Music and anxiety

A visit to the emergency department (ED) is anxiety provoking for patients by nature. Contributing factors may include the acuity of the visit,[1] a noisy environment,[2] an unfamiliar staff,[3] fear of painful tests or studies[3] and waiting in anticipation of a serious diagnosis or bad news.[4] Studies suggest that nearly 75% of adult ED patients experience mild to severe anxiety in relation to their ED visit.[5] In fact, anxiety or worry can be the second most common source, behind pain, of self-perceived acute "suffering" among patients visiting the ED.[4]

A visit to the ED may be particularly distressing for older adults (age > 65 years), who are more likely than younger adults to have a greater ED length of stay before discharge,[6] receive more diagnostic tests and venipuncture for intravenous access[6] and have less effective pain care.[7-9]

Anxiety can have deleterious effects on a patient in the clinical setting. Patients may report excessive pain complaints and manifest the typical signs and symptoms of anxiety (e.g., anorexia, dry mouth, nausea and chest pain), which complicate diagnosis.[10] Previous studies have found that patients awaiting procedures or surgery who have pre-procedural anxiety have lowered pain thresholds,[11] increased analgesic use,[5] greater need for sedation[12] and longer post-procedural recovery.[13] Patients may refuse evaluation or treatment because of anxiety surrounding the procedure or possible outcome.[10] Lastly, patient anxiety can impose barriers to communication with ED staff,[14] hindering successful delivery of important medical information.

Music listening as an anxiolytic has been studied across a variety of clinical settings. Four separate Cochrane systematic reviews have reported the beneficial effects of music listening on anxiety in mechanically ventilated patients,[15] in perioperative patients,[16] in patients with coronary heart disease[17] and in oncology patients.[18] Other studies have shown the anxiolytic effect of music listening in patients undergoing cystoscopy,[19] in pulmonary rehabilitation patients[20] and in pediatric ED patients undergoing laceration repair.[21] However, there is a relative paucity of published data on the use of music listening for adult patients in the ED. While some studies have demonstrated mixed findings on the impact of music on ED patients,[22-25] no studies, to our knowledge, have specifically evaluated the effect of music listening on anxiety in older adults in the ED.

Our aim was to perform a randomized pilot study comparing music listening plus standard care to standard care, with the goal of decreasing levels of anxiety among older adults as measured by the state- trait anxiety inventory (STAI).[26] The STAI is a validated

tool that measures state anxiety using a four-point forced choice Likert response scale (i.e., not at all, somewhat, moderately so, very much so). STAI scores range from 20 to 80, with 20 indicating mild to no anxiety while 80 indicates severe anxiety.

2 Methods

2.1 Study design and setting

This was a randomized pilot study that took place in the geriatric ED of The Mount Sinai Hospital, an urban academic tertiary care medical center, during the months of April-May, 2015. The geriatric ED is a space connected to the main adult ED that is dedicated to providing an environment more conducive to treating patients aged > 65 years (e.g., softer lighting, reduced noise, multiple private rooms). Only those who are triaged with an emergency severityindex(ESI)of2,3,4or5(1to5,1=urgent,5=non- urgent) are evaluated in the geriatric ED, while those with an ESI of 1 are seen in the main ED. This study received institutional review board approval from the Icahn School of Medicine at Mount Sinai. This study was not registered as a clinical trial as it did not meet applicable clinical trial guidelines under the Federal Drug and Administration Act. 2.2 Selection of participants

Subjects were recruited from 8:00 a.m. to 8:00 p.m. Inclusion criteria included speaking English. Exclusion criteria included being deaf, contact isolation precautions (given the nature of the intervention) and prisoners. Patients unable to participate in the process of informed consent (e.g., due to delirium or severe dementia) were excluded. Also excluded were patients who had been given a disposition of discharge by their ED provider at the time of screening, since these patients were likely to leave the ED before completion of the study. Screening of eligible participants was done through chart review using an electronic ED tracking board accessed through the ED electronic health record, which lists patients alphabetically; all subjects deemed eligible through screening were then approached alphabetically. As this was a pilot study, power analysis/sample size calculation was not required. As many subjects were recruited as possible during the study period (2 months).

Results

Based on effective music interventions in the literature,[28] the music used in this study was slow (60-80 beats/min) and non-lyrical. After controlling for these elements, participants were able to choose from a selection of genres since individual preference of, and inherent response to, different styles of music play a large role in whether a listener will find a certain type of music therapeutic.[30] In turn, music genre was not considered a confounder for which to control. The exact number of music-listening minutes also was not controlled for, as we found it difficult to monitor participants without risking a Hawthorne effect or altering standard care.

Intervention participants did not report dissatisfaction with or adverse outcomes due to the music intervention. One intervention participant withdrew after completing the first STAI survey but before receiving the intervention, citing not feeling well enough to participate as her reason not to continue. Few obstacles, which were easily overcome, were revealed during the study. Some participants initially expressed hesitation in using a tablet, citing inexperience, but this fear was usually alleviated after the 30-second tutorial. A second obstacle, which some subjects cited as a reason for study decline, was dissatisfaction with the music selection. Although not addressed in this study, adding more genres is a simple solution.

There are several limitations to this study, including the small sample size and low power. The sole researcher was not blinded to randomization allocation. This did not affect the approaching and enrollment of subjects nor the administration of the first STAI survey, since randomization was done after these steps, but it increased risk for expectation bias during administration of the second STAI survey. Likewise, with the absence of a sham intervention, subjects were not blinded, and their answers to the second STAI survey could have been subject to attention bias. Future studies on a larger scale could improve upon these problems by employing a sham intervention (e.g., a tablet and headphones without music or with white noise), as well as a second, blinded researcher to conduct the post-intervention STAI. Since the study took place at a single site and excluded all non-English speaking patients, the results are not generalizable. Additionally, the geriatric ED is designed to be less noisy than an average adult ED and, as such, may be more suitable for conducting a music intervention. Future studies should focus on incorporating non-English speaking patients in an average ED.

Other considerations for future studies evaluating the effect of music on anxiety in older ED patients include controlling for potential confounders such as medications received, tests or procedures performed, whether family or friends provide company at the bedside and whether subjects are seen by a care provider during the study hour. It would also be useful to determine a dose-response relationship between listening time and decreased anxiety levels (both duration and magnitude of the effect). This could be done by re-administering the STAI at regular intervals until anxiety levels return to pre-intervention levels or the patient is discharged from the ED. It could prove difficult to record the exact amount of time a patient listens to the music given the nature of the ED visit.

In conclusion, preliminary data show that music listening may serve to reduce anxiety among older adults in the ED. Music listening is a noninvasive, safe, and easy-to-administer intervention to reduce anxiety among patients age > 65 years old being evaluated in the ED. Additional studies are warranted to evaluate this intervention on a larger scale.

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