MJHS Music Therapy: Keys to Dementia Care

music therapy keys to Dementia

Care COVER

music therapy keys to Dementia

Care

INTRODUCTION Dear Administrator:

R

esearch suggests that more than 70 percent of skilled nursing facility residents over age 75 have dementia. Clinically significant neuro-psychiatric symptoms, such as agitation, depression and wandering, are found in more than 63 percent of moderately to severely-impaired residents with dementia. These same symptoms interfere with function, social interaction and care delivery. Traditional management includes chemical and physical restraint, often resulting in detrimental side effects. Through a generous grant from the New York State Department of Health, MJHS developed the enclosed protocols to show how music interventions offer safe, nonpharmacological approaches to relieve symptoms of dementia.

Over the period of three years, the innovative music therapy programs at Shorefront and Menorah Centers for Rehabilitation and Nursing Care were implemented and evaluated. The enclosed materials outline how skilled nursing facilities across New York can utilize a multidisciplinary care planning process led by music therapists—aided and supplemented by direct care staff—to provide individualized and small-group music-based activities. The information will also support your music therapists or other qualified health care professionals who train other dementia care providers, especially Certified Nursing Assistants and other direct care staff.

Each section, along with the accompanying DVD, gives dementia care providers additional tools to utilize during activities of daily living. The described music-assisted activities, namely sing-alongs, tonal activities, as well as “music & movement,” are designed specifically for skilled nursing facility residents with moderate to severe dementia. Implementation is inexpensive and training can be completed in one day or one week.

Results from our evidence-based research demonstrate that creative, musical activities help reduce depression and decrease agitation; residents often return to a calm state. In addition, music can improve resident range-of-motion, which can help prevent falls or other incidents. An additional benefit is that caring for residents who are happy increases efficiencies in resident care. This can lead to higher job satisfaction, as well as recruitment and retention of more highly trained staff.

During the past three years, MJHS has trained numerous staff on music-assisted care techniques.

The results show a higher level of care, with stronger bonds between residents, family members, as well as staff.

We are confident you will have the same experience.

Sincerely, MJHS Music Therapy Team Kendra Ray, MBA, LCAT, MT-BC Michael McGaughy, MT-BC Scott Stuart, MA, MT-BC

Music Therapy Keys to Dementia Care

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Section 1

TABLE OF CONTENTS n

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S ECTION 1 Overview of dementia, agitation and depression (15 Minutes)

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S ECTION 2 iPod—How to use in music-assisted care (30 Minutes)

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S ECTION 3 Singing protocol, followed by practice group (60 Minutes)

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S ECTION 4 Music & Movement (30 Minutes)

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S ECTION 5 Music-assisted range-of-motion, followed by practice group (60 Minutes)

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S ECTION 6 iPod—Working with playlists (30 Minutes)

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S ECTION 7 Tonal protocol, followed by practice group (60 Minutes)

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S ECTION 8 Music-assisted bathing and wound care (60 Minutes)

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S ECTION 9 Key elements of a successful music program (15 Minutes)

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S ECTION 10 Music intervention questionnaire (30 Minutes)

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S ECTION 11 Music intervention questionnaire answers

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Section 1

Overview of Dementia, Agitation and Depression

Music Therapy Keys to Dementia Care

SECTION 1

Overview of Dementia, Agitation and Depression Dementia is a chronic disease that affects the ability to function independently due to progressive cognitive decline1. A diagnosis of dementia is often a life-changing, distressing event that affects patients, their families and caregivers. A patient with dementia may experience: n

Memory loss

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Language deficiency

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Judgment impairment

n

Periods of anxiety and restlessness

n

Executive functioning decline2

Behavioral and psychological symptoms of dementia are seen in the majority of nursing home residents. In fact, 90 percent of residents with dementia will develop behavioral and psychological symptom, including: n

A gitation

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Depression

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Wandering3

Understanding Behaviors A behavior is a means of communicating feelings and needs. Research indicates that people with dementia are more easily agitated because the brain has physically changed and no longer functions in a healthy manner4.

1 Plassman BL, Langa KM, Fisher GG, et al. Prevalence of dementia in the United States: The aging, demographics, and memory study. Neuroepidemiology. 2007;29(1-2):125-132. doi: 10.1159/000109998.

2 Drouillard N, Mithani A, Chan P. Therapeutic approaches in the management of behavioral and psychological symptoms of dementia in the elderly. BC Medical Journal. 2013;55(2):90-96.

3 Drouillard N, Mithani A, Chan P. Therapeutic approaches in the management of behavioral and psychological symptoms of dementia in the elderly. BC Medical Journal. 2013;55(2):90-96.

4 Treatment of dementia and agitation: A guide for families and caregivers. J Psychiatr Pract. 2007;13(3):207-216. doi: 10.1097/01. pra.0000271667.53717.9f.

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Agitation Agitation occurs in 40 - 60 percent of patients in residential and long-term care. Exhibited symptoms include: n

Physical aggressiveness

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Restlessness and pacing

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Verbal insults and shouting

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Shouting and disruptive vocalizations

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Wandering and exit-seeking behaviors5

The four A’s of agitation are: “4 A’s” n Amnesia

— memory loss

n Aphasia

— inability to use words or inability to understand words of others

n Agnosia

— inability to recognize objects or faces

n Apraxia

— inability to perform familiar motor tasks6

EARLY STAGES Amnesia—Reminders or cues Aphasia—Written or demonstrated Agnosia—Gesture,demonstrate or assist to start Apraxia—Hand over hand

LATER STAGES

5 Drouillard N, Mithani A, Chan P. Therapeutic approaches in the management of behavioral and psychological symptoms of dementia in the elderly. BC Medical Journal. 2013;55(2):90-96.

6 Harper N. Train the trainer workshop: Alzheimer’s disease and dementia care. New York, NY: MJHS; 2007.

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Section 1

Music Therapy Keys to Dementia Care

Depression Depression with dementia is one of the most common mental disorders seen in clinical practice7.

It is also associated with psychological and behavioral symptoms.8 However, depression is often under diagnosed in nursing home residents. Some causes of depression with dementia include: n

Mental reaction to decline in cognition

n

Recurrence of early and mid-life depression

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Vascular depression

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Decline associated with Alzheimer’s disease

Some symptoms of depression include: n

Irritability

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Agitation

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Anxiety9

Music activities versus music therapy Research suggests that non-pharmacological interventions, such as music therapy, should be an early pursuit for treatment of behavioral and psychological symptoms. Music therapy, a noninvasive treatment, is the intentional use of music to achieve a therapeutic goal that can contribute to the quality of life for a person diagnosed with dementia10. An ideal psychosocial care plan should emphasize the following: n

Interest

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Social activities including music

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Comfort11

It is important to distinguish between music activities and music therapy. Music activities provide diversions and may be meaningful, as well as motivating. Music therapy is used to achieve specific goals, facilitated by a credentialed music therapist and addresses holistic needs.

7 Kobayashi T, Kato S. Depression-dementia medius: Between depression and the manifestation of dementia symptoms.

Psychogeriatrics. 2011;11:177-182.

8 Prado-Jean A, Couratier P, Druet-Cabana M, et al. Specific psychological and behavioral symptoms of depression in patients with dementia. Geriatric Psychiatry. 2010;25:1065-1072.

9 Prado-Jean A, Couratier P, Druet-Cabana M, et al. Specific psychological and behavioral symptoms of depression in patients with dementia. Geriatric Psychiatry. 2010;25:1065-1072.

10 Clair AA, Memmott J, eds. Therapeutic uses of music with older adults. Second ed. Silver Spring, MD: American Music Therapy Association; 2008.

11 Kobayashi T, Kato S. Depression-dementia medius: Between depression and the manifestation of dementia symptoms.

Psychogeriatrics. 2011;11:177-182.

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Music Therapy Keys to Dementia Care

Suggested strategies for the “Four A’s” Later Stages

g Reminders or cues Aphasia Written or g

demonstrated Agnosia Gesture, demonstrate g or assist to start Amnesia

Apraxia

g Hand over hand Early Stages

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Section 1

Music Therapy Keys to Dementia Care

SECTION OPENER Section 2

iPod—How to Use in Music-Assisted Care

Section 1

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Section 1

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SECTION 2

iPod—How to Use in Music-Assisted Care The iPod is a creative tool that is easy to transfer and adaptable to different situations in activities of daily living. It is important to learn to use the technique outlined in this curriculum prior to use with residents diagnosed with dementia. Mastery of the iPod will make learning the protocols a much easier process.

Directions for using the iPod shuffle (fourth generation) n

E nsure the iPod is off. The switch’s background should be silver.

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Turn iPod on by moving the switch 1 or 2 notches.

- If using a protocol playlist, slide the switch one notch to play songs in order.

The switch will be in the middle position, the background silver and green.

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- If not using a protocol playlist, slide the switch two notches to shuffle: The switch’s background will be green.

Plug speaker cord into the iPod and turn speakers on by sliding the switch on speakers.

T o hear the title and artist information for the current song, press and quickly release the voiceover button (next to the on/off switch).

voiceover button speaker or headphone

three-way switch volume up button

previous/rewind button play/pause button volume down button

all green: shuffle all silver: off switch in the middle: play in order

next/fast forward button clip

Section 1 2

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Section 1

SECTION OPENER Section 3 Singing Protocol, Followed by Practice Group

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Section 1

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SECTION 3

Singing Protocol, Followed by Practice Group This protocol uses live and/or recorded music to facilitate a meaningful opportunity to foster socialization and improve mood.

Staff Requirements: CNA Desired Objectives:

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P revent or reduce verbal and/or physical agitation during activities of daily living

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C alm agitated residents

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I mprove mood

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D ecrease wandering

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I mprove socialization

Entrance Criteria: Residents with mid-stage dementia who exhibit one or more of the following behaviors: wandering, agitation or depression.

Exit Criteria: Resident with no signs of improvement after four weeks or the behavior negatively impacts the involvement of others.

Group Size: Small, no more than six residents Duration: 30-40 minutes Safety Considerations

Environment: All equipment should be clean and without any sharp edges. Keep the floor area free of clutter.

Risks: Residents with high anxiety levels may become agitated with this group. Ensure no residents are noise-sensitive.

Facility & Equipment Required

Facility: Private rooms or resident lounges, areas with reduced distractions

Equipment: iPod, speakers, digital music software, digital music library, song sheets or songbook

Section 1 3

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Music Therapy Keys to Dementia Care

Methods:

1) Prepare a sing-a-long playlist on the iPod and adjust the volume of the mini-speakers before gathering residents (refer to the provided iPod player directions).

2 ) Gather the group in a circle and explain that you will be singing along to many different and familiar songs. Invite residents to join in the singing.

3) Begin the playlist and start singing along with the first song. Pass out song sheets as needed.

4) When the playlist has finished (or if the residents express a desire to end the sing-a-long at any point), turn off the iPod. 5) Talk with residents about the music, unless limited by a language barrier or cognitive impairments. Example questions:

a. Does this music seem familiar to you? b. What kind of music is this? c. What does the music make you think of? d. Who do you think is singing?

6) If they are able to answer, ask residents “Did you enjoy the music?�

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Section 1 3

Music Therapy Keys to Dementia Care

SECTION OPENER Section 4 Protocol: Music & Movement

Section 1 3

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Section 1

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SECTION 4

Protocol: Music & Movement This protocol involves leading a small group of residents in a movement activity with recorded music. The intention is to keep the residents engaged in the music activity so the symptoms of wandering and depression either lessen or do not appear.

Staff Requirements: CNA Desired Objectives:

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T o improve mood, as evidenced by smiling, laughing or making positive comments.

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T o decrease wandering by remaining in program.

Entrance Criteria: Resident has a diagnosis of mid-stage dementia with wandering or depression.

Exit Criteria:

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R esident’s behavioral symptoms worsen and/or negatively affect the involvement of other residents.

R esident begins to leave the group independently, or asks to be taken out of the group.

Group Size: Small group, approximately 4-6 residents Duration: 20-30 minutes Safety Considerations

Environmental Risks: Ensure all equipment is clean, and keep the floor area free of clutter.

Client Risks: Instruct each resident to make comfortable movements. Pay close attention to each resident’s posture, facial tension and reports of pain or exhaustion. Stop the movement activity and encourage the resident to rest if he or she exhibits signs of physical discomfort. Report sustained complaints or signs of pain to nurse.

Facility & Equipment Required

Facility: Small activity room or lounge

Equipment: iPod, portable speakers, chiquitas, egg shakers, jingle bells, scarves Method

1) Prepare activity before gathering residents for music group:

a. Set the iPod to a playlist designed for movement.

b. Place rhythm instruments and scarves so that you can easily access them.

Section 1 4

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Music Therapy Keys to Dementia Care

2 ) Once group members are in a circle, explain that they will listen to music while making movements using rhythm instruments and scarves. Emphasize that each resident should only complete comfortable movements. Instruct residents to let you know if they are experiencing any discomfort during the movement activity.

3 ) Turn on the iPod and speakers. Ask residents if the volume is too loud or too soft, and adjust it if necessary.

4 ) Offer a rhythm instrument to each resident, giving a choice between different instruments and colors. Ensure the instrument handle faces the resident. If the resident does not want an instrument, respect this decision. Mention that the residents can make the movements without the instruments.

5 ) Call out and then demonstrate movements.

6 ) Ask each resident to suggest or show one movement, and direct the group to copy it.

7) After 10-15 minutes, collect the rhythm instruments from each resident.

8) Explain that a cool down with scarves is next.

9 ) Hand out scarves, giving each resident a choice of color. If a resident does not want one, respect this choice and say that movements may be done without scarves.

10) Instruct residents to take a few deep breaths and direct them to follow your slow and easy movements.

11) After five minutes, announce that residents can relax and that you will collect the scarves.

12) Turn off the music. Ask the residents, “Did you enjoy the music?� Also ask how each resident is feeling.

13) Lead a discussion about the music activity, giving each resident an opportunity to express his or her own opinion. Ask specific questions about the recorded music. Be sure to take time to practice active listening with each resident. Your response should be of a positive nature, even if the resident had a negative view.

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Section 1 4

Music Therapy Keys to Dementia Care

SECTION OPENER Section 5 Music-assisted Rangeof-Motion, Followed by Practice Group

Section 1

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Section 1

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SECTION 5

Music-assisted Range-of-Motion, Followed By Practice Group This program uses recorded music to motivate the resident’s active involvement in range-ofmotion exercises, increase reality orientation, improve mood and decrease wandering.

Staff Requirements: At least one CNA or one caregiver Desired Objectives: n

I ncreased level of involvement in range-of-motion exercises, as seen when resident completes, or makes active efforts to complete, the exercises.

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Improved range-of-motion, as evidenced by resident’s increased range-of-motion.

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Increased reality orientation, as seen by verbal comments relating to the present moment.

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Improved mood, as seen by positive verbal comments and brightened affect.

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D ecreased wandering, as seen when the resident stays with caregiver or staff member during the range-of-motion exercises.

Entrance Criterion: Resident has moderate dementia, with or without depression, is withdrawn, shows verbal or nonverbal signs of poor mood, and/or has range-of-motion exercises in the individual rehabilitation plan that the resident resists.

Exit Criterion: Decline in the resident’s health that prohibits him or her from engagement in range-of-motion exercises.

Group Size: One resident Duration: 5 – 20 minutes Safety Considerations

nvironmental Risks: The floor should be free of clutter. The resident should be seated in a E firm chair with a straight back.

Client Risks: Avoid risk of overexertion by paying close attention to the resident’s posture, facial tension and verbal reports of exhaustion. Adjust or stop the exercises and music, when appropriate.

Facility & Equipment Required

Facility: Common area or resident’s room

Equipment: CD player, CD that is customized to resident’s music preferences and range-ofmotion session, iTunes, CD-burning software

Section 1 5

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Music Therapy Keys to Dementia Care

Methods:

1) Identify the resident’s personal music preferences, based on comments by the resident, family members or caregivers.

2 ) If no information is available regarding music preferences, consult the music therapist or recreation therapist.

3 ) Create a music compilation CD for the range-of-motion session. The first track should have a slow beat. Subsequent tracks should have a faster beat.

4 ) Greet the resident and ask, “Is it okay if I turn on some music?”

5 ) If the resident agrees, play the CD’s first track.

6 ) Adjust the volume of the music to the resident’s preferred listening level.

7) Toward the beginning of the second track, initiate and facilitate range-of-motion exercises that serve the resident’s individualized plan of care.

8) If the resident resists engaging in the exercises, encourage participation. If the resident still resists, allow him or her to stop.

Guidelines for Music-Assisted Range-of-Motion: n

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S elect music based on the resident’s music preferences. Always consider the resident’s music preferences and responses first.

I f there is no information available regarding the resident’s music preferences or responses, choose music that was popular when the resident was 20-30 years of age. When possible, choose music that reflects the resident’s cultural background.

T he music selection for the first track should have a slow beat, and be instrumental. This track will be in the background during greeting time.

M usic selections for the second and following tracks should have a fast beat, and may be instrumental or vocal. This upbeat music is meant to motivate the resident to complete the exercises.

Music Suggestions for Greeting (Track 1): Title Instrumental music Instrumental music “Adagio for Strings”

Composer and Lyricist Various Various Samuel Barber

Artist Kenny G Yanni Various

Music Suggestions for Range-of-Motion Exercises (Track 2 until end): Song Title “Alexander’s Ragtime Band” “Anchors Aweigh” “Give My Regards to Broadway” “Hava Nagilah” “Quizas, Quizas, Quizas”

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Section 1 5

Composer and Lyricist Berlin Zimmerman and Miles Cohan Hebrew Folk Song Osvaldo Farres

Artist Various Various Various Moshe Nathanson Various

Music Therapy Keys to Dementia Care

SECTION OPENER Section 6 iPod—Working With Playlists

Section 1

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SECTION 6

iPod: Working with Playlists Playlists are helpful compilations of songs that are saved on the iPod for repeated use.

This program includes playlists created for the outlined protocols. For example, the Music & Movement protocol has a playlist titled “For Movement”. Use of this playlist can motivate residents, improve mood, as well as decrease stress and burden on caregivers and/or residents.

In general, playlists should reflect the resident’s musical preferences. If the resident’s preference is unknown, choose songs that were popular when the resident was 20-30 years of age, remaining mindful of his or her cultural background.

Choose a playlist on the iPod: n

To choose a playlist, press and hold down the VoiceOver button until it beeps. n

The current playlist will be named, followed by others.

-To go forward, press and release arrows on the right >>|.

-To go backward, press and release arrows on the left |<<.

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Press and release the center button || to select a playlist.

Adjust the volume as needed.

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On speakers, slide dial to the right to get louder and to the left to get softer.

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On iPod, press + to get louder and – to get softer.

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To skip to the next song, press and release the button on right side >>|.

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To return to the previous song, press and release the button on the left side |<<.

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To put the music on hold, press and release the center button ||.

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To turn the music back on, press and release the center button again ||.

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T o reset the shuffle, first turn it off. Wait ten seconds, then slide the switch to either shuffle or play in order.

Playlist Order 1. All songs 2. Caribbean 3. Classical 4. Energizing 5. Movement * 6. Music-assisted care *

7. Sing-a-long * 8. Italian 9. Jazz 10. Jewish 11. Oldies

12. Relaxing 13. Russian 14. Latin * Protocol playlists

Note: iTunes software is necessary to create playlists for the iPod.

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Music Therapy Keys to Dementia Care

Playlists should reflect resident preferences and the cultural diversity of the resident population.

Playlists Designed for Protocols: Play songs in order Sing-a-long (24 minutes)

Tonal (7 minutes)

Music & Movement (25 minutes)

Music-assisted bathing (32 minutes)

Music-assisted range-of-motion (24 minutes) Music-assisted wound care (27 minutes)

Sing-a-long Playlist (24 minutes) Song-Artist Album

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Side by Side Kate Smith

Iâ&#x20AC;&#x2122;ll Be Seeing You

You Are My Sunshine Rosemary Clooney

Learninâ&#x20AC;&#x2122; the Blues

Hava Nagilah The Moshe Silberstein Ensemble and Chorus

The Music of Israel

Tumbalalaika Theodore Bikel

Yiddish Folk and Theatre

Quizas, Quizas, Quizas Celia Cruz

Cuba Bella

Michael Row the Boat Ashore Peter, Paul and Mary

Sing Along

Red River Valley Frank Corrales and Cisco Trio

Sing Along

Tzenah Tzenah The Neshoma Orchestra

Jewish Play Along

God Bless America Kate Smith

The Best of Kate Smith

Section 1 6

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Music & Movement (25 minutes) Song-Artist Album Under the Boardwalk The Drifters

Rock nâ&#x20AC;&#x2122; Roll 1964

Love Me or Leave Me Sammy Davis, Jr.

Rat Pack Disc 2

Cheek to Cheek Ella Fitzgerald

Pop Standards

Hava Nagilah The Neshoma Orchestra

Jewish Play Along

Quizas, Quizas, Quizas Celia Cruz

Cuba Bella

Stars and Stripes Forever London Festival Orchestra

Great Orchestra Marches

Thais: Meditation Massenet

Most Relaxing Classical Album

Music-assisted Range-of-Motion (24 minutes) Song-Artist Album Concerto for Violin and Orchestra No. 1 The Romantic Violin Max Bruch Alexanderâ&#x20AC;&#x2122;s Ragtime Band Ella Fitzgerald

Various

Semper Fidelis John Philip Sousa

Sousa Marches Forever

Beyond the Sea Bobby Darin

Pop Standards Vol. 6

Quizas, Quizas, Quizas Celia Cruz

Cuba Bella

Clair de Lune Debussy

Most Relaxing Classical Album in the World

Section 1 6

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Music Therapy Keys to Dementia Care

Tonal (7 minutes) Use C and G Tone bars Song-Artist Album Red River Valley Frank Corrales and Cisco Trio

Sing Along

Tzenah Tzenah The Neschoma Orchestra

Jewish Play Along

Oh, Susanna Frank Corrales and Cisco Trio

Sing Along

Music-assisted Bathing (32 minutes) Song-Artist Album

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In the Mood Glenn Miller

Glenn Miller 1938-1942 Disc 2

What A Wonderful World Louis Armstrong

Pop Standards Vol. 6

Chattanooga Choo Choo Glenn Miller

Glenn Miller 1938-1942 Disc 2

Over the Rainbow Judy Garland

The Complete Masters (Plus)

Thatâ&#x20AC;&#x2122;s Amore Dean Martin

Rat Pack Disc 2

What I Did for Love Shirley Bassey

Pop Standards Vol. 5, Side 1

At Last Glenn Miller

Glenn Miller 1938-1942 Disc 2

The Girl from Ipanema Sinatra/Jobim

Pop Standards Vol. 4

Beyond the Sea Bobby Darin

Pop Standards Vol. 6

Cheek to Cheek Ella Fitzgerald

Pop Standards Vol. 2

Section 1 6

Music Therapy Keys to Dementia Care

Music-assisted Wound Care (27 minutes) Song-Artist Album Part 1 Air, Sinfonia in G Bach

Various

Largo from Piano Concerto No. 3 Beethoven

Various

Intermezzo in E flat Brahms

Various

Part 2 Meet Me in St. Louis Mills and Sterling

Various

When Johnny Comes Marching Home Gilbert (Lambert)

Various

Stars and Stripes Forever Sousa

Various

Be creative and design your own playlists using these genres as a reference tool.

Playlists Organized by Music Type: May use shuffle Chinese

Jazz

Oldies

Classical Jewish Russian Italian Latin Soul/R&B/Motown

Section 1 6

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Music Therapy Keys to Dementia Care

Album Recommendations for Additional Playlists Playlist Chinese

Chinese Traditional Music

Classical

-Mozart: Concertos for Two and Three Pianos -Classical Escape Bach -Sonatas for Piano and Violin - Most Relaxing Classical Album in the World…Ever

Italian

-Italian Music Odyssey -Viva Italia! All the Favorite Italian Songs

Jazz/Big Band

- An Anthology of Big Band Swing (1930-1955) Disc 2 -Lady Day’s 25 Greatest: 1933-1944 -Pop Standards Vol.1 – 7 -Rat Pack -Glenn Miller 1938-1942 Disc 2

Jewish

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Album(s) Recommended

-The Music of Israel - To Life!: Songs of Chanukah and other Jewish Celebrations -Yiddish Folk and Theatre Songs -Jewish Play Along

Caribbean/Latin

-Beautiful Barbados -Medley Tropical -Celia Cruz Greatest Hits -2 Grandes de la Salsa

Oldies

-Rock n’ Roll 1962-1967 -25 All-Time Greatest Hits

Russian

-Russian Classical Guitar Music.

-Romance, Folk Songs - Songs of Russia Old & New/Songs of a Russian Gypsy -Balalaika Favorites

Soul/R&B/Motown

-James Brown Mix -What’s Going On (Marvin Gaye) -Smokey Robinson -Al Green’s Greatest Hits -25 All-Time Greatest Hits

Section 1 6

Music Therapy Keys to Dementia Care

SECTION OPENER Section 7 Tonal Protocol, Followed By Practice Group

Section 1

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SECTION 7

Tonal Protocol, Followed

By Practice Group Tonal: 1- and 2-chord songs Staff Requirements: CNA Desired Objectives n

P revented or reduced verbal and/or physical agitation during activities of daily living

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C alming of agitated residents

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I mproved socialization as evidenced by singing or humming lyrics

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I mproved mood as evidenced through words and facial expressions

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D ecreased wandering

Entrance Criteria: Residents with mid-stage dementia who exhibit one or more of the following behaviors: wandering, agitation or depression.

Exit Criteria: Residents who show no signs of improvement after four weeks or whose behavior negatively affects other participants.

Group Size: Small group; 4-6 residents Duration: 30-40 minutes Safety Considerations

Environment: All equipment should be clean and without any sharp edges. Keep the floor area free of clutter.

Client Risks: Ensure residents are not noise sensitive. Residents with high anxiety levels may become agitated in this group.

Facility & Equipment Required

Facility: Activity or similar room away from distractions

Equipment: S et of bass tone bars that are individually labeled C, G and C (Orff) with mallets (refer to the appropriate song sheets for instructions on when to play the tone bars C or G for the songs listed below).

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A table for the tone bar and for residents with limited motor skills.

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S uzuki hand bells.

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Music Therapy Keys to Dementia Care

Methods

1) The group is gathered in a circle.

2 ) First, show the residents the tone bars and then demonstrate how to use them. Then, pass out the mallets holding the ball end so residents reach for it with their dominant hand.

Next, hand out the tone bars.

3 ) The CNA should then demonstrate a rhythm (i.e. slow and steady or fast, loud, soft, etc).

4 ) Instruct the residents to hold their hands up and play together.

5 ) When the residents have mastered this, start singing. The CNA should conduct residents according to the song sheets in this guide.

6 ) When finished singing, ask residents to reflect on the sounds the group created.

Practice active listening with each resident. Respond positively, even if the resident had a negative view.

7) Repeat steps 2-5.

Suggested Songs for Tonal Activity “Row, Row, Row Your Boat” “Michael Row the Boat Ashore” “Three Blind Mice” “Hot Cross Buns” “You Are My Sunshine” “Oh Susanna” “Clementine” “De Colores”

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Section 1 7

C and G Tone Bars are marked by yellow and red stickers.

Play G Tone Bars on Red background

Play C Tone Bars on Yellow background

These color-coded lyrics provide guidance for playing C and G tone bars. Â

Tonal Chord Songs

Music Therapy Keys to Dementia Care

Section 1 7

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7 Section 1

Life is but a dream

Merrily, merrily, merrily, merrily

Gently down the stream

Row, row, row your boat

Row, Row, Row Your Boat

Music Therapy Keys to Dementia Care

As three blind mice

Did you ever see such a sight in your life

She cut off their tails with a carving knife

They all ran after the farmerâ&#x20AC;&#x2122;s wife

See how they run, see how they run

Three blind mice, three blind mice

Three Blind Mice

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7 Section 1

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Section 1 7

Hot cross buns Hot cross buns If you have no daughters Give them to your sons

Hot cross buns

Hot cross buns

One a penny, two a penny

Hot cross buns

Hot cross buns

Music Therapy Keys to Dementia Care

River Jordan is chilly and cold, hallelujah Chills the body but not the soul, hallelujah River Jordan is chilly and cold, hallelujah Chills the body but not the soul, hallelujah Michael row the boat ashore, hallelujah Michael row the boat ashore, hallelujah Michael row the boat ashore, hallelujah Michael row the boat ashore, hallelujah

Michael row the boat ashore, hallelujah

Michael row the boat ashore, hallelujah

Michael row the boat ashore, hallelujah

Michael row the boat ashore, hallelujah

Sister help to trim the sail, hallelujah

Sister help to trim the sail, hallelujah

Sister help to trim the sail, hallelujah

Sister help to trim the sail, hallelujah

Michael, Row The Boat Ashore

Music Therapy Keys to Dementia Care

Section 1 7

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Section 1 7

Oh my darling, Clementine!

Thou art lost and gone forever Dreadful sorry, Clementine

Excavating for a mine

Dwelt a miner forty niner

And his daughter

Clementine

Oh my darling, oh my darling

In a cavern, in a canyon

Clementine

Music Therapy Keys to Dementia Care

Dinah, won’t you blow, Dinah, won’t you blow your horn?

Dinah, won’t you blow, Dinah, won’t you blow, Dinah, won’t you blow your horn?

All the live long day

I’ve been workin’ on the railroad,

Just to pass the time away

Don’t you hear the whistle blowing?

Rise up so early in the morn

“Dinah, blow your horn?”

Don’t you hear the captain shouting

Dinah, won’t you blow,

I’ve been workin’ on the railroad,

I’ve Been Working on the Railroad

Music Therapy Keys to Dementia Care

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Section 1 7

I dreamed I held you in my arms When I awoke dear I was mistaken So I lay down my head and cried

You make me happy when skies are gray

You’ll never know dear how much I love you

Please don’t take my sunshine away

Please don’t take my sunshine away

You’ll never know dear how much I love you

You make me happy when skies are gray

You are my sunshine, my only sunshine

The other night dear as I lay sleeping

You are my sunshine, my only sunshine

You are My Sunshine

Music Therapy Keys to Dementia Care

Susanna, don’t you cry.

The sun so hot I froze to death

The weather it was dry,

It rained all night the day I left

I’m going to Louisiana, my true love for to see.

I came from Alabama with a banjo on my knee,

With my banjo on my knee

‘Cause I’ve come from Alabama

Oh don’t you cry for me,

Oh! Susanna,

Oh Susanna

Music Therapy Keys to Dementia Care

Section 1 7

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Colores me gustan a mi.

Amores de Muchos

De Colores, De colores es el arco iris Que vemos Lucir. Y por eso los grandes.

De Colores, De colores son los parajitos Que Vienen De Afuera

De Colores, De colores se visten los compos en la Primavera

Colores me gustan a mi

Amores de muchos

Y por Eso los grandes

De Colores

Music Therapy Keys to Dementia Care

Music Therapy Keys to Dementia Care

SECTION OPENER Section 8 Music-assisted Bathing and Wound Care

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SECTION 8

Music-assisted Bathing and Wound Care Music-Assisted Bath/Shower This program uses recorded music to reduce aggressive behaviors in a resident who is receiving a bath or shower.

Staff Requirements: At least 1 CNA or one caregiver Desired Objectives n

Improved mood, as seen by positive verbal comments and brightened affect.

n

Decreased physical tension, as seen by less muscle rigidity.

n

Relaxation, as seen by closing eyes and non-resistance of care.

n

Prevented or reduced aggressive behaviors, such as kicking, yelling or hitting.

Entrance Criterion: The resident has moderate dementia, with or without depression. The resident resists being bathed. The resident displays aggressive behaviors, such as yelling, hitting and kicking, during bathing/showering or during the preparation for bathing/showering. The resident is not sensitive to noise.

Exit Criterion: The resident’s aggressive behaviors do not improve over the course of four music-assisted baths/showers. The resident’s aggressive behaviors worsen during two musicassisted baths/showers.

Group Size: 1 resident Duration: 30–60 minutes Safety Considerations

Environmental Risks: All music-related equipment should be waterproofed and disconnected from an electrical outlet.

Resident Risks: Respect the resident’s right to refuse the bath/shower or the music.

Facility & Equipment Required

Facility: Shower-room, or wherever bathing/showering occurs.

Equipment: Waterproof CD player, CDs, CD-burning software such as iTunes.

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Method

1) Customize the CD based on the resident’s personal music preferences and on the music that has historically relaxed the resident.

2 ) If no information is available on effective music or preferences, consult the music or recreation therapist.

3 ) Set up music where the bath/shower will take place. Place the CD in the CD player and press play, adjusting the volume to match the resident’s preferred listening level.

4 ) If the preparation for the bath/shower occurs in a different location from the bath/shower, set up another CD player and CD in this location. Place a copy of the customized CD or one with similar music in the CD player and press play, adjusting the volume to match the resident’s preferred listening level.

5 ) Prepare the resident for the bath or shower.

6) If aggressive behavior or high stress level occurs, redirect the resident.

7) If aggressive behavior or high stress level worsens, change the track.

8 ) If aggressive behavior or high stress level further worsens, turn off the music.

9 ) Give the bath or shower, continuing to follow the three previous steps as needed.

Guidelines for Music-Assisted Bathing: n

n

S elect music based on the resident’s music preferences. Pay attention to verbal and nonverbal responses.

I f there is no information regarding the resident’s music preferences, choose music that was popular when the client was 20-30 years of age. If possible, choose music that reflects the resident’s cultural background.

Music Suggestions:

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Song Title

Composer and Lyricist

Artist

“In the Mood” “Chattanooga Choo Choo” “Singin’ in the Rain” “What a Wonderful World” “Over the Rainbow” Popular songs

Garland and Razaf Gordon and Warren Brown and Freed Thiele and Weiss Arlen and Harburg Various

Glenn Miller Glenn Miller Gene Kelly Louis Armstrong Judy Garland Frank Sinatra

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Music Therapy Keys to Dementia Care

Music-assisted Wound Care This program uses recorded music before and during wound care in order to increase the resident’s physical comfort, reduce the resident’s perception of pain and induce a relaxation response. The recorded music will also be used to prevent or reduce any aggressive behaviors, such as yelling, crying, pinching and biting during wound care, and to allow the nurse to more easily complete wound care.

Staff Requirements: At least one CNA or one caregiver, as well as one nurse Desired Objectives n

Increased physical comfort, as seen by less muscle tension or less aggressive behaviors.

Decreased perception of pain, as seen by fewer nonverbal or verbal signs of discomfort, such as yelling and moaning. n

n

Relaxation, as seen by eyes closing, sleep, less muscle rigidity.

Fewer or no aggressive behaviors, as seen by the absence of hitting, biting or pinching, or a reduction in these behaviors. n

n

Less resistance to wound care, as noted by nurse’s observation.

Entrance Criterion: The resident has moderate dementia, with or without depression. The resident requires wound care, and shows signs of physical discomfort during wound care, such as crying, screaming and moaning. The resident may or may not exhibit aggressive behaviors during wound care, such as hitting, punching and biting.

Exit Criterion: The resident demonstrates no change in physical discomfort or aggressive behaviors over the course of three wound care sessions. The resident expresses preference to have no music during wound care. Signs of physical discomfort or aggressive behaviors worsen over the course of one session.

Group Size: One resident.

Duration: As needed, prior to and during wound care.

Safety Considerations

Environmental Risks: Floor and bed should be free of clutter. Padding should surround floor and bed.

Resident Risks: Respect the resident’s wishes regarding music during wound change.

Facility & Equipment Required

Facility: Private room

Equipment: CD player, 2 CDs that are customized to resident’s music preferences, 1 CD with slow preferred music, 1 CD with upbeat preferred music, iTunes, CD-burning software.

Method

1) Identify the resident’s personal music preferences, per information given by the resident, family members or caregivers.

2 ) If no information is available regarding music preferences, consult the music or recreation therapist.

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3 ) Create music compilation CDs for the wound care sessions. Music on the first CD should be slow. Music on the second CD should be upbeat.

4 ) Greet the resident and ask, “Is it okay if I turn on some music?”

5 ) If the resident agrees, play the CD with slow music.

6) Adjust the volume of the music to the resident’s preferred listening level.

7) Just before the nurse begins wound care, change the CD and play another CD with upbeat music.

8 ) Increase the volume of the music on signs of physical discomfort, such as crying and yelling, or aggressive behaviors, such as hitting or pinching.

9 ) Decrease the volume of the music on signs of relaxation and decreased aggressive behaviors, and/or the ending of the wound change.

Guidelines for Music-Assisted Bathing: n

n

n

n n

S elect music based on the resident’s music preferences. Always consider the resident’s music preferences and responses first.

I f there is no information available regarding the resident’s music preferences or responses, choose music that was popular when the resident was 20-30 years of age. When possible, choose music that reflects the resident’s cultural background.

M usic selection for the first CD should have a slow beat and be instrumental. Play these tracks before wound care begins. They should help the resident relax.

M usic selections for the second CD should have a fast beat, whether instrumental or vocal.

I f the resident shows signs of relaxation, return to the slow music that was played before wound care began. This music is meant to reinforce the relaxation response, and to have a soothing effect.

Music Suggestions for Slow CD (Music played prior to wound care and after signs of relaxation) Selection Title

Composer

“Air, Sinfonia in G”

Bach

“Largo from Piano Concerto No. 3”

Beethoven

“Intermezzo in E Flat”

Brahms

Music Suggestions for Upbeat CD (Music played right before and during wound care) Song Title

Composer and Lyricist

”Meet Me In St. Louis”

Mills and Sterling

“When Johnny Comes Marching Home” Gilmore (Lambert) “Stars and Stripes Forever”

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Sousa

Section 9

Key Elements of a Successful Music Program

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SECTION 9

Key Elements of a Successful Music Program Preparation Music therapy is key to dementia care. Successful programs have a clear framework and adjust to resident needs. Before a group is created, ask: n

What is the atmosphere on the floor today?

n

Which residents in the group are not feeling well?

n

Who has declined and may no longer be appropriate?

n

What do residents most like?

n

Is there an activity from previous sessions that did not work well and why?

n

Have the residents asked for a different song?

Communication Many residents with dementia are also hearing impaired. When speaking with residents, remember to: n

Talk at eye level.

n

Use a friendly, welcoming tone.

n

Remember culturally appropriate body language and actions.

n

Speak slowly.

n

Be patient.

Setup The right setup helps programs thrive. Before residents arrive: n

Finalize activities, arrangements and music.

Consider the best seating arrangement for residents. A line, semi-circle or complete circle may encourage maximum participation. n

Instruments and materials, including song sheets, should be on the tableâ&#x20AC;&#x201D;making them easy to access and use. n

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Facilitation How information is delivered can make or break an activity. A good facilitator will:

62

n

Speak slowly and clearly so residents can understand.

n

Give physical and/or verbal cues and know when to use either or both techniques.

n

Rephrase directions when necessary, so all residents can be as fully engaged as possible.

n

Offer simple and direct directions in a friendly tone.

n

Adjust the volume or activity according to resident wishes.

Section 1 9 3

Music activities can help to: n Calm residents

n Improve mood

n Decrease wandering

n Reduce verbal and physical agitation

n Improve social interaction

These cards provide key guidelines for leading music activities with residents who have dementia and may seem agitated, aggressive or withdrawn.

Music Activity Cards for CNAs

Music Therapy Keys to Dementia Care

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Learn the residentâ&#x20AC;&#x2122;s favorite music by asking the resident, staff or family, and use that music

n

Set up the room and all equipment before the resident is present.

n

Ask if the music is too soft or too loud. Adjust as needed.

Invite residents to participate. If one refuses, invite that resident to stay and just listen to the music. If

n

n

In the last five minutes, let the resident know the music will end.

Ask the resident if he or she enjoyed the music.

n

n

3. End the music activity

the resident still refuses, stop the music or help the resident leave the group.

Tell the resident what you plan to do throughout the session.

n

2. Respectfully lead activity

Try to find a quiet room that will have minimal distractions.

n

whenever possible.

If the resident is highly sensitive to noise, do not include the resident.

n

1. Prepare

Key Points to Consider

Music Therapy Keys to Dementia Care

n

Resident

n

negatively impacts the involvement of others

Behavior

shows no signs of improvement after 4 sessions

symptoms of wandering, agitation or depression

Exhibits

n

n

Does this music seem familiar?

3. At the end of each song, put the music on hold.

Take a few minutes to discuss the music with the residents. For example:

2. Turn on music: select a sing-a-long playlist. Pass out song sheets as needed.

1. Gather residents in a circle and explain that you will be singing along to familiar songs. Invite them to join in the singing.

Steps

stop

go

Resident has mid-stage dementia

n

n

Did you enjoy the music?

Who do you think is singing?

What does the music make you think of?

What kind of music is this?

4. When the playlist has finished (or if the residents express a desire to end the sing-a-long at any point), turn off the MP3 player.

n

n

n

Group Size: Small (no more than 6 residents) Duration: 30-40 minutes Special Equipment: iPod player and speakers, song sheets or songbook

Sing-a-long

Music Therapy Keys to Dementia Care

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Section 31 9 n

Resident

n

negatively impacts involvement of others

Behavior

shows no signs of improvement after 4 sessions

symptoms of wandering, agitation or depression.

Exhibits

n

5. When residents seem comfortable playing the tone bars, start singing.

4. Then instruct residents to all play together. See song chord sheets for 1-chord songs.

3. Demonstrate a rhythm (i.e. slow and steady, fast, loud, soft, etc.)

2. Show residents the tone bars and demonstrate how to use them. Pass out mallets and then the tone bars.

1. Gather group in a circle.

Steps

stop

go

Resident has mid-stage dementia

n

8. Try 2-chord songs. CNA will conduct residents according to song sheets provided by music therapist.

7. Repeat steps 4-6.

6. After singing, take time to discuss the music with residents. Listen and practice active listening. Your response should be of a positive nature, even if the resident had a negative view.

Group Size: Small (4 residents) Duration: 30-40 minutes Special Equipment: Set of tone bars with mallets, song chord sheets (for CNA only), small table for instruments

Tonal/1 & 2 Chord Songs

Music Therapy Keys to Dementia Care

5. Call out each movement, then demonstrate it and invite residents to join. Encourage residents to suggest their own movements.

4. Start the music and hand out rhythm instruments.

Movements can be made without instruments if the resident wishes.

3. Before beginning movements, emphasize that each resident should only do a movement if comfortable; instruct them to let you know if they experience any discomfort.

10. Take a few minutes to discuss the session, then say goodbye.

9. After 5-10 minutes of slow and easy movements, collect scarves and then turn off music.

8. Instruct the residents to take a few deep breaths and to follow you as you make slow and easy movements.

7. Hand out scarves, offering choice of color. Honor wishes, if a resident declines to use a scarf. Movements can be performed free-handed.

a desire to leave

2. Arrange group members in a circle.

Signals

behavioral symptoms worsen or negatively impact involvement of other residents

Group Size: Small (4-6 residents) Duration: 20-30 minutes Special Equipment: iPod player and speakers, chiquitas, egg shakers, jingle bells, scarves

Music & Movement

6. After 10-15 minutes, collect rhythm instruments and tell residents you will now cool down with scarves.

n

Residentâ&#x20AC;&#x2122;s

n

symptoms of wandering, agitation or depression.

Exhibits

n

1. Turn on music: select a movement playlist or one that includes the residentsâ&#x20AC;&#x2122; favorite music.

Steps

stop

go

Resident has mid-stage dementia

n

Music Therapy Keys to Dementia Care

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4. Avoid risk of over-exertion by paying close attention to the residentâ&#x20AC;&#x2122;s posture, facial tension and verbal reports of

3. Initiate and facilitate range-of-motion exercises that serve the residentâ&#x20AC;&#x2122;s individualized plan of care.

5. If the resident resists engaging in the exercises, redirect the resident by discussing the music. You may want to pause the range-of-motion exercises until the resident seems less resistant.

Group Size: One resident Duration: 5-20 minutes Special Equipment: iPod player and speakers, firm chair with straight back

2. Seat the resident in a firm chair with a straight back.

in health prohibits range-of-motion exercises

Decline

resistant to rehabilitation plan exercises

exhaustion. Adjust or stop the exercises and music when appropriate.

n

Is

n

signs of withdrawal, poor mood

Shows

n

Music-assisted Range-of-Motion

1. Turn on music: select a movement playlist or one that includes the residentâ&#x20AC;&#x2122;s favorite music.

Steps

stop

go

Resident has mid-stage dementia

n

Music Therapy Keys to Dementia Care

Aggressive

n

behaviors do not improve over the course of 4 sessions or worsen throughout 2 sessions

aggressive behaviors prior to, or during, bathing/showering

Displays

n

3. If yes, or if the residentâ&#x20AC;&#x2122;s agitation has not worsened, let the music continue.

2. Inform the resident that you will now begin the bathing, and ask if the music can continue.

1. Turn on music for resident 20-30 minutes before the bathing begins: select a music-assisted care playlist or one that includes the residentâ&#x20AC;&#x2122;s favorite music.

Steps

stop

go

Resident resists being bathed

n

4. While bathing the resident, notice any aggressive behaviors or general agitation; if either increases, direct the resident to listen to the music. If they continue to increase, change the music to a different track or playlist.

If the aggression or agitation rises, turn off the music.

Group Size: One resident Duration: 30-60 minutes Special Equipment: iPod player and speakers

Music-assisted Bath/Shower

Music Therapy Keys to Dementia Care

Section 1 3 9

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Section 1 9 Signs

Resident

n

n

says no to music at any time

shows no improvement in physical discomfort or behaviors after 3 different attempts

of physical discomfort or aggressive behaviors worsen

Resident

n

3. If yes, or if signs of agitation and discomfort have not worsened, let music continue as wound care begins.

2. Five minutes before wound care, ask the resident if the music can continue.

1. Turn on music 20-30 minutes before wound care is scheduled to begin: select a music-assisted care playlist or one that includes the residentâ&#x20AC;&#x2122;s favorite music.

Steps

stop

go

intense wound care and shows signs of physical discomfort or exhibits aggressive behaviors during wound care

Requires

n

4. If there is an increase in the residentâ&#x20AC;&#x2122;s signs of physical discomfort or agitation, direct the resident to listen to the music. If the signs continue to increase, change the music to a different song or playlist. If the signs elevate, turn the music off.

Group Size: One resident Duration: As needed, prior to and during wound care Special Equipment: iPod player and speakers, padding around floor and bed

Music-assisted Wound Care

Music Therapy Keys to Dementia Care

Music Therapy Keys to Dementia Care

Section 10

Music Intervention Questionnaire

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Music Therapy Keys to Dementia Care

SECTION 10

Music Intervention Questionnaire 1. Peggy is throwing her food again and agitating other residents. What kind of music should you offer Peggy to reduce her throwing behaviors?

a. Slow, instrumental music

b. Peggyâ&#x20AC;&#x2122;s favorite songs

c. Music that you find calming

d. All of the above

2. Russell is refusing to get out of bed this morning. He is having difficulty getting motivated. Name three items from the movement protocol that you should use to motivate Russell.

1.

2.

3.

3. Lacy repeatedly wanders around the nursing station, calling for a nurse. You checked her for pain and other signs of discomfort. Which protocol do you use to help reduce her wandering, and why? What playlist would you chose from the iPod?

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4.

Name two of your residents with whom you can use each protocol:

a. Tonal

b. Movement

c. Bathing

d. Wound Care

74

Choose an iPod playlist for each resident.

10 Section 1

Music Therapy Keys to Dementia Care

SECTION OPENER Section 11 Music Intervention Questionnaire Answers

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Music Therapy Keys to Dementia Care

SECTION 11

Music Intervention Questionnaire Answers 1) Peggy is throwing her food again and agitating other residents. What kind of music should you offer Peggy to reduce her throwing behaviors? a. Slow, instrumental music b. Peggyâ&#x20AC;&#x2122;s favorite songs c. Music that you find calming d. All of the above The correct answer is d. The best approach is to sing or play Peggyâ&#x20AC;&#x2122;s favorite song that is slow and calming. Music that is slow in tempo can reduce the state of agitation for everyone in the room, especially Peggy.

2 ) Russell is refusing to get out of bed this morning. He is having difficulty getting motivated.

Name three items from the movement protocol that you should use to motivate Russell.

The correct answers are rhythm instruments, scarves or other props, as well as iPod and speakers.

3) Lacy repeatedly wanders around the nursing station, calling for a nurse. You checked her for pain and other signs of discomfort. Which protocol do you use to help reduce her wandering, and why? What playlist would you chose from the iPod? The correct answer is Music & Movement. The use of this playlist requires minimal set-up and can be facilitated on a one-to-one basis. It is best to use a playlist that involves moderately slow to upbeat music that represents the culture of the resident that you are working with.

4) Name two of your current residents with whom you can use each protocol: Sample answers: a. Tonal b. Movement c. Bathing d. Wound Care

Beth Joseph Beth Joseph

Tonal Music & Movement Music-assisted Bathing Music-assisted Wound Care

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Section 1

This project was made possible through a grant from the New York State Department of Health. Continued funding for this program provided by MJHS Foundation.

Mary Mittelman, DrPH, of New York Universityâ&#x20AC;&#x2122;s Langone Medical Centerâ&#x20AC;&#x2122;s Center of Excellence on Brain Aging provided scientific oversight of the project. Suzanne Fitzsimmons, Nurse Practitioner, of University of North Carolina, provided clinical guidance and supervision.

For more information on music therapy call 1-855-241-4313

MJHS Foundation provides financial assistance for the charitable efforts of MJHS and its affiliated agencies.

The philanthropic spirit of The Four Brooklyn Ladies has been a cornerstone and guiding philosophy of MJHS for more than 100 years. The culture of philanthropy they inspired led to the formation of MJHS Foundation, which has been instrumental in raising the funds necessary for the provision of charitable health care as well as the development of innovative services and programs to serve our growing community. The extraordinary efforts of MJHS would not be made possible without grants from MJHS Foundation, which relies on the support of generous donors like you and employees through the Employee Giving Campaign.

www.mjhs.org

(855) 860-0981

MJHS does not discriminate against any person on the basis of race, color, national origin, disability, gender or age in admission, treatment, or publication in itâ&#x20AC;&#x2122;s programs, services, and activities or in employment. For further information about this policy, contact the MJHS Compliance Officer at 718-921-8400.