agree 12 60

Agree 18 90 Disagree 7 35

Satisfied with ML ML helped me feel

more like myself

Using ML equipment was

easy

Strongly Agree 2 10 Agree 7 35 Agree 10 50

Agree 18 90 Neutral 7 35 Disagree 5 25

____________________________________________________________

Means and Standard Deviations for ML in Minutes by Session

________________________________________________________

n Minimum Maximum Mean SD

________________________________________________________

D1T1 20 53.00 60.00 1.400 .8826

D1T2 18 35.00 60.00 1.056 .2357

D2T1 17 60.00 60.00 1.000 .0000

D2T2 14 30.00 60.00 1.286 1.069

D3T1 6 45.00 60.00 1.333 .8165

D3T2 4 40.00 60.00 2.250 2.500

______________________________________________

___________

Reasons For Missed Scheduled Doses

0 2 4 6 8 10 12 14 16 18

D1T1

D1T2

D2T1

D2T2

D3T1

D3T2

D1T1 D1T2 D2T1 D2T2 D3T1 D3T2

Family Visits 0 0 1 0 1 1

Medication Request 0 0 0 0 1 3

Procedures 0 0 0 2 1 1

Transfers 0 1 1 0 8 2

Discharge Planning 0 1 1 4 3 9


Results: Index of Procedural Consistency

D1T1 D2T2

Achieved Very Well 12(60%) Achieved Very Well 6(43%)

Achieved 4(20%) Achieved 5(36%)

D1T2 D3T1



D2T1 D3T2



Repeated Measures ANOVA for Variable D1T2SBPpreML and

D1T2SBPpostML

____________________________________________________

Variable df1 F p

____________________________________________________

D1T2SBPpreML

and D1T2SBPpostML 1 10.44 .003

____________________________________________________

__________________________________________________

Means and Standard Deviations for variables

D1T2SBPpreML and D1T2SBPpostML

________________________________________________

Variable M SD

_________________________________________________

D1T2SBPpreML 136.37 18.48

D1T2SBPpostML 132.71 17.80

_________________________________________________


130

131

132

133

134

135

136

137

D1SBPpre2 D1SBPpost2

Mean score of D1T2SBPpreML, D1T2SBPpost ML

Mean

_____________________________________________

Repeated Measures ANOVA for Heart Rate (HR) ML

_____________________________________________

HR ML df1 F p

_____________________________________________

D1T1HRpreML,

D1T1HRpostML,

D1T2HRpostML,

D2T1HRpostML,

D2T2HRpostML 4 4.75 .001

______________________________________________


_____________________________________________________

Means and Standard Deviations for variables D1T1HRpreML,

D1T1HRpostML, D1T2HRpostML, D2T1HRpostML, D2T2HRpostML

_____________________________________________________

HR ML M SD

____________________________________________________

D1T1HRpreML 80.18 14.13

D1T1HRpostML 80.92 13.73




_____________________________________________________

70

72

74

76

78

80

82

D1HRpre1 D1HRpost1 D1HRpost2 D2HRpost1 D2HRpost2

Mean scores: D1T1HRpreML, D1T1HRpostML, D1T2HRpostML, D2T1HRpostML, and D2T2HRpostML

Mean

___________________________________________________________

Mean and SD for CAM-ICU scores T2, T3, and T4 for ML and UC group

_____________________________________________________________

ML = 1 UC = 0 N M SD

_____________________________________________________________

CAM Negative: ML

T2 19 2.00 .000

T3 17 2.00 .000

T4 4 2.00 .000

CAM Negative: UC

T2 19 2.00 .000

T3 14 2.00 .000

T4 7 2.00 .000


• “I am not sure if I was anxious, but the music did help me relax.”

• “I was not anxious, but I did feel nervous not knowing.”

• “It was a nice distraction and overall I found it very calming.”

• “The headsets did not completely block out noise, I could hear my

neighbor talking on phone.”

• “I do not like headsets with my oxygen.”

• “I would like a music player at my bedside so I can listen when I am

feeling anxious.”

• “I would have preferred to listen when I wanted to, company or the Dr.

may be here during scheduled times.”

• “Your choices were calming, but I like my music that I have at home.”

Summary• Strengths:

o Randomized design

o Use of a theory based intervention

o Innovative use of an established intervention with a

different patient population.

• Limitations:

o Increase in missed intervention sessions over time.

Results• Support for ML among older adults admitted to a TICU and TOU

setting.

• Over time statistically significant differences in HR with ML group

compared to UC group.

• Statistically significant differences in SBP with ML group compared to

UC group.

• All participants (ML and UC) remained CAM-ICU negative.

• Evaluation of Intervention Acceptability:

o 85% agreed or strongly agreed that ML was helpful in the hospital.

o 90% helped participants relax


Implications for Further Research

• Setting Implications

• Dose and Delivery

• Sensitivity of outcome measures

• Emerging characteristics of delirium

• Patient acuity

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nicheprogram.org • 2016 Annual NICHE Conference • Care ...Listening+for... · Synthesizer Selection #1 Comfort Zone Steven Halpern ... Piano Gigi #3 Nadia’s Theme Roger Williams

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