It is with pleasure that I would like to welcome, as a guest columnist, Steve Toll to The HeartBeat of Case Management column. He is sharing with us an example of how his passion for music and his commitment to use it as a therapeutic tool can provide a quality of life that benefits both those we care for and the caregiving community. Case managers are accountable for leading the team in care planning that addresses and optimizes the physical, emotional, spiritual, financial, and individual health care needs. We, as case managers, look for the best options of care that will be safe, provide an enhanced quality of life, as well as bring a patient into his or her most comfortable and enjoyable self. When a patient's physical and behavioral health capabilities are compromised, the options for a solid, individualized plan is many times limited, and what made a patient flourish in the past may not be recognized in the present. We, in our role of leading the team to developing a sustainable plan of care, have an ethical duty as patient advocates to seek out safe, quality measured, and individualized tools and interventions, just like we hope would be done for us if we needed the same care. Practicing in a benevolence manner (our commitment to do good for others), as outlined in Medical Ethics Made Easy, is our duty as case managers and is Steve's commitment to those he serves. Steve is a certified dementia care specialist as well as an accomplished musician and composer, one who recognizes the importance of sharing his gifts and talents and the rewards that sharing brings. Today, he is the Director of Therapeutic Music Programing at ComForCare Health Care Services. His insights and outcomes demonstrate a focus on the quality of care in a compassionate manner. Perhaps, leading us to include this concept in our assessment and development of our patients' individualized care plan?

Thank you Steve, for sharing...

Mindy Owen

I have been a musician as long as I can remember. Music has been an integral part of my life and has inspired me in so many ways. Music has helped me express myself and relate to the world. When I started working with people with dementia, I had no idea how powerful a tool we all have at our command. Connecting deeply with another person through the power of music has profoundly amazed me. To help someone remember who they are, to motivate them to participate in a social activity, to orient them to their environment, and to experience joy have become an important mission in my life.

Various research studies have confirmed that the areas of the brain that store musical memories are the last to deteriorate. This explains why individuals who rarely speak will often spontaneously sing when a familiar song is played and those who experience trouble walking are often motivated to stand and dance in place. When I lead a music program, I observe people respond with smiles, singing, foot tapping, and clapping. Music has been shown to elevate mood, increase socialization, and reduce agitation in people with dementia. These benefits are attributed to the stimulation the brain receives during a music session-a sort of "cognitive workout."

Positive outlets for emotional expression are critical to maintaining quality of life for those with dementia. Music is conducive to keeping strong social connections with others. As speech, writing, and other traditional forms of communication are compromised, music provides an alternative means of connection.

I have met some amazing people along the way. Let me tell you about two of the most memorable. These stories demonstrate how musical skills endure and provide a powerful form of nonverbal communication when language skills are compromised.

Bud

I met Bud at a senior community in which he was a resident. Although he participated in music sessions by tapping out rhythms to the songs by slapping his legs, he rarely spoke or otherwise communicated verbally. Through speaking with Bud's wife, I learned that as a young man he had been a professional musician, a drummer in a dance band in the 1930s. On the basis of our conversation, Bud's wife volunteered to bring in his snare drum.

As soon as the drum was placed in front of Bud, he displayed a huge smile of recognition and skillfully began playing along to the song, "Has Anybody Seen My Gal." He never missed a beat, made eye contact, and smiled while we played and even winked at me. It was delightful!

In subsequent daily sessions, due to Bud's animated response, the staff would include songs of this era with similar rhythms. Bud's identity as a musician was restored and his quality of life was greatly enhanced as a result of a little investigation into his life and interests. His care plan now includes a daily dose of music and drumming.

Betty

Betty is another great example of how we retain musical abilities despite dementia. Betty and her daughter were participating in a program designed specifically for Alzheimer's care at home. Betty's daughter was looking for meaningful activities that would interest her mother during the day, as well as an activity she could share with her mother. During a visit to the home, I spotted a piano in the corner with the lid closed, covering the keys. This prompted me to ask about Betty's interest in music.

Betty's daughter explained that her mother had enjoyed playing the piano all her life, but "could no longer play because of Alzheimer's." At my direction, Betty sat down in front of the piano. When I raised the lid revealing the piano keys, Betty's eyes registered instant recognition. It was clear Betty simply had not recognized the piano because she did not see the keys. Placing her hands on the keys, Betty began to play. The simple act of reintroducing her to the piano was enough to immediately stimulate her memory of how to play the instrument. Not only was Betty reunited with her beloved piano and the music of her past but she now also has a meaningful activity to engage in on her own, as well as an activity to share with her daughter. Betty and her daughter frequently sing together as Betty plays.

I am amazed by the wonderful people I meet along the way who inspire and teach me about the importance of music in our lives. Music embraces and sustains us throughout our journey in life. It is present in our celebrations, marking passages and milestones, and strengthens us with courage when we are in fear or despair. Music helps answer questions of who we are and what we value, both individually and collectively. Music helps us understand ourselves and others; console and comfort when there are no words and communicate through disability or other barriers. When you are at "at a loss for words" or when "words just can't express" your true feelings, music is there to communicate the inexpressible.