Music Therapy Can Reduce Anxiety in Critically Ill Patients
Abstract & Commentary
SYNOPSIS: In mechanically ventilated ICU patients, availability of music via headphones resulted in a greater reduction in anxiety and sedation exposure.
SOURCE: Chlan LL, et al. Effects of patient-directed music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support: A randomized clinical trial. JAMA 2013;309:2335-2344.
Critically ill, mechanically ventilated patients are known to experience a variety of adverse symptoms, including significant levels of anxiety. Commonly, sedative and analgesic medications are used to manage these symptoms, but they have well-known side effects. The goal of this study was to test whether self-initiated, patient-directed music therapy could reduce anxiety and sedative exposure compared to self-initiated use of noise-canceling headphones or usual care. The subjects were 373 patients admitted to 12 ICUs at five hospitals in the Minneapolis-St. Paul area who were randomized to use of music (n = 126), noise-cancelling headphones (n = 122), or usual care (n = 125). Anxiety was measured using a 100 mm visual analog scale. Daily sedative/analgesic exposure was determined for eight commonly administered medications (midazolam, lorazepam, propofol, dexmedetomidine, morphine, fentanyl, hydromorphone, and haloperidol) using a complicated formula. Subjects in the music group were given a MP3 player, noise-abating headphones, and CD of relaxing music. They were encouraged to listen to music at least twice a day, but were not required to do this. Patients randomized to noise-cancelling headphones were advised to wear the headphones when they wanted to block ICU noise or have quiet time. Patients were followed as long as they received mechanical ventilation or for 30 days.
The sample was 86% white, 52% female, and 59 ± 14 years of age, with an APACHE III score of 63 ± 22. Patients in the music group listened to music 80 ± 126 minutes a day (range, 0-796 minutes). Patients in the noise-cancelling headphones group wore their headphones for 34 ± 90 minutes a day (range, 0-916 minutes). Use of music resulted in a greater reduction in anxiety compared to usual care (P = 0.003), but not compared to use of noise-cancelling headphones. Findings in regard to sedation administration were mixed. Music resulted in a greater reduction in frequency of sedation use compared with usual care and noise-cancelling headphones. There was also a greater reduction in sedation amount compared to usual care, but not compared to use of noise-cancelling headphones. On the fifth study day, usual care patients received an average of five doses of one of the eight sedative/analgesic medications compared to three doses for patients in the music group.
The important contribution of this study relates to evidence that a non-pharmacological intervention, listening to music via headphones, can reduce self-reported anxiety and sedation administration. The intervention tested was simple to use, inexpensive, and without known side effects, characteristics that are rare when selecting critical care interventions. As noted in an accompanying editorial,1 there were a number of limitations to this study. When responding to the visual analog scale, patients were asked "how are you feeling today?" Thus, the question may have tapped feelings of global well-being rather than anxiety. The 12 ICUs were not required to use a uniform protocol for sedation administration, so there were likely variations in management. Patients were encouraged, but not required, to use the music and headphones. Some chose not to use them, as evidenced by the substantial variation in use recorded for the music (0-796 min/day) and headphone (0-916 min/day) group. Consequently, the study was a "real-world" test, wherein patients were given the freedom to use or not use the intervention.
Entry criteria required that patients be alert, able to participate in daily care, appropriately follow commands, and cognitively intact with adequately corrected hearing and vision. Patients were excluded if they required vasopressors, were unresponsive or delirious, or had a cognitive disorder that might interfere with the ability to initiate use of music or the headphones. These criteria omitted a large majority of patients whose care is managed in a high-acuity ICUs.
The subset of patients enrolled in this study were, perhaps, more characteristic of those admitted to a long-term acute care hospital for weaning from prolonged mechanical ventilation or short-stay ICU patients who recover quickly. Mean stay for the total sample was 5.7 ± 6.4 days. These considerations do not detract from the message of the study. For this subset of ICU patients, the study provides convincing evidence that music can be an effective means to reduce anxiety and sedation exposure.
1. Azoulay E, et al. Music therapy for reducing anxiety in critically ill patients. JAMA 2013;309:2386-2387.