Group's Core Theoretical Foundation

Background - Relation between music and people with dementia

Music interventions for people with dementia: a review of the literature
https://www.tandfonline.com/doi/pdf/10.1080/13607860310001613275?needAccess=true

Main findings in this paper:

• Qualitative review published by Brotns et al. (1997) concluded that people with dementia had a positive response to music, but this remained unclear. One could investigate the influence of different variables in detail, such as the music modality, disease severity, type of music played, nature of the intervention, and the professional providing it.
• Koger et al. conducted a meta-analysis to test the hypothesis that music or music therapy would be an effective intervention for use with people with dementia. Results revealed that the overall effect of music was highly significant, although the effect sizes were not constant across all studies.
  This review focuses on examining the methodological and theoretical issues relating to problem behaviours such as agitation and behaviours of engagement and participation. 

A few researchers who studied the effects of music interventions on problem behaviours such as agitation outlined changes concerning the physical and pharmacological interventions to manage dementia symptoms. Other researchers who studied the effects of music on participation and engagement highlighted the importance of improving a person's quality of life and sense of self-esteem, especially for those who are receiving long term residential or institutional care.

Most studies reported the effects of music to decrease the range of behaviours, such as agitation, aggression, wandering, repetitive vocalisation, and irritability. Music was also found to increase reality orientation scores, memory recall, time spent with one's meal, levels of engagement and participation, and social behaviour. The mid-range theory hypotheses that a person's most preferred music will help them connect with the past. The music will also focus on attention and a stimulus that the person can receive and process. The recall of memories will produce a soothing effect, which should prevent or reduce agitation, as the person's stress level is prevented from reaching and exceeding the threshold. 

However, one study found no differences between levels of agitation during conditions of no music and music. They suggested that this was because the music was not a personal preference of those individuals. Another study found that individuals participated more during the exercise sessions than in sing-along sessions. Lastly, a study found that although music significantly increased the levels of relaxation, it did not significantly reduce the frequency of aggressive behaviours. 

It was noted that playing recorded music, which the individual selected, rendered environmental noise familiar and predictable, and provided a connection with positive memories from the past, which invoked soothing feelings in the present. Another research showed that playing recorded music created a relaxing atmosphere. The music activity was vital as it placed few cognitive demands on participants and provided an opportunity for social interaction that did not rely on verbal skills.

The importance of music for people with dementia: the perspectives of people with dementia, family carers, staff and music therapists https://www.tandfonline.com/doi/pdf/10.1080/13607863.2013.875124?needAccess=true

In this study, a quantitative study was conducted to develop insights into the musical experiences of people with dementia and explore the meaning of music in their lives.
Music-based interventions are beneficial for the psychological well-being of people with dementia. It is easily accessible and a stimulating medium that can be enjoyed alone or with others, even when someone has severe dementia. The residents of care homes and their family members have highlighted that music listening, dancing and singing are significant among all care home activities. In addition, studies found that people could appreciate and engage with the music even as their cognitive functions deteriorated. 

A total of six themes were discussed and evaluated. The nature of the six themes may be broadly described as the impact of music on the individual, the effect of the impact of music, and evaluating and communicating the impact of music. Based on the analysis, it was understood that music taps into an individual's sense of self regarding their personal preferences and life history. Thus, music is not only used as a tool to fix a behavioural problem, such as agitation, but rather is a part of a broader application of life. This can be seen as self-actualisation and self-transcendence, the two highest levels of Maslow'sMaslow's Hierarchy of Needs. 

Families, staff and therapists have highlighted the immediacy of residents' responses to musical stimuli. Families notice a visible uplifting effect on the residents' moods and increased alertness and interest in their surroundings, suggesting that music has a stimulating effect. The staff realised that music had a relaxing effect on the residents' mood and thus on the care home environment. Therapists also highlighted the importance of musically matching whatever the clients said here and now, including repetitive vocalisation, crying or wandering, which are perceived as challenging behaviours in other circumstances. 

The choice of music was highly personal. Every person had a musical identity that was often closely linked to different life events, personal and cultural identity, and a particular era. It was also noticed that people with a late stage of dementia found it emotionally meaningful when they recognised familiar music. One resident said that he could recognise songs from his childhood even though he often forgets things. So this helped support his identity. 

Many people recognise themselves as independent individuals who are now dependent on a terminal illness or disease. The deconstruction and reconstruction of identity have a significant impact on personal psychology. Music may help to protect a person's identity or support the process of redefining their identity through positive person work. Music therapy seemed to encourage clients to share their challenges of living with dementia verbally and non-verbally during group music-making. 

Carefully planned music interventions will provide opportunities to support the personal psychology of the person with dementia and help sustain excellent social psychology in their care settings. All in all, it was found that music has a positive impact on a self of self, helped to protect self-identity, lessened feelings of isolation and loneliness, helped the development of connecting with other people and provided an experience of spirituality. An individual's musical identity and the need for shared meaningful musical experiences are retained through the ageing process, even in the context of dementia. 

About music and how we used it

Several non-pharmacological interventions to prevent people with dementia from wandering already exist. Engaging PwD in social activities, navigation and monitoring technology, or environmental modifications, has been tested in studies to determine if PwD could be prevented from wandering and getting lost [1]. However, not all of these methods seem successful or harmless (e.g. thinking of tracking systems).
Especially activities related to music have a positive effect on the mood and emotion of PwD. Certain music or songs can trigger mutual, emotional memories [2]. Therefore, it is not far-fetched to take advantage of these positive effects and use music to keep people from wandering. Lancioni et al. (2011) found out that PwDs tend to start wandering less than if they did not perform activities like colouring or listening to music [3]. Non the less, these social activities can not reliably prevent wandering at all times. In case the activities do not distract PwD enough, and he/she still heads to the exit door, these methods are powerless to prevent them from leaving.

In the study of Lancioni et al. (2011), music was used as a distraction activity. In our project, we will use the positive effects of music, but differently. In our case, the music should not avoid the original thought of going out but deflect when the person comes up with that thought. This means that the person is trying to leave the care home but will be interrupted at the door. At this point, the music is used to take their mind off leaving.

Aim of the use of music
What we want to achieve with music are, in general, two things:

1. Distract from the original idea to leave the house
2. Remind the Person that there is no reason to leave the house

The first goal can be achieved by introducing certain activities related to music, e.g. dancing. Then, the robot starts playing dancing music and invites us to join for a dance. The PwD is distracted and no longer thinking about leaving by executing this task.
Another possibility to use music is to remind the person of their surroundings and situation. For example, some patients do not consider the nursing house their home. If a specific song is connected to a room in the care home, this brings the patient back to reality and reminds them of being in the care home. This could be a song they usually sing before lunch, the opening song from their yoga lesson or just a short jingle of their favourite tv program. 

choice of music
The selection of music should always depend on the reason for leaving and the person's mood. Therefore it is relevant that a broad selection of music is available. In a further development, an individual playlist for each patient could be created in an introduction session with the robot. However, we provide one general playlist with only one song for each situation - a mood combination due to lack of time.

Background - Evaluation
Questionnaires can be complicated and require a substantial amount of effort. Standardised questionnaires have higher reliability and validity compared to ad-hoc questionnaires. In a study by Lewis [4], 3 most commonly used questionnaires for voice interaction design are considered, which include - The Mean Opinion Scale (MOS); the Subjective Assessment of Speech System Interfaces (SASSI), and Speech User Interface Service Quality (SUISQ). For this project, we used the SASSI questionnaire proposed by Hone et al. [5] to measure the co-attention and attention allocation between the Humanoid Robot and PwD. 

After the score is collected, it is essential to measure the reliability score per section. For measuring the reliability score, we used the Cronbach Alpha score. After that, to prove improvement over some baseline conditions in a controlled experiment, it is mandatory to show that the difference in results for baseline and experimental conditions is statistically significant. Therefore, we used the t-test between the values in both conditions for the significance test.

Finally, for validating the claim that the interaction with the humanoid robot improves the emotional condition, it is needed to capture the emotion before and after the interaction. Unfortunately, measuring emotion can be quite challenging as it cannot be easily quantified. The most commonly used scale for measuring emotion is the Semantic Differential Scale, devised by Mehrabian and Russell in 1974. This scale has 18 bipolar adjective pairs, with each rated on a 9 point scale. After that, a factor analysis of these 18 pairs provides the emotion of valence, arousal and dominance. However, it can be cumbersome to measure 18 points, and a verbal scale can easily be misinterpreted, resulting in erroneous results. Hence Bradey et al. [6] proposed a picture-oriented scale called the Self Assessment Mannikin (SAM). SAM scale has 5 figures along each important affective dimension - Valence, Arousal and Dominance. Owing to the intuitiveness of a picture-based scale, we used it to measure emotion in this project.

[1] MacAndrew M, Brooks D, Beattie E., NonPharmacological interventions for managing wandering in the community: A narrative review of the evidence base. Health Soc Care Community. 2019;27:306–319. https://doi.org/10.1111/hsc.12590

[2] Peeters M.M., Harbers M, Neerincx M A., Designing a personal music assistant that enhances the social,
cognitive, and affective experiences of people with dementia. Computers in Human Behavior. 2016;63:727 - 737 https://doi.org/10.1016/j.chb.2016.06.003

[3] Lancioni, G. E., Perilli, V., Singh, N. N., O'Reilly, M. F., & Cassano, G., A man with severe Alzheimer'sAlzheimer's disease stops wandering during a picture colouring activity. Developmental Neurorehabilitation. 2011 14(4), 242–246. https://doi.org/10.3109/17518423.2011.575439

[4] Lewis JR. Standardised questionnaires for voice interaction design. Voice Interaction Design. 2016 Apr;1(1):1-6.

[5] Hone KS, Graham R. Subjective assessment of speech-system interface usability. In Seventh European Conference on Speech Communication and Technology 2001.

[6] Bradley MM, Lang PJ. Measuring emotion: the self-assessment manikin and the semantic differential. Journal of behavior therapy and experimental psychiatry. 1994 Mar 1;25(1):49-59.