Art, music and pet therapy.

Today's - and tomorrow's - consumer of long-term care services is demanding a more holistic approach to care - one in which the emotional aspects of life are considered just as critical as the physical. To that end, Part 2 of "Today's Ancillaries" explores modern approaches to art, music and pet therapy.

Overall Status

The therapeutic effects of art and music are well-documented. But in the nursing home, as in other health care settings, both still tend to be viewed more as diversionary activities than as bonafide therapeutic modalities. Nevertheless, a growing number of nursing homes are discovering the benefits of both art forms in achieving a number of therapeutic ends.

Music therapists are trained in a four-year college program followed by a six-month internship, and are registered through the National Association for Music Therapy in Silver Spring, MD. Medicare and Medicaid have been reimbursing for music therapy in long-term care, on a case-by-case basis, for over eight years. As with all ancillary therapies, music therapy goals, objectives and outcomes need to be spelled out specifically and in detail, especially when dealing with managed care payers.

Art therapists are registered through the American Art Therapy Association upon completion of a masters-level program and 1,000 hours of supervised clinical experience above and beyond graduate internships.

While some private insurance reimburses for psychologist-ordered art therapy sessions, third-party payers generally don't reimburse for art therapy in the nursing home, a situation that may change as art therapists seek state licensure.

Art Therapy

Art as a means of creative expression is a natural for the nursing home. Many residents are unable to express their thoughts and feelings verbally due to the effects of conditions such as stroke or dementia. The therapeutic effects of art are inherent in both the artistic process and in the artwork itself, a tangible finished product.

Art therapist, Katherine Kahn-Denis, MA, ATR coordinates a one-year private foundation grant aimed at training staff to incorporate various expressive modalities, including art and music, into their day-to-day work with the residents of Judson Retirement Community in Cleveland, OH. Much of her work is done on Judson's unit for residents with advanced cognitive impairment due to stroke and dementias. "I try to teach staff to seize the moments when residents are responsive and to recognize a reaction to art or music and take advantage of that reaction."

Denis uses a variety of media including paints, ceramics, natural materials and fabrics, to guide residents through everything from one-on-one painting sessions to group quilting projects.

Evaluative Uses

To the skilled eye of the art therapist, a piece of artwork can sometimes reveal clues about the severity of a medical condition that might not otherwise be apparent. This is especially true of residents with dementia, whose artwork can be used to help caregivers assess disease progression.

The three paintings in Figure 1 were all done by an Alzheimer's patient over a two-year period. "Despite intact social routines throughout this time span, her paintings demonstrated the progression of her dementia and functional losses," says Denis. She explains that artwork by dementia patients tends to have certain common elements that suggest organic changes in the brain: omission of essential features, an impoverished, cramped appearance, and multiple repetitions of lines or features, to name a few. In this case, says Denis, the progression of the dementia is suggested by the changes in the paintings: the short, "picky" lines in the background of the first painting, the second painting filled with fragmented lines, and the eventual disappearance of form in the third.

These paintings illustrate another important point - the need to know when the use of art becomes a source of confusion rather than of joy. Denis, who no longer holds art sessions with the resident described above, explains that, now that she is "in the throes" of her dementia, she no longer understands the function of a paint brush, and suggesting that she use one would prove frustrating and confusing.

Reminiscense

Both the act of creating art and the artwork itself can elicit reminiscing and socialization when verbal communication is impaired or simply not occurring. Artwork that depicts aspects of a resident's life story, for example, can serve as impetus for discussion, and can help "personalize" residents to staff who learn the story of residents' lives through their art.

Nonverbal Communication 

Art offers a creative, nonthreatening means of expressing emotions that may be too difficult, painful or even frightening to express verbally: loneliness, isolation, loss, fear of dying, and so on. This is especially valuable when verbal communication is limited.

The self-portrait in Figure 2 was done by a woman with multi-infarct dementia and Alzheimer's who was able to speak only a few words due to expressive aphasia. After seeing the completed work, Denis asked the resident a simple question, "Are you sad?", to which she responded with a resounding "Yes." The self-portrait proved to be this resident's sole means of communicating her feelings, and this visual expression provided Denis with a way to "see" how she was feeling and to initiate verbal communication about those feelings.

As experienced staff know, cognitive impairment does not prevent residents from experiencing a range of feelings, which often include frustration and anger, both of which are compounded by the inability to express those feelings. Art therapy, says Denis, provides "a vehicle for affective discharge of feelings and a way to communicate those feelings to caregivers and family."

Denis also uses art as a means of sensory exploration and stimulation. During the advanced stages of progressive dementias, when the ability to regulate responses to internal and external stimuli becomes increasingly difficult, the exploration of art materials and the sensual quality of the art medium itself can be a source of simple pleasure. Denis notes that because of this, normally restless, inattentive residents will often focus on their creative endeavors for extended periods.

Art as a "self-reflective" activity, can help residents to rekindle a sense of their own personality, says Denis. While the sense of personal identity probably persists far into the end stages of dementia, that "sense of self" becomes increasingly difficult to express. Art provides a vehicle for doing so.

Fine Motor Skill Development

The act of creating a piece of art - manipulating a paint brush, working with clay, putting paint on a canvas - is an effective and creative way to improve dexterity and range of motion. Denis sometimes works with occupational therapy on these skills, using adaptive equipment such as table easels and large grips for pens, pencils and brushes.

These types of activities provide residents not only with a vehicle for self-expression, but also with a success-oriented way to improve physical dexterity and a tangible finished product that allows residents to see and take pride in the results of their efforts.

Other forms of art therapy focus on the artwork itself rather than on the process of creating it. Artline, Ltd. in Waukesha, WI. produces a line of "Interactive Therapeutic Art" aimed at facilitating wayfinding, encouraging reminiscence and providing visual, tactile and auditory stimulation. The artwork is created in conjunction with the Alzheimer's Association of Southeastern Wisconsin.

A creative long-term care provider can usually find a way to provide art therapy services for his or her residents - either by contracting for the services of an art therapist to run specialized groups and teach art therapy techniques to staff, or by hiring an art therapist under the departments of Recreation Therapy or Rehabilitation. Start-up costs for basic materials for an art therapy program range from about $300 to $500 and, Denis notes, the materials tend to last longer than they might in other settings. She adds that supplies are often donated as well.

The finished product of art therapy also gives the facility the opportunity to share the program with the community through exhibitions, which are often well-received. Denis also notes that residents frequently make gifts of their artwork to family, staff or as a memorial to a loved one.

For more information on art therapy, contact the American Art Therapy Association, Inc. 1202 Allanson Rd. Mundelein, IL 60060: 847-949-6064.

Music Therapy

All of us have turned on the car radio, heard a song we haven't heard in 20 years, and thought, "Boy, does that take me back!" Not only can we still sing every word, we can also remember the last time we heard the song - what we were doing, where we were, how we were feeling.

Music is an extraordinarily powerful trigger of memory, emotions and the senses and, as such, has great therapeutic potential in a range of settings, not the least of which is the nursing home.

In the well elderly, music is increasingly used for health maintenance. On the West Coast, Rhythm for Life, a program jointly sponsored by the AOA and Remo, a manufacturer of percussion instruments, is being used to encourage socialization, relieve depression and maintain cardiovascular fitness through rhythm exercises and activities - all appropriate goals for independent and assisted living residents.

In the nursing home, the therapeutic uses for music are limited only by the creativity of the therapist. Molly Waldrup, RMT provides contractual music therapy services to area nursing homes through her agency, Southeastern Music Therapy Services. She uses music to encourage socialization and decrease isolation, as a tool for reminiscence and memory enhancement, as an aid in communication, pain management, fine motor skill development - and the list goes on.

Waldrup generally holds weekly group and individual sessions, always using live music and familiar songs. Sessions can range from therapist-led singing at the piano, to resident participation with rhythm or melodic instruments or movement, to individual bedside sessions.

Music as a tool for reminiscence provides a nonthreatening vehicle for interaction and communication among nursing home residents who are often lonely, isolated or withdrawn. During a reminiscence session, the song "Over There," for example, prompted one woman to reminisce about watching the trains carrying soldiers off to war as a little girl, says Waldrup. That prompted another to chime in with recollections of her brother leaving home to fight in "the Great War." The two residents, who had never had a reason to speak with one another before, found that they had a common experience. Music was the vehicle for forming that bond.

Music's ability to tap into memory is evidenced by residents with dementia, who may be completely disoriented to time and place, but can often remember, and sing every word of, songs from the distant past. For residents frustrated by their inability to remember, singing a song they learned decades ago provides them with a sense of pride and accomplishment and a link to their past that remains intact despite their cognitive impairment.

The calming effect of music makes it an effective tool for reducing agitation, increasing attention span, and even decreasing disruptive behaviors, as evidenced by one resident who wandered almost ceaselessly when she wasn't restrained (which she almost always was) and had a practically nonexistent attention span. "She loved music and had sung in the church choir all her life," says Waldrup, "and though her verbal responses were limited, she always joined in the singing as she passed the music room." When Waldrup finally convinced a skeptical nursing staff to let the resident attend her music sessions unrestrained, she sat still, focused intently for 40 minutes, and sang every word to every song.

These calming effects can last well after the sessions have ended. "The CNAs on the Alzheimer's unit have told me that the residents are much calmer, and eat and sleep much better, after attending music therapy sessions," says Waldrup (thus benefitting the front-line staff as well as the residents).

Waldrup also uses music to facilitate communication in residents whose speaking ability is limited. by dementias or verbal aphasia, and notes that residents who are unable to speak can sometimes sing complete songs. An end-stage Alzheimer's patient, for example, began to join in and sing during a bedside session, and later thanked Waldrup for her music - all of which astounded the staff who had known this resident to be "non-verbal" for the past five years.

"We're not sure why this happens," says Waldrup. "We know that music elicits responses from beyond the physiological, into the psychological and spiritual realm. It may be that music taps into a different part of the brain."

In any case, the ability to sing can, in some cases, translate into an ability to speak. Therefore, speech therapists have been known to use music in their work with verbally aphasic patients. Ideally, says Waldrup, music, occupational and speech therapy should work together to provide the intensive therapy required to make the transition from the sung to the spoken word.

Waldrup also uses music for pain management. Similar to the Lamaze technique, in which the patient focuses on an object or person rather than the pain, music becomes the focal point, helping residents to relax and ease discomfort through passive or active listening.

Music as a means of fine motor skill development can sometimes prove more successful than other more traditional modalities in subacute and rehabilitation settings, says Waldrup. For example, playing a keyboard is an excellent way to increase finger dexterity in patients with arthritis, or in those recovering from stroke or injury. "The patients may be working on 'occupational therapy skills,' but they don't associate playing the piano with 'therapy,' and the music produced from manipulation of their fingers provides instant gratification and positive feedback."

While a full-time music therapist might be considered a luxury, nursing homes can contract for the services of a music therapist who can run group and individual sessions and teach staff to use music in their work with residents. Waldrup notes that, in some cases, costs are covered on a per diem basis or by family members of residents who request music therapy services.

"After all these years, the power of music still amazes me," says Waldrup. As evidence, she relates the story of a resident with Alzheimer's, whose outbursts of aggression and agitation were especially upsetting to his wife. When Waldrup began to play "Let Me Call You Sweetheart" at the request of the resident's wife, he turned to her and they began to dance. Afterwards, Waldrup received a tearful thank-you. "This was the first time in ten years that he's held me in his arms. For a few moments, I had my husband back."

For more information about music therapy, contact the National Association for Music Therapy, 8455 Colesville Rd., Suite 930, Silver Spring, MD 20910: 301-589-3300, or Southeastern Music Therapy Services, PO Box 30363, Charlotte, NC 28230-0363: 704-338-5802.

Pet Therapy

During my "previous life" as a nursing home director of social services, nothing I did for our residents seemed to have a more immediate positive impact than bringing my dog, an almost-springer spaniel named Kelley, to work with me. Agitated residents became calm, unhappy, withdrawn residents smiled and laughed, "nonverbal" residents spoke to, and about, the dog, and normally isolated residents gathered and reminisced about childhood pets.

Kelley's most memorable encounter was with "Mr. Smith," a resident who left his room only for meals and spoke to no one. One day, I found Mr. Smith sitting in the lobby, gently stroking Kelley's head in his lap and telling him about the dog he and his late wife had had when they were first married. These were the first words I had ever heard Mr. Smith utter. He then asked if I would be bringing the dog back to visit - the first words he had ever spoken to me.

Researchers have documented the therapeutic effects of pets, such as a lowering of blood pressure and, most recently, a reduction in stress. But as any pet owner can attest, it's the unconditional love and affection that are our pets' most therapeutic attributes. In the nursing home, where residents are dealing with isolation, loneliness, loss, separation from home and family (which often included a pet) and a sense of no longer being needed, the comfort, humor and sheer joy a pet provides is truly a gift.

Visiting Pets

Fortunately, it's easy to give this 'gift' to your residents. One way to do so is through a "visiting pet" program in which animals are brought to the nursing home for hands-on interactions with your residents, who are encouraged to hold, pet and play with the animals.

Finding pets to visit is easy. Many local animal shelters have volunteers who take dogs, cats, puppies and kittens (and the occasional rabbit) to nursing homes and other facilities. Zoos often have similar programs with more exotic animals. These programs are generally free of charge (donations are always appreciated) and can be scheduled as a regular recurring (ie, monthly) activity or as a special event.

Arranging for these visits is as easy as making a phone call. Some tips for ensuring a successful visit follow:

* Schedule the visit during a regular activity time that doesn't conflict with meals or therapy appointments.

* Hold the visit in a large, but enclosed, room so the animals can wander from resident to resident without risk of wandering off the premises.

* Include as many residents as possible. Even the most disabled or disoriented resident will usually respond to the gentle licks of a dog or the purring of a kitten cuddled in their laps. After the "main event," ask the volunteers to take a dog or cat into the rooms of residents who were unable to attend. Time and time again, I saw the faces of even the most impaired residents light up at the sight of a dog in their room.

* Assign a few nurse aides or other staff members to assist (these sessions are great morale boosters for staff as well).

* After the event, encourage residents to talk about the activity and reminisce. Seeing a dog or cat stirs up memories of childhood pets, when residents felt safe and secure. Even those generally disoriented to time and place can remember a childhood pet and the feelings that pet evoked. The love of animals also forms a common bond among residents who might have felt they had nothing in common before the event.

Other sources of visiting pets are your residents' families, staff, or a notice posted in a local veterinarian's office (you'll probably end up turning people away).

At Animal Therapeutics Unlimited in Spanish Fork, UT, Bob Reid and Debbie Eyre provide a range of pet therapy services to area nursing homes, including taking their own dogs and cats to interact with residents. How much does a visiting pet really mean to nursing home residents? When Reid's golden retriever Gilbert, died, after five years of weekly visits to an area nursing home, twelve residents boarded a bus and arrived at the dog's grave site to offer a prayer and say good-bye.

Reid also takes canine companion dogs, trained to assist the disabled by pulling wheelchairs, providing standing and walking assistance, etc, into facility rehab departments. He explains that this not only gives rehab patients an opportunity to see how a canine companion dog can enhance their quality of life - something to think about during discharge planning-it also helps to motivate patients and provide a break from what can be a long, monotonous process.

In a study published in the April 3,1996 issue of JAMA (Vol 275, p. 1001), the authors reported "significant positive changes" in psychological well-being, community integration and school and work attendance, as well as "dramatic decreases" in the number of assistance hours required by patients paired with service dogs.

Reid also provides educational seminars related to pet therapy and advises nursing homes about having a resident dog or cat. This brings us to your next option: adopting a pet as a permanent resident of your facility.

Resident Pets

At Hospice of the Western Reserve in Cleveland, OH, Sally, the resident golden retriever, has an uncanny talent for knowing when she's needed and by whom, often seeking out patients without visitors, sitting with her head in their laps or curling up on the floor next to their beds. The staff happily attends to Sally's needs - walking, feeding, etc - and half of a storage room on one of the wings has been converted into a "dog supply room" where Sally's "belongings" are stored. Visitors are also invited to bring their dogs with them - which they often do - when they visit. This is a source of comfort to both patients and family members.

At Ballard, a skilled nursing facility in Des Plaines, IL, Dexter, a nine-month-old beagle-basset hound mix who was rescued from the local animal shelter, recently "signed on" as a part-time "employee" of the activities department.

When the Ballard staff discussed the possibility of a resident dog, their main concerns related to sleeping arrangements and care during the night. The solution: a staff member who was already thinking about getting a pet would adopt a dog, with Ballard's input, bring the dog to work with her and take him home in the evening. Ballard would help with the expenses, but the dog would belong to the employee.

Today, Dexter (named in a facility-wide "name-the-dog" contest) comes to work every day with his owner, Tifani Lea, Director of Admissions, and returns home with her at night. While he's "at work," Dexter spends his time in, and is the responsibility of, the activities department. Director of Community Services Kristin Joyce says Dexter is a hit at Ballard. "The residents and staff adore him. It's hard to remember you're in a nursing home when there's a puppy sitting in your lap, licking your face."

Your local animal shelters and animal welfare organizations have hundreds of healthy, loving dogs and cats just waiting for a good home. A nominal fee includes initial shots and sometimes spaying or neutering as well. Considering the hundreds of thousands of unwanted dogs and cats that are destroyed each year, adopting one of these animals amounts to saving a life, a concept that your residents, who may feel unwanted or unneeded, will certainly respond to.

Of course, adopting an animal is, or should be, a lifelong commitment, and bringing a dog or cat to live in your facility for the next 12 to 15 years is a decision that should never be made lightly.

At Ballard, community services assistant (and animal lover) Stacy Pfeiffer spent several months laying the groundwork for Dexter's arrival, making sure there was a program in place well before his adoption. She researched adoption facilities, arranged for veterinary care, budgeted for and located supplies and even enrolled Dexter in an on-site training program. Before going to the animal shelter to find a dog, all arrangements with respect to where the dog would spend his time and who would assume responsibility for his care had been made and finalized.

This kind of preparation is key to ensuring that you'll never regret your decision to have a resident pet. In addition, there are several other important issues to consider and decisions to make.

* Dog or cat? Cats are essentially "low maintenance." They don't have to be walked and can be left for longer periods of time than dogs. It is, however, this dog-lover's admittedly biased opinion that a dog usually makes a better resident pet, primarily for two reasons: 1) Cats can be affectionate - if you're lucky enough to find a "lap cat," but a dog that doesn't like to be petted and be around people is a rare animal (excuse the pun), while a cat with those characteristics is much more common. 2) People are more likely to have allergies to cats than to dogs.

If you can't decide, adopting a dog and cat (they generally get along with one another quite well) may be an option. Some nursing homes are also setting up aviaries or small animal "petting zoos." For the purposes of this article, however, we'll assume you've decided to adopt a dog.

* What kind of dog? The ideal resident dog is gentle, affectionate, trainable and people-oriented. A number of breeds, such as golden and labrador retrievers, are known for their gentle nature. I have a personal bias for mixed-breeds who, in my experience, are always gentle, eager to please and have loads of personality. A rule of thumb when selecting your dog: a dog that is gentle and affectionate with children will also be so with older, frail residents. For this reason, it's a good idea to take a child along during the selection process.

* Puppy or adult? There's nothing cuter - or more destructive than a puppy. Unless your staff is committed to spending a great deal of time training a puppy and following through with that training, as is being done at Ballard, an adult dog is probably a better, and certainly easier, choice. It might also be wise to get a dog that's large enough to reach from a wheelchair or bed without bending over and risking a fall.

Once these decisions have been made, you'll need to make arrangements for the care of your dog. A good portion of your pet care budget should be ear-marked for veterinary care: initial exam and shots (before bringing the dog to your facility), spaying and neutering (healthier for the dog and averts future problems), and subsequent routine and non-routine care, including emergencies. Needed supplies will include a collar, leash, ID tag, food, treats, food and water bowls, brush, toys, a dog bed and, if you have an appropriate outdoor area, a dog run.

If you make a few calls you'll probably find that many of these services and supplies can be had at reduced rates or will even be donated. At Ballard, many of Dexter's supplies, as well as his training, initial veterinary care and neutering, were gladly donated.

It's also important to decide who will be responsible for day-to-day care: walking, feeding, etc. It's a good idea to have two people on each shift take care of these needs; if one is busy or calls off, the dog will always be taken care of. Asking staffers to volunteer for "dog duty" rather than assigning them to it also helps to ensure that the dog will be well cared for. One or two people should also be designated as those responsible for taking the dog for veterinary care. Volunteers are often willing to do this.

It's also important to involve your residents in their dog's care. Residents can volunteer to feed, brush or walk the dog as part of a pet therapy program that reinforces a sense of usefulness and encourages socialization and even ambulation. (It's a good idea to post a feeding schedule or make a flip sign (ie, "Dexter has been fed" and "Dexter has not been fed") to avoid over-feeding.)

Sleeping arrangements should be well thought out before you adopt a pet. It's a good idea to set aside a room, with a dog bed, where your dog can go to sleep or simply "get away from it all" during the day.

Once you've adopted your pet, you can take advantage of some unique marketing opportunities. By adopting a resident dog or cat, you're setting your facility apart as one that provides progressive, compassionate care aimed at enhancing quality of life in a home-like environment.

To get the message out, tell the public about your pet in your brochures and newsletters and call your local newspaper and suggest a human interest story about your residents and their pet. For every one potential resident who might be "turned off," there are ten more who will count the pet among the reasons to choose your facility over another.

Your occupational or physical therapist may enlist the aid of your resident dog in encouraging ambulation, increasing range of motion or providing relief to arthritic hands (by reaching for and stroking the dog). Or, your dog might end up assisting in activities, like Dexter. But your resident pet doesn't have to be part of structured program in order to be "therapeutic." Your residents will benefit simply by virtue of having a pet in the facility.

The bottom line is this: pets don't care what your residents look like, or if they're confused, incontinent, in wheelchairs, or bedbound. They simply want to love and be loved. And what could be more therapeutic than that?

For more information about pet therapy, contact Animal Therapeutics Unlimited. 859 North 300 East, Spanish Fork, UT 84660: 801-379-2758, or call Therapy Dogs, Inc. at 307-638-3223.