Music Intervention for Symptom Management

1. Music Intervention for Symptom Management

2. Presentation Overview • Scientific basis of music for anxiety reduction • Importance of music preference assessment for music listening interventions • Music intervention research for symptom management in critically ill patients receiving mechanical ventilatory support • Exemplar of a program of research testing an integrative therapy • Multidisciplinary team

3. What are Symptoms? • Departure from normal function or feeling which is noticed by a patient, potentially indicating the presence of disease or abnormality; acute, chronic, wax/wane, resolve • Subjective & observed by the patient; self-reported • Can be specific (pain) or non-specific symptoms • Can be acute or chronic, associated with medical conditions, whether physical or mental, and may be either a primary or secondary symptom • Fatigue • Anxiety • Pain

4. BACKGROUND • Approximately 5 million patients receive mechanical ventilatory support yearly in the U.S. • 55,000 adults admitted daily to ICUs in the U.S. • Commonly used ICU supportive modality • 34% require ventilatory support for > 48 hours; increasing • ICUs are inherently stressful for patients and family • Distress from noise, lack of sleep, social isolation, frustration, etc.

5. Patient Symptom Reports • 10-item checklist physical and psychological symptoms (pain, tired, short of breath, restless, anxious, sad, hungry, scared, thirsty, confused) • Presence (yes/no), intensity (1/mild, 2/moderate, 3/severe), distress (1/not very distressing, 2/moderate, 3/very distressing) • 34% mechanically ventilated in two ICUs • Anxiety, thirsty, tired reported by 50-75% of assessments • No difference in intensity or distress if MV, except anxiety • Pain: mild-moderate intensity; mod-severe distress • Dyspnea was most distressing Puntillo KA, Shoshana A, Cohen N, Gropper M. et al. Symptoms experienced by intensive care unit patients at high risk of dying. Crit Care Med 2010; 38:2155-2160.

6. Patient Responses to Mechanical Ventilatory Support • Physiological Stress Stress of critical illness or infection +Delivery of mechanical breaths • Critical illness or injury • Lung injury • Ventilator associated pneumonia • Psychological stress • Anxiety: a heightened state of arousal • Fear • Feel miserable • Inability to speak; cannot convey needs, feelings, etc.

7. Anxiety Ratings in Mechanically Ventilated Patients • Common bothersome symptom • Cross-sectional ratings; importance of descriptive research • State Anxiety Inventory (score range 20-80) • < 5 days 48.6 + 12.0 • 6-21 days 50.2 + 12.5 • 22+ days 54.2 +11.9 • Chronic/long-term 45.8 +14.5 Chlan L. Description of anxiety levels by individual differences and clinical factor in patients receiving mechanical ventilatory support. Heart Lung 2003; 32:275-282.

8. Individual Anxiety Plots

9. Anxiety Ratings in Mechanically Ventilated Patients • Previous work limited to cross-sectional ratings • State Anxiety Inventory (score range 20-80) • < 5 days 48.6 + 12.0 • 6-21 days 50.2 + 12.5 • 22+ days 54.2 +11.9 • Chronic/long-term 45.8 +14.5 Chlan L. Description of anxiety levels by individual differences and clinical factor in patients receiving mechanical ventilatory support. Heart Lung 2003; 32:275-282.

10. SUSTAINED ANXIETY Physiological responses: • SNS stimulation; CV responses; increased WOB and oxygen demand; myocardial stimulation Psychological responses: • Fear, inability to focus, inability to relax or sleep • Usual treatment for anxiety is sedative medications • Limitations and adverse side effects

11. Adjunctive Interventions • Sedative agents are warranted at times yet induce significant and numerous adverse effects • Safe and scientifically sound interventions are needed • Does not induce adverse effects • Can a non-pharmacologic, adjunctive intervention (music) reduce anxiety and sedative exposure over the course of mechanical ventilatory support?

12. Why Music?Scientific Basis of Music to Reduce Stress • Music perceived as familiar and soothing occupies the brain • Interrupts the stress response • facilitates relaxation • Focuses attention on pleasing stimuli of music • reduces anxiety • Music can be a powerful distractor • Reduces amount of sedative medications during medical procedures (colonoscopy, ambulatory surgery)

13. Scientific Basis of Music to Reduce Stress: SR Interruption • Reception of music produces neural impulses that dampen the arousability of the CNS through inhibitory neurotransmitters • Withdrawal of sympathetic activity through diminished norepinephrine release • Induces relaxation • Diminished SNS activity • Increased PNS activity

14. What is Relaxing Music? • Tempo at or below resting heart rate (< 80 bpm) • Predictable dynamics • Fluid, melodic movement • Pleasing harmonies • Regular rhythm without sudden changes • Soft tones • Strings, flute, piano, or specially synthesized

15. Anxiety Reduction Through Music Intervention • Steady, slow, repetitive rhythms exert a “hypnotic” effect • Cognitive quieting • Altered states of consciousness alter perceived anxiety and facilitate more relaxed states • Music perceived as pleasant and relaxing reduces tension as relaxation is incompatible with anxiety

16. Music for Distraction • Preferred music can be a powerful distractor • Provides an alternative focus to a more pleasing, comforting stimulus, rather than focusing on stressful environmental stimuli or thoughts. • Important to assess music preferences, familiarity, cultural context

17. Psychophysiologic responses of mechanically ventilated patients to music: A pilot studyChlan L. Am JlCrit Care 1995; 4: 233-238 • Randomized n = 20 mechanically ventilated patients • 30 min. music listening or resting quietly with headphones • Pre-post design with repeated measures • Music intervention consisted of MusicRx choices (Dr. Helen Bonny); all classical music • Generalized relaxation response • Decreased HR, RR; BP trended downward • Reduced distress associated with illness

18. Effectiveness of music therapy intervention on relaxation and anxiety for patients receiving ventilatory assistance.Chlan L. Heart Lung1998; 27: 169-76 • Randomized n = 56 mechanically ventilated patients • 30 min. music listening or resting quietly • Pre-post design with repeated measures • Music intervention consisted of variety of instrumental music; choice • Significant state anxiety reduction after music • Decreased HR & RR • Participants desired to listen to music throughout the time in the ICU; asking for names of music choices

19. Investigating the feasibility of a music intervention protocol with patients receiving mechanical ventilatory support.Chlan L. Alt Therapies Health Med 2001; 7: 80-83 • N = 6 mechanically ventilated patients (feasibility) • Aim was to determine if ventilated patients can and will initiate music listening (descriptive research) • Music intervention consisted of a wide variety of music genres guided by assessment • Patients did initiate music listening; equipment • Requires wide variety of music and knowledge of music to accommodate personal preferences

20. Influence of music on the stress response in patients receiving mechanical ventilatory support: A pilot study.Chlan L. Am JlCrit Care 2007; 16: 139-143 • N = 10 mechanically ventilated patients • Randomized to 60 min. of relaxing music or resting quietly • Aim was to determine if music could alter select indicators of the stress response (SR) • E, NE, ACTH, cortisol • Interruptions during protocol • Serum is problematic to obtain; sampling, stability • Trends toward decreased ACTH & cortisol in music subjects; slight increase in rest group

21. Reducing Sedative Exposure in Ventilated ICU Patients • Primary Aims: To determine if patient-directed music (PDM) reduces anxiety and sedative exposure over the course of ventilatory support R01 NR009295 NCT00440700

22. DESIGN • Three-group randomized clinical trial • Remained on protocol as long as mechanically ventilated, up to 30 days • Subjects randomized to: • 1) Patient-directed music listening (experimental) • Preferred, relaxing music; tailored music collection • Assessment of music preferences daily by music therapist • Allows choice, control, and self-management of anxiety • 2) Noise-canceling headphones (active control) • 3) Usual care (control) • No formal sedation protocols in place

23. Sedative Exposure • Daily Sedation Intensity Score • Daily Sedation Frequency • Accounts for sedative medications from disparate drug classes • Aggregate data from all patients on 8 commonly received medications Weinert C, Calvin A. Epidemiology of sedation and sedation adequacy for mechanically ventilated patients in a medical and surgical intensive care unit. Crit Care Med. 2007; 35(2):393-401.

24. SETTING and SAMPLE • 5 medical centers in the Minneapolis-St. Paul urban area • 12 ICUs total (medical, medical-surgical) • Adult critically ill patients receiving acute mechanical ventilatory support for a primary pulmonary component • Pneumonia, COPD, respiratory failure, pulmonary edema, etc. • Alert and interacting appropriately with nursing staff • Provide own informed consent • IRB and intervention requirements

25. MEASURES • Anxiety • 100-mm Visual Analog Scale-Anxiety • Illness severity (APACHE III) • Length of time mechanically ventilated • Length of ICU stay • All daily medications • Music Assessment Tool (experimental)

26. Patient Characteristics • N = 373 enrolled; 52% female • Age = 58.5 +14.4; Range 21-88 • 86% White, 12% Black, 1%Native American, 1%Asian • APACHE III 63.2 + 21.6; Range 15-123 • 55% respiratory failure, 25% respiratory distress, 5% pneumonia, 3% COPD, 2% hypoxemia, 10% other • Median total ICU days = 17 (1-86) • Median total ventilator days = 10 (0-80)

27. RESULTS • Baseline anxiety 48.8 + 29.3; range 0-100 • Moderate anxiety • Highly variable and individual symptom • PDM patients listened to music 79.8 minutes/day • Wide variety of preferred music • Headphones patients wore them for 34 minutes/day • 5.7 + 6.4 days on protocol; Range 1-30 days

28. Primary Analysis • Change by assigned group first assessed using scatterplots • Mixed-effects models • Change over time & deals with missing data • Series of best fitting models accounting for covariates of interest (illness severity, age, gender, time, baseline anxiety, sedative exposure) • Included data on subjects with 2 or more data points to model change over time

29. RESULTS • Please refer to the original publication for detailed model parameters and results (Chlan L., et al., JAMA June 2013)

33. Discussion of Results • Participants self-initiated music listening when desired • Individual control and management of highly variable symptom • PDM significantly reduced anxiety and sedative exposure during mechanical ventilatory support; compared to usual care • No difference between HPs and usual care • PDM patients had symptom reduction along with reduced sedative exposure • Anxiety -19.5 points; reduced 36.5% by 5th study day • Sedation intensity reduced 36% by 5th study day • Sedation frequency reduced 38% by 5th study day • Significantly less than HPs and Usual care

34. Implications for Practice and Future Research • Beneficial, effective adjunctive intervention for anxiety • No documented adverse effects • Integrate appropriately into ICU care • Self-directed and preferred music allows for choice and control; empowers patients • Impact of PDM on other outcomes warrant future research • Ventilator-free days? • Cost? • Influence on post-ICU outcomes is unknown