Music Therapy in Geriatric Care - A practical guide

3    People in geriatric settings

By Dorothee von Moreau & Michael Keßler

The geriatric setting in residential homes and nursing homes, senior citizens’ day care facilities, specialist hospitals and rehabilitation clinics includes senior citizens with illnesses and illness-related limitations, specialist staff such as nurses and specialist therapists, social workers, pastoral workers, doctors, and also the relatives of the patients, volunteers, everyday companions and housekeepers. Some of these groups of people will be described in more detail below with their respective individual challenges and needs and the possibilities for interdisciplinary cooperation.

3.1   The patient

The patient is typically 70 years and older. Because of the higher life expectancy of women, the proportion of female residents is often considerably higher. From the age of 80 onwards, seniors are particularly vulnerable to the onset of illness due to the risk of complications and their resulting conditions, the risk of chronic illness, and the increased risk of loss of both autonomy and of the ability to engage in self-help practices (Neubart, et al., 2015).

However, according to the German Society of Geriatrics, the German Society of Gerontology and Geriatrics and the Geriatrics Association (BV Geriatrics), geriatric-related multimorbidity is more important than biological age. This stage is reached as soon as at least three relevant diseases such as hypertension, fat metabolism disorders, stroke, pneumonia, osteoporosis, bone fractures, atrial fibrillation, Parkinson’s disease, delirium, dementia, incontinence, sleep disorders or certain tumour diseases (Neubart, 2015) present simultaneously.

Frequently, those affected believe that the consequences of the disease compromise their quality of life to a greater extent than the disease itself does. The International Classification of Impairments, Disabilities and Handicaps (ICIDH) describes here a so-called cascade model: a disease (e. g. brain tumour) causes damage (e. g. paralysis), which leads to disruptions in everyday abilities (e. g. inability to walk) resulting in a participation disorder (e. g. no possibility to attend a social afternoon for senior citizens). Neubart (2015) cites disruptions in mobility, daily activities and communication as well as problems in the processing of disease as capability disruptions, which can have a particularly limiting effect on the quality of life of geriatric patients. Preserving or improving quality of life is currently an important criterion for the evaluation of therapeutic interventions in geriatrics, as many chronic diseases cannot be cured or treated as aggressively in old age (Dichter et al., 2011; Dröes et al., 2006).

The following sections describe the most common age-related diseases and their effects on those affected in more detail.

Figure 3.1: In old age, maintaining quality of life is of great importance.

3.1.1  The dementia patient

Dementia (F00-F03) is manifested by disorders of cortical functions in memory, thinking, orientation, perception, arithmetic, learning, language and judgment. Cognitive deficits can also affect emotional regulation, social behaviour and motivation. Dementia can occur in neurodegenerative diseases such as Alzheimer’s disease, cerebrovascular disorders (e. g. vascular dementia), as well as other primary or secondary brain diseases. Tumours, hematomas or other spatial events can also be associated with dementia (DIMDI, 2018). Mixed forms are not uncommon. Depending on the type of dementia, there are different presentations of dementia. The classification into severity levels has therefore proven to be valid across the various forms of progression (Möller et al., 2015).

Progression forms and degrees of severity

Mild dementia (phase I of Alzheimer’s dementia): This phase is characterised by mild memory loss with weak memory of recent events, impaired judgement, impaired visual-spatial orientation (especially in a foreign environment), and disorders of word finding. Those affected can no longer store new information, items are misplaced, the way to well-known places is no longer found as quickly, everyday activities are forgotten or neglected and not infrequently those affected put themselves at risk (e. g. forgetting to switch off the stove). Many sufferers perceive the loss of their skills clearly and painfully and try to conceal it from themselves or compensate for these loses in front of their relatives and friends. Feelings of fear or shame, depression, indifference or restlessness can occur. Social withdrawal is often the result and goes hand in hand with this mild form. At the same time, a loss of control over affects is reported, which is why affected people often react differently (aggressively, irritably dismissively, exuberantly …) when they are moved on an emotional level. This is often perceived as alienating and irritating by those in the shared environment as well as by the person affected.

Moderate dementia (phase II of Alzheimer’s dementia): This stage is characterised by profound memory disorders: not only recent events, but also earlier memories are lost, sometimes including the recognition of relatives or familiar environments. This disorientation in everyday life and the inability to plan and carry out actions necessitates guidance or accompaniment in almost all areas of life. Linguistic communication becomes increasingly difficult due to impediments in speech comprehension and linguistic expression (e. g. word confusion, syllable twisting). The ability to judge is more severely impaired. There is no difference between then and today, no before and now. The person concerned is completely at the mercy of the current situation. The loss of one’s own control is no longer perceived and therefore no longer denied, covered up or fended off. Emerging memories cannot be classified as past events, but are experienced unfiltered in all their intensity in the here and now. In addition, those affected are often unsettled by sensory illusions (their own mirror image is perceived as an alien person); delusions are also reported (although it is often unclear whether the experience is distorted in a delusional manner or whether an unclear biographical memory dominates the momentary experience). The loss of autonomy, control, self-determination, orientation and understanding is often difficult to bear for those affected and is accompanied by fear and a feeling of isolation. Restless wandering, strong affective fluctuations, sometimes also aggression present relatives or carers with great challenges. A well-intentioned redirection of the affect (if it does not recognise and validate the existing affect) can intensify the confusing feeling in the person concerned, making him feel that he is not understood, has offended or is even wrong.

The symptoms of the disease can often no longer be addressed or compensated for in the home environment. It is not uncommon for them to lead to emotional overload on the part of those affected and their relatives. In addition, for the relatives the experience of being misjudged or no longer recognised is a shock and is frequently experienced as an insult that cannot be understood or accepted. The loss of the self also alienates the affected person from their relatives (and vice versa). In view of the changed experience of those affected, everyday communication is difficult or becomes impossible depending on the situation. Day care or relocation to a nursing home becomes inevitable.

Severe dementia (phase III of Alzheimer’s dementia): This stage manifests itself in the most severe memory disorders, especially with the loss of procedural memory. Even the simplest of procedures that have been automated in the course of life (e. g. eating and hygiene) are lost, so that even basic functions are no longer controllable. This can lead to walking disorders, insecure standing, swallowing disorders, incontinence and even result in the patient becoming bed-ridden. The simplest processes, such as drinking, are forgotten, so that the affected person is dependent on help without being able to understand their necessity. Care can become a great challenge here because it appears to be an attack or an assault. Often it comes with the loss of one’s own language as self-expression and with the loss of understanding language. Verbal expressions have a meaningless character (e. g. echolalia, palilalia). Individual impulses of affects and also the need for exchange of affects seem to recede. The person concerned can neither adequately express his own feelings nor his own needs, even if he is still capable of verbal expression. Similarly, verbal offerings from others often run into emptiness. Relatives cannot understand that the person concerned can no longer classify words. The person suffering from dementia can no longer be reached in this phase via spoken words. On the other hand, the atmosphere of helplessness that intensifies the retreat of the affected person is conveyed in the failed encounter. The experience of the affected person is described as dream-like or surreal, whereby the demarcation between sleep or dream and alertness becomes blurred. There are no reactions to aid or assistance. Muthesius et al. (2010) speak of a “disappearing self” at this stage. Here, when words are nothing more than sound and no longer convey meaning, it is important to provide the person concerned with an atmosphere of protection,...