Pressure to reduce antipsychotic drug use in nursing home residents with dementia, along with broader culture-change efforts to achieve high-quality, person-centered care, appear to be spurring more integration of music therapy, aromatherapy, and other approaches that fall into the complementary and alternative medicine (CAM) realm. Advocates say the approaches are alternatives to pharmacology for preventing and addressing agitation and other behavioral symptoms of dementia. In May of last year, the Centers for Medicare & Medicaid Services upped the ante on nursing homes to reduce inappropriate use of antipsychotic medications, after years of mounting scrutiny and concern. In announcing the “Partnership to Improve Dementia Care,” CMS Chief Medical Officer Dr. Patrick Conway cited his agency's finding that “almost 40% of nursing home residents with signs of dementia were receiving antipsychotic drugs at some point in 2010, even though there was no diagnosis of psychosis.” CMS educational materials urge nursing homes to emphasize drug alternatives such as increased time outdoors and more individualized activities, and AMDA and other stakeholders have also promoted nonpharmacological strategies. No one knows the precise number of nursing homes turning to CAM, but according to a sampling of experts and nursing home leaders who are exploring such modalities, the current push to improve dementia care gives impetus for postacute and long-term care (PA/LTC)to look closely at what CAM can offer. “We've correctly identified the need to reduce the use of psychotropic medications, but we can't stop using the medications without having serious tools and approaches for using nonpharmacologic techniques,” said Dr. Harold Bob, CMD, regional medical director for Five Star Physician Services and Seasons Hospice of Maryland. Nursing homes can look to some hospitals’ experience with CAM. A growing number have thriving integrative-medicine programs that add acupuncture, massage, music, Reiki, and other alternative techniques to traditional treatments for pain, postoperative recovery, cancer, and other conditions. Improvements in anxiety, pain, mood, and quality of life are among the often-cited benefits. Yet with PA/LTC's different population, mission, and funding streams, there are limits to what can be translated or applied from the hospital industry. Still, the nursing home leaders who spoke with Caring for the Ages said that they are mindful of trends and the small but growing body of outcomes data. Leaders of Eden Alternative facilities and the Pioneer Network say that music therapy and other techniques regarded and studied as CAM therapies in the medical world are common-sense parts of a larger movement in nursing homes toward holistic, person-centered care – in other words, simple tools within the much larger toolbox of culture change. “If we find that there's therapeutic benefit [to these therapies] – measurable reductions in agitation or pain, for instance – that's great. But it's the more global benefit to overall well-being that's most important,” said Peter Reed, PhD, chief executive officer of the Pioneer Network, a group that advocates consumer-driven, person-centered models of postacute and long-term care. When The Buckingham at Norwood in Norwood, N.J., became an Eden Alternative facility several years ago, the nursing home's leaders vowed to find ways of better understanding and engaging their residents – and in a typical resource-constrained nursing home, they also vowed to do so with only existing staff. One of the goals: more music. “Nursing homes typically have entertainers who come once a week or once a month for programs,” said facility administrator Helaine B. Ledany, CNHA. “We wanted to do more, to use music to enrich daily routines, to improve [well-being] and to provide more person-centered care.” Music therapy can take many different forms and have varying effects. It can be calming, stimulating, or agitating. It requires providers to be mindful of each individual's preferences and needs. Advocates of music therapy – which, like other CAM therapies, is intended to relieve or heal an individual – maintain that it can relieve pain, anxiety, and stress, as well as enhance immune and brain function. With this in mind, when a position in the recreation staff became vacant last year, Ledany and Diane Bayles, directors of recreation at The Buckingham at Norwood, decided to build in-house expertise. They hired Joseph Calderon, who formerly taught music in local schools, as their “recreation assistant/music specialist.” Calderon led the staff in instituting a “music journal,” playing different types of music each morning in the multipurpose recreation-dining area; Elvis on Monday and the Andrews Sisters on Tuesday, for instance. He also began holding a bell choir two times a week, where residents hold color-coded bells and learn to make music through repetition and drill. Sessions on doo-wop and karaoke are ongoing. Mr. Calderon also selected softer music in quiet places for residents who might otherwise be overstimulated. As have other types of change underway in the facility, music therapy has required teamwork and a trial-and-error approach to identify what types of music and musical activities will benefit individual residents. Staff regularly provide feedback on how their residents with dementia – many with advanced-stage dementia – respond to different types of music and related activities. While reducing behavioral symptoms of dementia was not a primary goal of The Buckingham at Norwood's changes, music has had a striking impact on these residents. It may well be contributing to the nursing home's steady reduction in facilitywide antipsychotic drug use, said staff leaders. Usage declined from an already low 11% of residents in the first quarter of 2011 to just over 2% in the fourth quarter of 2012. “It's been easier to manage problem behaviors without going to medications,” said Laura Claeys, LPN. “You can often distract [agitated] residents with some sort of musical intervention.” Mr. Calderon said, “With music, you can see residents return to their environment. Suddenly, they're “in tune” with their senses and surroundings, he said. Staff at the Gwynedd Square Center for Nursing and Convalescent Care in Lansdale, Pa., have similarly found music to be good for both residents with early- to mid-stage dementia and those with late-stage disease. Music triggers reminiscences by the former and stimulates the senses of the latter, particularly those with low verbal capacity. CMS has recognized the facility for its care practices and for reducing its use of antipsychotic medication, now in approximately 10% of residents. “I think of these ‘alternative therapies’ – music therapy, aromatherapy, other sensory therapies – as behavior management approaches,” said Gwynedd Square administrator Morris Kaplan, NHA. “They help us to address issues before people get agitated.” For many of The Buckingham at Norwood's low-functioning residents with advanced dementia whose stress or agitation causes them to cry out, “soothing music played in a quiet place, often with hand massages,” has relieved distress and helped keep medication use at bay, Ms. Ledany emphasized. Last fall, she and her team began investigating the potential use of aromatherapy. Some nursing homes use lavender sprays and scents, but “we're thinking that the smells and scents you'd use for a dementia resident might be specific-recall smells, things that remind them of something,” said Ms. Claeys. “During the day, we'd be looking for something stimulating, and at night, something soothing.” Of all the nonpharmacologic approaches studied for Alzheimer's disease and other dementing illnesses, music therapy is “probably the [one] with the most convincing research behind it,” said Cornelia Beck, PhD, RN, a professor who studies dementia and PA/LTC at the College of Medicine at the University of Arkansas for Medical Sciences, Little Rock. Recent literature reviews of dementia care have included alternative therapies. A systematic evidence review released by the Department of Veterans Affairs in 2011, for instance, concluded that agitation in patients with dementia may be reduced by calming music, aromatherapy, hand massage, and other “sensory interventions.” For instance, three randomized controlled trials found that when individuals listened to music, it reduced their aggression, agitation, and wandering (www.hsrd.research.va.gov/publications/esp/Dementia-Nonpharm.pdf). Similarly, a Canadian review of studies conducted in PA/LTC settings concluded that “music therapy or other forms of sensory stimulation” were among the nonpharmacologic interventions associated with declines of neuropsychiatric symptoms of dementia (J. Am. Med. Dir. Assoc. 2012:13:503-6). Among the small studies that Dr. Beck points to is one from Japan, in which 10 nursing home residents with moderate-to-severe dementia received music therapy twice a week for 8 weeks, whereas 13 other residents with dementia did not receive the therapy. The researchers measured significantly lower irritability scores on the Multidimensional Observation Scale for Elderly Subjects, as well as less salivary chromagranin-A (a marker of stress hormone levels), in the residents who received music therapy (Nurs. Health. Sci. 2004;6:11-8). Few other studies of nonpharmacologic interventions have measured physiologic markers of distress. Since the National Center for Complementary and Alternative Medicine (NCCAM) was launched in 1991 under the aegis of the National Institutes of Health, a growing body of peer-reviewed studies has validated various CAM protocols. (Information on the safety and efficacy of CAM treatments can be found on the website: http://nccam.nih.gov.) Overall, however, there is a paucity of good data on the effectiveness of nonpharmacologic interventions for behavioral symptoms of dementia, and few, if any, published studies have directly compared the effectiveness of such interventions with each other or with medication. “The [information] is out there. It's just not as strong we'd like,” said Dr. G. Allen Power, an Eden Alternative mentor at St. John's Home in Rochester, N.Y., and author of the book, “Dementia Beyond Drugs: Changing the Culture of Care” (2010, Health Professions Press, Baltimore, Md.). “Part of the difficulty in talking about and studying these therapies is that there are so many different facets to them. With music therapy, for instance, is it the music? The emotional connection? The socialization? A broader cultural change? It's hard to tease out what's having an impact.” Dr. Beck has tried compensating for the data shortage by comparing drug trials for dementia with studies of nonpharmacologic therapies with similar outcome measurements. At the annual meeting of the American Health Care Association last fall, she reported that nonpharmacologic approaches ranging from music and aromatherapy to exercise and light therapy were “just as, if not more, effective” than cholinesterase inhibitors for cognition and atypical antipsychotics for behavior. Nursing homes can also extrapolate from studies done in other populations, Dr. Beck and others advised. Hand massage has been shown to cause measurable differences in heart rate and other parameters of agitated behavior in people free of dementia, for instance. “There shouldn't be any reason why it wouldn't have the same effects in dementia patients,” she said. Theoretically, as person-centered care grows and nursing homes increasingly ask incoming residents what aspects of their environments make them comfortable, a wider array of CAM therapies will find their way into nursing homes. Forty percent of adults participating in the often-cited 2007 National Health Interview Survey reported using some form of CAM, most commonly for musculoskeletal problems but also for anxiety, headache, and other conditions. “We're just seeing the beginning of it,” said Dr. Power, a clinical professor of medicine at the University of Rochester (N.Y.). “My generation is much more used to things like massages and yoga and other complementary approaches than today's 80-to-90-year-olds.” The problem is, such services are generally not reimbursed through Medicaid and Medicare, and there are concerns among nursing home leaders about safety, liability, and oversight – especially for “contact” therapies, such as acupuncture and massage therapy. Dr. R. Sean Morrison, director of the National Palliative Care Research Center and the Hertzberg Palliative Care Institute at Mount Sinai Hospital in New York, said he is hopeful that massage therapy, in particular, will move further into LTC's comfort zone. He has seen its benefits firsthand at Mt. Sinai, where a 10-year-old massage-therapy program in the hospital's palliative care program “has more demand than we can fulfill.” “Particularly for nursing home residents with dementia, there is very little comforting therapeutic touch. … They're so used to touch being aversive,” said Dr. Morrison, also vice chair of research and professor of geriatrics, medicine, and anesthesiology at the Mount Sinai School of Medicine. “We need to change that, and massage provides a way to redefine human touch in this setting, and to [reap its benefits].” Massage takes many forms, not only the robust “deep-tissue massage” or “spa massage” that many people have experienced. Naomi H. Hall, owner of the Touchpointe Centre in Little Rock, Ark., has performed what she refers to as “calming touch therapy” for local nursing home residents with dementia. “It's a gradual, careful process” that involves teamwork with the nursing staff, said Ms. Hall, who has been hired by family members for her services. With understanding of each patient's clinical situation, massage strokes, pressure, and technique can be individually tailored. “With dementia, chunks of the brain's highway are missing,” she said. “Massage can help keep calm in what is a very tense environment.”