¶ … music therapy reduce the level of sundowning agitation of the elderly dementia in-Patients in comparison to standard care only or to no music therapy? Sundowning is a phenomenon that occurs within elderly people showing middle stages of dementia. Many treatments have been studied and offered to help reduce the level of sundowning agitation in these elderly patients. Some have used standard care only while other facilities se music therapy. Music therapy has been researched for quite some time and has resulted in some level of reduction in regards to sundowning agitation. However, it is important to compare the results to standard care in order to see which is more effective, or if a combination of both is the best treatment option.

In order to understand efficacy of treatments, especially in relation to elderly dementia in-patients, it's important to understand what sundowning is. Astonishingly, it is a question with a complex answer. Sundowning is an expressive term rather than a diagnosis

(KLAFFKE & STAEDT, 2006, p. 169). Various researchers have differing opinions and definitions on what sundowning is. There have been many complex attempts to study the symptom, determine what may cause it and its treatment. Generally speaking, sundowning is a "cyclical increase in agitation (which may include restlessness, confusion, disorientation, wandering, searching, escape behaviors, tapping or banging, vocalization, combativeness, and/or hallucinations) that takes place at roughly the same time every day" (Alzheimer's Compendium, 2011, p. 1).

Notwithstanding its name, and the wide-spread certainty that sundowning happens during late afternoon and early evening, studies suggest the peak of sundowning activity has a higher rate of occurrence in the early- to mid-afternoon. This can range from 1-2pm. And then other patients can have occurrences late at night. It has a broad time range with peaks occurring in some patients even during the early morning. It may even peak in the early morning in a fairly high percentage of patients. Sundowning is important to take note of because the occurrence of sundowning is typically linked to middle stages of dementia, and vanishes as the dementia progresses.

Numerous articles and researchers consider sundowning to be a kind of agitation, called "spontaneous agitation." The two factors that cause this are:

1. Confusion, over-stimulation, and fatigue during the day, which results in increased disorientation, restlessness, and insecurity at night. And 2. Fear of the dark, perhaps because of the lack of familiar daytime noises and activity and the lack of visual cues. The loved one may not be able to see as well in the gathering dusk, and/or be disturbed by strange shadows or reflections in window glass (Alzheimer's Compendium, 2011, p. 1).

Some may suggest sundowning is somewhat common with reports of sundowning in Alzheimer's patients being from the 10 -- 25% range, but have shown percentages as low as 2.4% and as great as 66% (Staedt & Stoppe, 2005, p. 507 -- 511). Because sundowning is hard to label and diagnose, reports of "sundowning" is largely dependent on the definition used to diagnose the patient and kind of population being diagnosed or studied. Therefore it is important to fully understand what sundowning is and how it can affect an individual experiencing it to develop a suitable and effective treatment plan.

In an article by Rindlisbacher & Hopkins (1991), links with sundowning and sleep disturbance may appear to be connected to each other since something such as sleep disordered breathing, can be related with a daytime behavior disorder. As the writers of the article share, because sundowning is so hard to understand and fully grasp, the treatment options available are not optimally suited for patients to reduce the occurrence of this disorder. "It is concluded that in spite of many references to it in clinical texts, sundowning remains a poorly understood phenomenon" (Rindlisbacher & Hopkins, 1991, p. 2-9). Conservative recommendations for treatment of sundowning behavior revolve around attempting to institute "good sleep hygiene" or good sleep habits, a reproduction of the commonly held belief that sundowning is a sleep disorder. This is where the standard of care in regards to sundowning stems from. Nevertheless is important to view other approaches to see how effective they are in treating sundowning agitation.

Wall & Duffy conducted a literature review with an aim to explore how music therapy affects the performance of elderly with dementia. Their information revealed that music therapy is frequently and casually used in residential care units to improve the communication, emotional, cognitive and behavioral skills in elderly patients who were diagnosed with dementia both on a national and international level. Their research revealed generally positive outcomes from introduction of music therapy. In fact they suggest that music therapy should be used with patients...

"Music therapy should be welcomed into care of the elderly settings in Ireland and elsewhere; however, more research is required to validate the effects of this therapy as a holistic tool to build altruistic connections between carers and clients" (Wall & Duffy, 2010, p. 108-113).
As it applies to standard care, an article by Cohen-Mansfield (2001), views the need for various options not including music therapy to reduce the untimely behaviors common in patients with dementia that are linked to sundowning. "Three main psychosocial theoretical models have generally been utilized to explain inappropriate behaviors in dementia: the "unmet needs" model, a behavioral/learning model, and an environmental vulnerability/reduced stress-threshold model" (Cohen-Mansfield, 2001, p. 361-381). The categories of interventions studied were: sensory which involved social contact, either real or simulated, staff training, behavior therapy, environmental interventions, structured activities, medical/nursing care interventions, and combination therapies. One of the reasons why treatments for dementia and sundowning tend to be so complex is because of the consideration of non-pharmacologic and pharmacologic methods to these types of patients. According to the reviewed literature, chronic pain syndrome, a consequence of arthritis and malignancy along with patients experiencing organ systemic disorders ischemic heart disease and asthma coupled with the possibility of psychiatric conditions such as anxiety and depression create the need for several avenues of treatment like prescription medication and behavioral therapy. In demented patients and patients with sundowning, physical uneasiness and illness may also be articulated as behavioral irregularities. Sundowning agitation can be a consequence of any of these conditions.

Another study by Ledger & Baker (2007) aimed to examine the long-term effects of group music therapy on agitation demonstrated by nursing home residents with Alzheimer's disease. The results were as follows: "Although music therapy participants showed short-term reductions in agitation, there were no significant differences between the groups in the range, frequency, and severity of agitated behaviors manifested over time" (Ledger & Baker, 2007, p. 330-338). They also go as far as to suggest numerous measures of treatment efficiency are essential to better comprehend the long-term effects music therapy programs have on this population. So yes music therapy does have a short-term application in reducing sundowning agitation, (sundowning is often experienced in patients with Alzheimer's disease) but there appears to not be enough concrete information providing long-term benefits. It appears many studies have come up with the same conclusion such as Opie, Rosewarne, & OConnor. "Despite this, there is evidence to support the efficacy of activity programs, music, behavior therapy, light therapy, carer education and changes to the physical environment. The evidence in favor of multidisciplinary teams, massage and aromatherapy is inconclusive." (Opie, Rosewarne, & OConnor, 1999, p. 789 -- 799).

There are articles available however that suggest that depression and the behavioral symptoms related with dementia continue to be two of the most noteworthy mental health matters for nursing home residents. Since music therapy is known to relieve the emotional symptoms of patients with sundowning agitation, perhaps there is some need for in-patient care facilities to include music therapy into their standard of care. Recreational activities like music therapy have been shown to be effective for major and minor depression groupings. However this kind of therapy has not been proven to provide total elimination of behavioral symptoms. The same can be said for traditional pharmacological approaches. "Neither pharmacological nor nonpharmacological interventions totally eliminate behavioral symptoms, but both types of interventions decrease the severity of symptoms" (Snowden, Sato, & Roy-Byrne, 2003, p. 1305 -- 1317).

One study sought to show not only the effectiveness of music therapy, but also what kind of structure was in the sessions and how facilitated engagement encouraged reduction in agitation and anxiety in elderly patients with dementia. "This study, as part of a larger program of research, sought to investigate the effect that participation in a 40-min live group music program, involving facilitated engagement with song-singing and listening, three times a week for eight weeks" (Cooke, Moyle, Shum, Harrison, & Murfield, 2010, p. 905-916). Their results suggested not the efficacy of the music therapy, but the factors that led to increased agitation in certain patients. They found that factors such as gender and length of time living in the facility, and level of cognitive impairment proved to be predictors of agitation overall.

Participation in the music program did not significantly affect agitation…