VEDAVAANI- A GURUKULAM PROJECT

Dr Suvarna Nalapat Dr Suvarna Nalapat Trust http://drsuvarnanalapattrust.org Contents : 1 Gurukulam as I envisaged 2 Finding solutions to the inequality of disease prevention ,therapy and information to rural population of economically backward places through a HEALTHVILLAGE scheme ((Application sent from Amrita institute of medical sciences .Ref call for application , strategic, social ,economic and behavioural research Jan 2003) 3 An experience and Evaluation of Music Therapy workshop in Pankajakasthuri Ayurveda Medical college in 2006 4 Analysis of Feedback Pankajakasthuri workshop 2006 5 FOR MONITORING THE QUALITY OF MUSIC THERAPY- Indian Music Therapy Association Registration Process : Gave the following project for helping them formulate the byelaws . 1.Suggestions for developing a pioneer music therapy education center, a pioneer music therapy center (a hospital), and a university center, and preferably a laboratory where one can standardize the results (lab results in research and treatment).These 4 centers can function in different districts but with a coordinating function.

1.GURUKULAM AS I ENVISAGED To become an educationist and to plan for the coming generations of people a way of life and education is no easy task to be done by people who never have thought about the problems of the society and of education and its goals.For this activity one may have to learn many arts and sciences ,should have a loving mind and a sharp extraordinarily receptive intellect and a love for nature and nurture.And one should have lead a life of purity as a model for the students to emulate.But ,these things are of the past,some people argue.And others think that a gurukula is the function of celibate nuns and sphincters or of swamins and sanyasins.I do not think that this is a correct view.In ancient India every gurukula had a guru and a gurupathni,and the guru lead an excemplary life of studies and austerities and a domestic life so that the students learnt even the way of a good householder.The religious institutions make a jail for the students and expect them to be sanyasins and even a small mistake is not tolerated .A Gurukula style of education which I envisage for the 21st century teachers and students is not one run by a sanyasi but by a normal human being living a householders life ,fulfilling all duties of the householder and achieving excellance in learning,and in duties .A place where the good citizens of the world and of the nation are created ,useful to society ,nation and world and above all to themselves ,to their family and to the institutions they work for. Bharath is the cradle of civilizations and in this ancient land of rishis and sages Guru is equivalent to God.Guru and shishya makes a meaningful whole in generating vidya and upholding the traditions.Before they start a learning process they chant together. Sahanou yasa:sahanou Brahmavarchasam (let us aquire fame and divine energy together).In the generation of Guruparampara for creation of knowledge ,Guru is the poorvaroopa,shishya is the uthararoopa and their sandhi is vidya and their offspring is prediction (pravachana).Medicine being a predictive science the teachers and students have to chant together let me be filled with intellect(medha)and by that nectar of intelligence let us develop dhaarana(understanding).My body and mind are healthy.My words are sweet as honey.Let all the ears hear that sweet voice of love.God is hidden in the cells of intelligence .Let my knowledge be preserved for posterity and propagated by the coming generations (of shishyaas). Then the Guru continues to pray alone:Let there be more and more students in my care.Let them come even from distant places .Let them be happy ,intelligent,disciplined and thirsty of knowledge. Whenever an educational institution is trying to draw more students to it,apart from the curriculum and the syllabus,a feeling of oneness between the teachers and students and a bond of love between them is essential.The student ,after leaving the institution nostalgically remembers the people who have given them love and a feeling of security.A good educational institution should be a home away from home,and good teachers should be giving parental(motherly/fatherly)affection ,love and care and advice (councelling)and should not be policemen and women making life difficult for them.Children are always good.The only thing that they need is proper love and care,not to turn to bad things and

company.They are not criminals who needs constant vigil from the teachers.This is what happens in very strict gurukulaas run by religious institutions which I have seen in some of the professional institutions also. We have to revive the old gurukula system of India where the guru is a father/mother figure and the student is the son/daughter and in such a situation only one can give security and a feeling of belonging to the students and by sharing their happiness and sorrows the teacher becomes part of his/her training programme and of life. Only by creating such an atmosphere in the campus we can make it a happy place to live in and study and work.The happiness(aananda)or bliss is always associated with sath,chith (truth and energy of intelligence).Happy environment is the best for intellectual and physical work.Each and every faculty member should be able to understand this and create such an atmosphere in the college campus and each and every student should be able to respond to it by their natural instinct. For this the gurukula should have good and happy teachers, intelligent and free individuals leading a dutiful and pure domestic life. 2. FINDING A SOLUTION TO THE INEQUALITY OF ACCESS TO DISEASE PREVENTION ,THERAPY,AND INFORMATION TO RURAL POPULATION OF ECONOMICALLY BACKWARD PLACES ,THROUGH A HEALTH VILLAGE SCHEME. (Application sent from Amrita institute of medical scinces .Ref call for application , strategic, social ,economic and behavioural research Jan 2003) Statement and description of the problem and its priority. India is a country rich in culture and its traditional ways of healthcare including ayurveda,yoga and music therapy.These are the ways of life topromote health and are preventive measures as well as curative.The villages in India at present lack proper healthcare and this is mainly due to lack of willing doctors to work in the villages,due to lack of proper watersupply ,lack of nutritious food and the environmental pollution and lack of awareness.The economically backward rural population do not get access to proper prevention ,therapy and information about diseases and healthrelated topics.The changing economic sociopolitical and civil structures and use of new drugs ,insecticides,pesticides and other chemicals also have contributed to spread of various types of diseases in rural population ,in tropical underdeveloped and developing countries.A better identification of such problems at a regional level and providing solutions to the problems for future needs is essential.The current proposal is such an innovative one for providing a solution to theproblems in a rural environment of kerala which belongs to the developing nation(India).Since this is for giving solutions to the problems of rural India ,the research is of national importance as perceived from the peoples perspective. Background To identify the problems faced by the nation(society)and to give a solution for that,one individual has to devote the entire lifetime in service of society and in touch with the rural common man.The principal investigator has done that and after years of contact with the common rural man ,has come up with a solution for the problems of rural

India.But before accepting this solution at a national level (or for that matter at a global level)one has to prove that it will work out well at local ,regional levels.Hence implementation at a regional level is mandatory.Therefore the research becomes important from the point of view of the nation and the world. Objectives and philosophy behind the proposal Health according to the definition of the WHO is not merely the lack of physical disease.The mental ,spiritual,intellectual health also has to be taken into consideration .A multidisciplinery approach including ayurveda,yoga,classical music ,Indian philosophy will be implemented in the study period in selected villages so that there will be 100%participation from the public and their preferences and choices of therapy will given prime importance to have overall development of mental ,intellectual,spiritual and physical health.This will be in tune with the traditional sciences and customs of the Indian subcontinent.The aim of the adoption of the health village is to improve overall physical,mental,intellectual,spiritual development and improvement of the community in which holistic approach to health including alternative medicine will be tried. The aim of the project is to improve the villages of India and to develop them in all fields and to make a model for the whole country to follow as a health village ,healthy not only physically but also mentally ,intellectually,spiritually.The gestalt field theory of educational psychology is defining human beings as dynamic systems within dynamic systems growing by the environment in the field in which they live,and stimulating the growth and development of the field they live in. ( For entire project Refer : Music Therapy in Administration, management and education : Dr Suvarna Nalapat. Readworthy Publications : New Delhi ;2008)

3 An experience of music therapy workshop and its evaluation at Pankajakasthuri Ayurveda medical college.
EVALUATION REPORT OF AWARENESS PROGRAMME Music therapy-research methods and project planning Training. Conducted at Pankajakasthuri Ayurveda Medical college Kattakada,Trivandrum. From 8.4.2006 to 10.4.2006 8.4.2006. Inaugural function. Welcome speech by Dr Hareendran Nair MD,Introduction by Prof Omanakkutty (musicologist), presidential address by Dr Sambasivan (neurosurgeon), felicitations by Dr Mathew Thomas (general medicine) Sri M.G.Radhakrishnan (composer), Dr K.A.Kumar (psychiatrist), & vote of thanks by Dr Sankarankutty (principal).Dr Kumari Bhagavathy (psychologist)did not turn up for the function.Bhajans by Abradita Banerjee

was an interesting part of the morning session.Her surdas and Meera bhajans were sweet and charged with bhakthi.The accompaniment (Tabla) could have been a little bit more softer so that it does not get the upper hand than her voice. The day was special since they were inaugurating the free noonmeal programme for 1500 people , and they had named it Patheyam.( Being the name of my spiritual autobiography , it was a synchronicity for me!) Afternoon session.Though the scheduled time was from 1.30 to 3.30,the morning session and meal session went on and the afternoon session started only well after 2.30.Time management is something which we keralites have never mastered. The afternoon session started with prayer of Bhuvaneswary.she sang charukesi (tharangini) as it also remembers my manasic Guru due to the name in Dikshithar sampradaaya.Written feedback from participants was very good.They had liked the voice, lyrics and composition and had beautiful visions of mother Goddess Mookambika and of nature in her green colour. 1.The informal introduction by participants. 2.A short concised questionnaire was given before session to assess what they know of music therapy and from where and why they are interested to undergo this session of training.They were asked to draw a small family tree .the learning /learned skills of music and the professional status asked. There were 25 participants and 10 observers and 4 were extra altogether 39 people.Of these 3 students were males .All others (22 )females. 3.The participants were divided into 5 groups for small group discussions and project planning activities. Group A. Geetha,Vimala,Sudha,saraswathy,kamalalakshmy,sruthy Roy. The doctor of the group Dr Surekha. Group B.Dineshini,Sonia Nedungadi,Lekshmy,shylaja,uma.divya rajendran. Doctor.Preetha and Dr Gireeshaprasad. Group C.G.Sreelatha.,G.Bhuvaneswary. Indu P.M Roslin Francis.(no doctor in the group) Group D.Ammu.,sunitha,meera,sindhu,Lekha,mayashree. Dr sreekumar Group E. G.S.Balamurali,Arun .v.kumar,udayasankar,vijaya,priya paul.Dr Binu. First lecture on principles of medical/clinical research and how to make a project plan to be submitted to the supervisors/guides before it is approved. Power point presentation used to illustrate the points . Explained in detail the different types of research methods, doubleblind studies, RCTs and the legal implications and the need to have consent in both mothertongue and English etc. How to elicit MLP by informal interview also was described. Asked participants to prepare the project at home (at night) individually and to come in the morning at 9AM (to make up the time lost the previous day )and to discuss and finalise the project with their group members and make a written project and one among the group to present it in front of all,so that others can raise their doubts and get clarification/or give their opinions

for modifications/additions etc. This is to encourage group dynamics and healthy academic , scientific discussions. The handouts distributed by Dr Suvarna to all participants : HARS scale for stress /anxiety rating;Pain scale,consent form in 2 languages.These were given because the students are very new and the subject also is new to them and because of that they may find it difficult to give the scales on their own.The procedures I had already done and the charts.questionnaires I had already made for my studies were distributed to them to make their process easy.

9.4.2006. The first session from 9-10.Small group discussion of group members and project planning. Projects chosen by the 5 groups. 1.Music therapy for professional stress.- presented by kamalalakshmy 2.Music therapy on paralytic patients with special reference to mental depression. presenter sonia nedungadi 3.Alzheimers dementia. Presenter Bhuvaneswary 4.Music therapy for cardiac and diabetic patients. presenter Meera Ramdas 5.Music therapy for hypertension. presenter Balamurali. The group members were clearing doubts and asking questions, contributing their comments and opinions very freely and actively. This session continued till 11 in the morning. Then an audio of Yesudas voice without accompaniments except a thambura was played and participants asked to give their written feedback .The results were really good and sweet .The visualization of music was perfect and 100 % and the identification of the voice with the mothers lullaby, to nostalgic feelings of a loving father, to the village where a temple and its quiet surroundings exude shanthi, to a quiet river, lake,with lushgreen nature, and a soft breeze were all very very pleasing.The self-imagery visualization technique was thus introduced to the participants by a small and short exercise of self-healing . How to listen to music with your emotional aspect dominating is the crux of music therapy. The students had that faculty.No one except Dr Omanakkutty , thought about the logical part (finding fault with the music and the singer) which is against the self-healing technique . For Therapy , one has to forget ones ego and intellectual supremacy and get immersed and involved totally in the emotional aspect of the music . The practical session of eliciting the MLP from a patient through an informal interview and also finding out the musical preferences by singing together was then carried out. Since the students were not yet ripe to have real patients at their hands , I had asked someone to volunteer as a patient. Dr Binu volunteered . Sudha Ganesh did the roleplay of a music therapist and Dr Binu that of a patient and demonstrated the informal interview for MLP and musical preferences. The flows in it were demonstrated and a few examples shown after the session, by Dr Suvarna Nalapat. After this roleplay demonstration the second lecture with powerpoint presentation, elaborating on the most important aspects of project planning again was done.

How to measure pain, with different scales, what is a scale how the pretest and post test values should be drawn, what is the statistical significance,why Metaanalysis(of different studies by 2 reviewers) is done , how the confounding factors can be minimized and how we have to do literature survey, the importance of computer literacy to get references etc stressed. QOL and RCT were discussed. Metaresearch using pretest-posttest two group design , principles of unbiased, relevant, reliable assessment stressed but without using much jargon.(because the group is not familiar with that) The title, the listing of authors in chronological order, writing an introduction, an abstract,and the aim of experiment, the materials and methods, were discussed in detail. The materials and methods infrastructure you need, the facilities, the tools, equipments, personnel and the approximate cost etc come in the materials. The scientific methods, the different types of scales , questionnaires, the ways of data collection you employed all come in methods. If you do a lab test, the method of doing it come under methods. The chemicals, equipments used come under the materials. All these were given in the most simplified terms so that there is no confusion among the students who do not belong to the clinical/medical/scientific community. Afternoon : was given entirely to the participants to show their talents in singing and that was very nice. The atmosphere suddenly changed to one of lightheadedness and humour , laughter and fun. From science and education to art and lively humour of life.Vimalas priyamaanasa had shifted the mood from the elated bhakthy ecstacy mood of mine, and everyone seemed to shift from heaven(swrloka) to earth (bhooloka) with that sringaara mohiniyattam piece. Even I had a feeling that my yudhishtiraratha (chariot of king Yudhishtira) which is always in a transcendental plane , coming down to earth , bringing the old nostalgic memories of a 17-18 year old girls MLP and I shared it with the group. That was pleasant Questionnaire in 3 parts (TO BE FILLED IN BY PATIENT,BY THERAPIST, BY CLINICIAN ) DISTRIBUTED 10.4.2006 1.Prayer Bhuvaneswary:From vishnudharmotharapuranam. 2.Lecture: Story of that music. The principle of melakartharaaga in music therapy. The bhakthy bhava and creativity in Indian aesthetics.The lecture was on bhakthy and emphasized the role of the students karma with perfect gurubhakthy and devotion to God. The rasa theory and sandhyabhasha explained. 3.Summing up and recapitulaton of what is said about project planning followed.(powerpoint ) 4.A written questionnaire given (15 questions) to assess the students feeling about the sessions, how useful it was to them. but also to assess the educational psychology of the group and the educational psychology of the individuals of the group and to compare with other groups.

5.Navasakthinayaki amman paadal of yesudas-(first sloka on rajarajeswary, the song on abhiraami and the one on Mookambika) were played to demonstrate how Bhakthybhava can bring the aesthetics (rasa) and how rasa is the same experience as Brahma. Every participant enjoyed and got immersed in it and there was 100% silence and rasanubhava with it. 6.Visit to the ward Laryngeal carcinoma with multiple secondaries in terminal stage, cachexia, pain . Is on palliative treatment -on morphine. Sudha Ganesh was with me. How silence and soft speech are necessary at such situations and how it is different from the demonstrated music preference session on a normal individual was demonstrated to her. How softly we should touch a patient-as if it is a child. How important it is to teach that touch to relatives, bystanders, caretakers like nurses. How to instruct them to use devotional music at a very low volume and to keep silence so that they are not disturbed. (WITH NO MLP or musical preference elicitation). How different is the methods depending upon the real life situation, individual patient, severity and type of disease etc. Afternon session: distribution of certificates. Dr Priya and Prof Omanakutty talked about the sessions. Those who didnt get chance to sing yesterday sang so that 100% participation was ensured. The day ended with a very very positive note and everyone was happy with a combination of gnaana, bhakthy and the future anticipation of karma (that is carrying out the submission of the project plan after necessary modifications to Dr Suvarna after one week, getting it approved, and then finishing the project and reaching the endpoint of the desired goal). The conclusion was with the omanathinkalkidavo of omanakuttyamma And towards the close of the programme as if mother nature was pleased with the whole programme, she took the beautiful colour of Vishnu , and dark clouds accumulated in the sky , great rumblings and thunder peeled as if Panchajanya and saranga were active, and finally a few nectars from Dhanwantharis amrithakalasa fell. The parched earth was cooled. And everything was well and good. I take this opportunity to thank Pankajakasthuri, Prof Omanakuttyamma and all the participants for giving me this happy birthday gift. Let Lord Guruvayurappan bless you all to continue this good work and to get ihaparasukham and ayuraarogyasoukhyam. Dr Suvarna Nalapat 4. ANALYSIS OF FEEDBACK (10.3.2006) 35 PAPERS EVALUATED 1.What do you feel about your awareness of Music therapy? Any alteration from what you had before the session? (answer in 2 0r 3 sentences only. All the 35 feel that they have gained more information than they had before the session.(100%)

2.Do you feel a genuine interest in pursuing the music therapy research and treatment? A. yes. 35 (100 %_) B.. No. 3.Which of the following do you like best? A.group discussions/problem solving 2 B.lectures. 2 C self study. 1. D.combination of all these. 35(85%) 4.Teachers behavior inside classroom, A.friendly 23 B.approachable. 12 C.strict and rude. 0 5.Outside classroom the teachers were A.not ready to talk 1 B.unapproachable. 0 C.do not care for students 0 D.do not have involvement in subject 1 (30 did not write .Not applicable) 85%. One wrote they are ready to talk and one wrote do not have involvement in the subject(I doubt whether that student has actually understood the question) 6.My (the students) behaviour in class was A.Attentive 34 B.sleepy 0 C.bored 0 D.could not concentrate 0 E.talkative with neighbours,disturbs them. 0 7.Response of teacher to my behaviour in class. A.does not pay any heed 5 B.tolerates 5 C.gets angry 0 D.takes it easy.calm , with sense of humour. 25 8.What was your listening technique in class? A.Marginal listening (words reach ears.do not linger in mind.) 0 B.Attentive.(can grasp,forgets after a while) 2

C.Projective(can grasp,correlate,imagine a real life situation,and hence can remember) 33 9.Are the following essential for MT teaching? A,Audio-video 1 B Problemsolving with human subjects C Both 34 10.Is the time of the study course given A.optimum? 2 B.more than required? 2 C.less than required? 30 ( They needed more such classes and liked them.) 11.Would you have liked to get some more hours of teaching,practical training,interaction ? A.YES B.NO 35 (100%)

12.Which is more ideal? A.group assignments? 31 B individual assignments? 3 (first group, and then individual according to one participant) 13.In group assignments how many of your group members were contributing actively? A. Specify the number B. B.names. ( No one answered ) compare this with the next question and its answer .Contradictory answers. 14.Behaviour of group members in general was A.silent 3 B.negative comments 0 C positive comments 3 D.actively participating 22 15.The following qualities are essential for teachers. (If there are are more than one quality you like in your teachers ,just number them on the right hand side) A.welldressed B.humble,meek. C.mature,honest D.deep knowledge in subject taught E.Intelligent F.pronounciation of English language superb

G.lack of self consciousness. H.responsibility to control class orderly I.strong social ,clinical sense J.experience in subject K.integrated personality and creativity. L.moral responsibility to students and society M.love to students,and to humanity in general ITEM 1.welldressed POINT 5 GRADE TOTAL 2 GRADE POSITION 4 12 4 9 4 11 1 10 8 nil 2 3 5 2 3 1 2 4 5 6 2 6 Ammu Priya Meera Priya Meera,Ammu Meera Ammini Ammu Ammu Meera Meera Ammu FROM WHOM ? Dr Priya Ammu Meera Ammu Meera Ammu All Ammu Ammu

2.Humble,meek 3.mature honest 4.deep knowledge in subject taught 5.intelligent 6.pronounciation of English language 7.lack of selfconsciousness 8.responsibility to control class orderly 9.strong social and clinical sense. 10.experience in subject

8 8 12 5 3 1 10

2 2 4 1 1 nil 3

8 11

3 3

11Integrated 6 personality,creativity 12.moral responsibility to students/society

13.Love to students and humanity in general

12

1 3 5 7

Meera Ammini Priya Ammu

The 3 projects taken up by the students at Pankajakasthuri : 1.Meera Ramdas 2.sudha Ganesh 3.Dr Bhuvaneswary.

PROJECT PLAN

TITLE

: THE VALUE OF MUSIC THERAPY IN DIABETES MELLITUS AND ITS COMPLICATIONS

AUTHOR : MEERA RAMDAS ABSTRACT AND INTRODUCTION Diabetus Mellitus is a metabolic disorder due to deficiency or ineffective action of insulin which is produced by the beta cells of the islets of langerhans in the pancreas. The predominant type of this disorder is the Type II diabetes, which constitutes about 95% of the diabetic patients and starts in later adult life. Type I diabetes occurs predominantly in the younger age group and is due to the destruction of the beta cells by probably an auto immune process or virus infection. Diabetes has been increasing in alarming proportions especially in the Asian population and with it the numerous complications which affect the entire human body. The most important management of this condition is life style modification apart from the medicines. This involves dietary modification, reduction of weight, reduction of stress and proper monitoring. Diabetes affects the bigger as well as the smaller vessels of the body and thus affects all the vital organs. The purpose of the study is to assess the value of music therapy in reducing the progression of the disease and help in better control and also produce a sense of well being and optimism which is most vital. AIM This study aims to effectively control both Type I and Type II diabetes with music therapy. We plan to approach the patient in a holistic manner. The patients will be on regular medication. We would like to find out whether the patients who receive music therapy are able to control diabetes more effectively than those who do not receive the same. Our therapy intends to bring about an over all improvement in the patient both in the physical and mental state.

MATERIALS AND METHODS Our hospital runs a diabetic clinic in which there are facilities for all the necessary investigations which are routinely done in the management of diabetes objectively. A well equipped lab which facilitates the estimation of blood sugar, GTT, HbA1C, serum electrolytes etc. To check whether the heart is affected ECG, Echo Cardiogram and all the associated investigations for blood parameters like serum lipid profile. To check whether kidney is affected blood investigations like blood urea, serum creatinine, creatinine clearance, micral test which assesses micralbuminuria which is predictor of neuropathy as early as five years in advance. Biothesiometre for assessment of peripheral neuropathy. Doppler studies Both peripheral as well as carotid Doppler. Smoking cessation clinic This acts in collaboration with the Sree Chithrathirunal Institute, Trivandrum. Daily classes for both outpatients and inpatients on the various aspects and complications of diabetes mellitus. Presence of Podiatrist, Dietician and also a clinical psychologist with regular classes in stress management.

Methods : We plan to proceed the study by taking two groups each consisting of 15 patients :1) 15 Patients those who will undergo music therapy. 2) 15 Patients those who will not be given music therapy. A well equipped consulting room with a cot, CD and cassette player, CDs, cassettes etc. Repeated counselling sessions with each patient to study their problem in detail, to get an idea about their family history and to know about their taste in music. Giving an assortment of ragas to each patient (both light and classical songs) advising the patient to listen to these ragas for atleast half an hour in the morning and evening according to their convenience. Patients will be asked to give regular feed backs. All the tests will be done regularly to monitor the changes. Cost : As the hospital has all the facilities mentioned above, significant expenditure will have to be made only for the purchase of CDs and Cassettes. The cost should approximately be between Rs. 3,500/- and Rs. 5,000/-.

Thanking you, Yours sincerely,

Meera

2.Project of Dr Sudha Ganesh. Introduction Music has a tremendous relaxation effect on our mind as well as our body. Modern therapeutic science says that music has a massaging effect on our brain. Music therapy is gaining more and more grounds in the treatment of various disorders. The resonative effect of music enables the patient to thread back to normalcy or original state of mind. Music is a significant mood-changer and reliever of stress, working on many levels at once. The word Stress is defined by the Oxford Dictionary as a state of affair involving demand on physical or mental energy. At one point or the other everybody suffers from stress. In to days lifestyle management of stress plays a very vital role. Systematic living, structured working and living habits works to a large extend eliminate stress. Stress is found in various age groups in different forms. a. 0- 5 years b. 5 -10 : c. 10-22 : d. 22-55 : e. 55-65& beyond : - toddler stress - entering the school - educational stress - professional stress - old age stress

Stress can cause headaches , eating disorders, allergies, insomnia, backaches, hypertension, asthma, heart ailments and even cancer. Professional stress is a chronic disease, relatively new phenomenon of modern lifestyle. It poses a threat to physical health. Typical symptoms of professional stress can be : a. Insomnia b. Loss of mental concentration c. Anxiety, stress d. Absenteeism e. Depression f. frustration

g. Extreme anger h. Family conflict i. Physical illness such as heart disease, migraine, headaches, stomach problems and back problems Professional stress is found in people in the IT sector commonly referred to as BOSS- Burn Out Stress Syndrome, in entrepreneurs and other professionals who work for longer durations under stressful conditions. This is more prominent among employees in call centers and BPOs ( Business Process Outsourcing ) The basic reason being lack of physical exercise, extended working hours, loss of sleep and appetite due to abnormal working hours all lead to professional stress. Basically the demand for better output under very limited resourcefulness is the reason for development of stress. Reference taken:- Internet, The Hindu dated April 12, 2006 ( Opportunities )

5 S Management It has been our experience that most people want a ready-made mantra or formula to manage themselves, rather than an intellectual paradigm to work on all by themselves. This is borne out by the success of Stephen Coveys 7 habits and similar capsules. No doubt they are extremely good (we are ourselves ardent admirers of Covey), but it is ultimately up to the individual to digest, assimilate and implement all such mantras in his / her own context. sasthri foundation have observed that most busy executives and professionals of today have faulty habits on the 5S front, namely sleep, sex, snacks, stamina and spirit(s). As a result, their 6th S of soft skills gets disturbed leading to the 7th S of stress. It may sound a bit clichd, but if put into practice, 5S management can go a long way in rearranging your mindset so that you can manage your stress (there is no way to eliminate it, is there?) in your own unique way. All these are presented in our book, health @ your finger tips, in a simple, reader-friendly language. Here are some items covered:

Sleep: sleep debt and its consequences, how to repay it, power naps, effects of alcohol, caffeine, and nicotine, sleep hygiene Sex: DINK (double income no kids); DINS (double income no sex); sex debt; sexual intelligence; sexual paradox sex, sex anywhere but..; performance anxiety; sex enhancing drugs; fulfilling sex Snacks: get your fundas right; know your carbs and fats; do the balancing act; eat heart-healthy foods; keep off diet frauds; know your BMI

Stamina: aerobics; target heart rates; abs; muscle building; exercising at home; improving habits at workplace; blending it all into your daily routine Spirit(s): theory vs practice; myths vs realities; good for your heart?; women and alcohol, effective drink management

Materials And Methods Materials a. Collection of CDs and cassettes including music in different languages, instrumental music, chanting hymns of different religions, sounds of nature, folk songs, devotional songs, film songs in various languages b, Tape recorder and CD player c. earphones d. calm room with all facilities like fan, bed, table, chair, books and periodicals e. design a questionnaire 1.Questionnaire :Name Age Sex Educational qualification Professional qualification Profession Nature of work Duration of work Place of work Description of work station interface a. with the computer b. with the workers c. with a team of professionals d. with public e. with patients d. with beaurocrats Description of stress condition(This you have to elaborate.I will give 2 tables with the references.See below.) a.Physical pain b. mental disorders c. psychological imbalance The following suggestions given by Dr Nalapat for making the project more scientific.

Table 1. Assessing Insomnia Complaints (lack of sleep) Stage of Assessment Initial screening Goal Identify the nature of the sleep complaint

What to Look for Is there difficulty initiating or maintaining sleep? Experience early awakenings? Is sleep nonrestorative? Daytime consequences are required for a diagnosis of insomnia

Determine presence of daytime consequences Determine the frequency of the complaint Duration

Chronic insomnia: 2-3 nights/week

>/= 1 month suggests subacute or chronic insomnia Is the complaint worsened by stress or medical/psychological factors? Is it easier to sleep away from home, or when not trying to sleep? Is there a conditioned arousal in response to trying to sleep? Information from sleep log: Is there evidence for phase advance or delay, or irregular patterns? Does the patient do shift work? Nightmares, terror, panic, parasomnia (and other behavioral), headache, pain, reflux, nocturia, night sweats, hot flashes, sleep paralysis, hallucinations Physical, emotional, or cognitive overactivity before sleep; nocturnal waking behaviors (prolonged time in bed without sleep); food or substance ingestion just prior to sleep

Additional history: Precipitating factors, course, and progression of the disease

Factors that alleviate or exacerbate the complaint

Sleep-wake schedule

Other nocturnal symptoms or events

Associated behaviors

Sleep-related thoughts

Negative expectations ("I'll never be able to sleep") Distortions -- erroneous assumptions about sleep needs Creating catastrophic scenarios around sleep loss Psychiatric disorders: mood, anxiety, or other psychiatric disorders Substance misuse or medication use: bronchodilators, steroids, diuretics, stimulants, antihypertensives, activating antidepressants, hypnotic rebound Medical/neurologic illness: chronic pain, nocturnal headache, gastroesophageal reflux disease, chronic lung disease, nocturnal angina, congestive heart failure, end-stage renal disease, cancer, HIV/AIDS, menopause, dementias, stroke Sleep disorders: obstructive sleep apnea, PLMD, and other movement disorders

Previous treatments: Responses and attitudes

Assessing for precipitating or causative factors

Adapted from: Sateia MJ, Nowell PD. Insomnia. Lancet. 2004;364:1959-1973

Table 2. Nonpharmacologic Treatments for Insomnia Stimulus control therapy In bed only when sleepy and maintain a regular schedule. Avoid naps and use the bed only for sleep. When unable to sleep within 20 minutes, get out of bed and engage in a relaxing activity until drowsy, then return to bed. Repeat as necessary. Keep a sleep log, and determine the mean total sleep time for a baseline period. Start staying in bed only as long as the baseline mean total sleep time, but not < 4.5 hours. If sleep efficiency is over 90% for 5-7 days, increase time in bed by 15 minutes. If sleep efficiency is under 80%, decrease time in bed by 15 minutes. Repeat adjustments

Sleep restriction

every 5-7 days. Sleep hygiene

Maintain a regular sleep schedule, and do not nap, especially close to bedtime. Avoid sleeping in after a bad night's sleep. Avoid watching the clock, and do not lie awake in bed for long periods. Restrict excessive liquid intake or heavy evening meals. Exercise regularly, but not within 3-4 hours of bedtime. Minimize or avoid caffeine, alcohol, tobacco, and stimulant intake.

Paradoxical intention Progressive muscle relaxation(Music therapy helps this) Biofeedback: Electromyography, electroencephalography, and others These methods have had limited application and assessment. Cognitive therapy(music therapy helps this)

Deliberately attempting to remain awake to reduce performance anxiety. Alternately tensing and releasing muscles to facilitate relaxation and inhibit anxiety-associated arousal

Electromyography: muscular biofeedback with a treatment rationale similar to that of progressive relaxation Electroencephalography: theta or sleep spindle feedback

Restructuring an attempt to identify maladaptive and distorted thoughts that are common among those with insomnia, and replace these attitudes with more beneficial beliefs Most approaches used now involve combinations of treatments, usually including sleep hygiene and stimulus control, sleep-restriction therapy, or both. Cognitive therapy and progressive muscle relaxation may also be part of the combination.

Multicomponent strategies(we are using MT as part of a multicomponent strategy)

Adapted from: Sateia MJ, Nowell PD. Insomnia. Lancet. 2004;364:1959-1973 Ref 1. Sasthri memorial foundation.htt p 2 How to assess insomnia Sateia MJ, Nowell PD. Insomnia. Lancet. 2004;364:19591973

HARS anxiety scale and painscore (if patient reports pain ) has to be used as and when necessary. Clinical Equipments a. BP apparatus b. Thermometer c. Weighing scales d. ECG apparatus e. EKG apparatus Methods(Not specified in the project) Include the following points. How many people u plan to meet and collect data? How many controls u meet? How are u going to make the controls and the test matching-age, sex, profession, education, socioeconomic status etc How are u planning the music therapy session(which is very important and u have to include that since u are doing music therapy counceling) a. Counseling:- The person under stress should undergo a councelling session where he will elaborate his routine b. Identification of problem To identify the problem ,we are using the tables (as mentioned above) c. Analyzing the problem d. Finding the root cause e. Therapeutic treatment f. Metabolic treatment g. Re-scheduling the life style h. Constant evaluation

Because change is constant in life, stress is an integral part of it. Professional stress may be caused by a complex set of reasons such as job insecurity, technology, personal or family problems, workplace culture etc. Music also has measurable physical effects on the body, certain kinds of music actually lower blood pressure and heart rate, regulate breathing and lower cholesterol. Music can be much more powerful and safer than many prescribed drugs. The following Reference was given to Sudha Ganesh for continueing her project. Effects of Job Strain on Blood Pressure: A Prospective Study of White-Collar Workers

Chantal Guimont, MD, PhD; Chantal Brisson, PhD; Gilles R. Dagenais, MD, FRCP; Alain Milot, MD, MSc, FRCP; Michel Vzina, MD, MPH, FRCP; Benot Msse, PhD; Jocelyne Moisan, PhD; Nathalie Aflame, PhD; Caty Blanchette, MSc Am J Public Health. 2006;96(8):1436-1443. 2006 American Public Health Association Posted 07/26/2006 Abstract Objectives: We evaluated whether cumulative exposure to job strain increases blood pressure. Methods: A prospective study of 8395 white-collar workers was initiated during 1991 to 1993. At follow-up, 7.5 years later, 84% of the participants were reassessed to estimate cumulative exposure to job strain. Results: Compared with men who had never been exposed, men with cumulative exposure and those who became exposed during follow-up showed significant systolic blood pressure increments of 1.8 mm Hg (95% confidence interval [CI] = 0.1, 3.5) and 1.5 mm Hg (95% CI = 0.2, 2.8), respectively, and relative risks of blood pressure increases in the highest quintile group of 1.33 (95% CI = 1.01, 1.76) and 1.40 (95% CI = 1.14, 1.73). Effect magnitudes were smaller among women. Effects tended to be more pronounced among men and women with low levels of social support at work. Conclusions: Among these white-collar workers, exposure to cumulative job strain had a modest but significant effect on systolic blood pressure among men. The risk was of comparable magnitude to that observed for age and sedentary behavior. Men and women with low levels of social support at work appeared to be at higher risk for increases in blood pressure. IntroductionHigh blood pressure is a major risk factor for cardiovascular disease.[14] Several factors such as age, obesity,[57] sedentary behavior,[6,8,9] alcohol consumption,[6,8] and salt intake[8,10,11] may contribute to the development of high blood pressure. Epidemiological studies have shown that psychosocial factors (including workplace psychosocial factors) may contribute to high blood pressure.[1216] Most studies examining the association between workplace psychosocial factors and blood pressure have been based on the job strain model developed by Karasek,[17] in which adverse workplace psychosocial factors are defined as a combination of high psychological demands and low decision latitude. Lack of social support in the workplace could further increase the effects of job strain.[18,19] Studies assessing the impact of job strain on blood pressure have involved several limitations and have generated different results. Some cross-sectional studies using casual blood pressure measurements (i.e., a small number of measurements taken at rest)[2023] and most cross-sectional studies assessing ambulatory blood pressure[19,2433] have reported significant associations

between job strain and blood pressure. However, cross-sectional designs may be biased by selection effects[34] and do not allow evaluation of the temporal relation between exposure and outcome or the impact of cumulative exposure. To our knowledge, 4 prospective studies have evaluated the effects of cumulative exposure to job strain on blood pressure in normotensive individuals, and these studies have produced mixed results. Chapman et al.[35] and Fauvel et al.[36] found no effect on blood pressure over 5 years of cumulative exposure. Schnall et al. found that systolic and diastolic blood pressure levels were 5.7 and 4.4 mm Hg higher, respectively, among workers with 3 years of cumulative exposure to job strain than among workers who had never been exposed.[29] Moreover, higher blood pressure was found among men who had been employed for 25 years or more and who had been exposed to job strain for 50% of their working life than among men without past exposure to job strain.[37] Recently, Markovitz et al.[38] reported that changes in psychological demands and decision latitude ratios affected systolic blood pressure. Limitations of these studies relate to low (40%[35]) or unknown[38] participation rates, high rates of loss to follow-up (25%,[35] 31.5%,[29] and 38%[38]), inclusioWe prospectively evaluated whether cumulative exposure to job strain significantly increased blood pressure levels over a 7.5-year period among men and women employed in white-collar occupations. In addition, we evaluated the potential modifying effects of social support in the workplace. Methods Study Design and Population The study population involved white-collar workers aged 18 to 65 years old employed by 22 public organizations in Quebec City. Their jobs encompassed the full range of white-collar occupations (manual workers were excluded[39]), including senior management (10.4%), professional (35.5%), technical (20.8%), and office (30.6%) workers. Education levels ranged from no high-school diploma to university degree. The study design and population have been described elsewhere.[40] Briefly, between 1991 and 1993, 9189 workers, 75% of the target population, participated in a prospective study intended to evaluate the effects of job strain on blood pressure and cardiovascular disease. All invited participants who were working 20 hours per week or less (0.8%), who were pregnant (1.5%), or who had cardiovascular disease, including treated hypertension (5.2%), were excluded from the study. Of the 8395 participants, 7.7% refused to take part at follow-up, and 2.3% were lost to follow-up. Between January 1999 and June 2003, 89% workers were rescreened. Exclusions were also made at follow-up; namely, 1.2% of the participants had died, 3.0% had been treated for hypertension detected at baseline, and 0.7% were pregnant. Finally, workers with more than 2 missing answers related to psychological demands or decision latitude at baseline (0.9%) or at follow-up (1.2%) and those missing blood

pressure measurements (5.0%) were excluded from the analyses. Thus, data were available for 6719 participants. Data Collection and Variables At baseline and follow-up, workers completed a self-administered questionnaire focusing on demographic characteristics, risk factors for hypertension and cardiovascular disease (smoking, low level of physical activity, high cholesterol, diabetes), family history of cardiovascular disease or hypertension, and characteristics of work and social life. At the worksite (with the exception of those not working at follow-up who were seen at a research clinic), trained nurses measured blood pressure, weight, height, and waist circumference using validated protocols.[41,42] In accordance with the American Heart Association protocol,[41] workers' blood pressure was measured at rest after they had been sitting for 5 minutes. The averages of 2 blood pressure measurements taken at baseline and 3 taken at follow-up, 1 to 2 minutes apart, were used as baseline and follow-up blood pressure levels. Two outcome variables were created separately for systolic and diastolic blood pressure. The first was mean follow-up blood pressure. Workers treated for hypertension at follow-up were excluded from these analyses because their blood pressure level value had been lowered via medication. The second was a dichotomous variable identifying workers with mean blood pressure increases in the highest quintile of the sample. This variable allowed inclusion of workers treated for hypertension, who were assigned to the highest quintile group. We measured both components of Karasek's job strain model at baseline and follow-up using 18 items from the Job Content Questionnaire.[43] Psychological demands reflect quantity of work, time constraints, and level of intellectual effort required. Decision latitude reflects opportunities for learning, autonomy, and participation in the decisionmaking process. The results of previous studies have supported the psychometric properties (internal consistency, factorial validity, and discriminant validity) of both the original English[4446] and French[4648] versions of the questionnaire. We computed psychological demands and decision latitude scores using algorithms recommended by Karasek. In the case of workers with missing data on 2 or fewer items on a given scale, we imputed an average score based on their answered items. This score was applied to 131 and 86 workers for psychological demands and decision latitude, respectively, at baseline and to 81 and 50 workers, respectively, at follow-up. Workers with missing data on more than 2 items were considered as having incomplete data. At both baseline and follow-up, we used the quadrant method to assess exposure. Workers with psychological demands scores of 24 or higher (the

median for the general Quebec working population) were classified as having high psychological demands, and others were categorized as having low psychological demands.[49] Workers with decision latitude scores of 72 or lower (again, the median for the general Quebec working population) were classified as having low decision latitude; the remainder were classified as having high decision latitude.[49] The exposed group comprised workers with high psychological demands and low decision latitude; the active group comprised workers with high psychological demands and high decision latitude; and the passive group comprised workers with low psychological demands and low decision latitude. Other workers were classified as unexposed. Workers who were unemployed or retired at follow-up (n = 866) were considered unexposed at follow-up. Cumulative exposure to job strain was assessed according to exposure observed at baseline and follow-up: exposed at both baseline and follow-up, became exposed during follow-up (exposed only at follow-up), exposure ceased during follow-up (exposed only at baseline), and active, passive, or unexposed at both baseline and follow-up (never exposed; reference group). Several factors were considered as potential confounders, including the demographic variables age, marital status, and education (highest level completed). Family responsibilities were assessed according to the number of children living with the worker.[50] Overweight was defined as a body mass index (weight in kilograms divided by height in meters squared) of 25 or above.[51] Waist circumference was measured in centimeters. We defined abdominal obesity as waist circumferences above 102 cm in men and 89 cm in women.[51] Smokers were defined as those smoking 1 or more cigarettes per day.[50] Alcohol consumption, measured according to average number of alcoholic drinks consumed per week in the preceding 12 months (1 drink = 1 glass of beer or wine or 1 oz [30 mL] of liquor), was categorized as either alcohol abuse (more than 20 drinks consumed per week) or non abuse.[50] We defined sedentary behavior as having engaged in physical exercise less than once per week during the previous 6 months.[50] One exercise session was categorized as 20 minutes or more of rigorous recreational physical activity. Results were similar when sedentary behavior was defined as engaging in physical exercise fewer than 3 times per week during the previous 6 months. Cumulative exposure to these potential confounders over the 7.5-year study period was taken into account. Other factors assessed were family history of health problems (cardiovascular disease or high blood pressure) and personality profile (evaluated in terms of hostility,[52] cynicism,[52] and anger[53]). We measured social support at work at follow-up using 6 items related to supervisor support and 5 related to coworker support.[43] Analyses

All analyses were conducted separately for systolic and diastolic blood pressure and for men and women.[54] Student t tests and 2 analyses were used to compare baseline characteristics among included and excluded workers. We estimated mean follow-up blood pressure values for each job strain group using analyses of covariance adjusting for baseline blood pressure values.[55] When we conducted analyses that instead focused on blood pressure change between baseline and follow-up, the results were identical to those described here. We estimated risk ratios (RRs) for blood pressure increases in the highest quintile for each job strain group using binomial regression analysis adjusting for baseline blood pressure values.[56] These analyses were also used to assess confounding. A variable was considered to be a confounder if its introduction into a model resulted in a change in effect of more than 10%. The level of statistical significance was set at .05. The modifying effects of social support at work, age (younger than 45 years vs 45 years or older), and highest completed education level (college or less vs university) were evaluated through stratified analyses. These effects were also evaluated through the statistical significance (P <.10) of interactions obtained from analyses of covariance. A complementary analysis compared the effect of job strain on blood pressure with that of known blood pressure risk factors. Body mass index and waist circumference yielded similar results. The effects of alcohol abuse could not be evaluated because fewer than 2% of the workers abused alcohol. SAS statistical software[57] was used in conducting all of the analyses. .

Discussion In this study of white-collar workers, cumulative exposure to job strain led to significant increases in systolic blood pressure among men. Men who became exposed during follow-up showed similar increases. Effects tended to be more pronounced among men and women with low levels of social support at work. Four prospective studies, all involving normotensive workers, have evaluated the effects of cumulative job strain on blood pressure. Fauvel et al.[36] found no difference in 5-year follow-up systolic or diastolic ambulatory blood pressure, unadjusted for baseline blood pressure, between workers with cumulative exposure to job strain and those with no exposure. This study was limited by its small sample size (n = 158) and the fact that only 54% of the participants were evaluated at follow-up. Thus, it is likely that the study lacked the necessary power to detect effects of job strain on blood pressure.

Chapman et al.[35] showed no effects of cumulative job strain on casual blood pressure over 5 years among 2634 workers. This difference could have resulted from the use of proxies of Karasek's questions, different measurements of cumulative job strain, use of casual blood pressure measurements, and the fact that only 40% of the target population was represented. Markovitz et al.[38] reported that changes in psychological demands/decision latitude ratios had an effect on casual systolic blood pressure. However, no effect of cumulative job strain on hypertension incidence was found, possibly as a result of the minor overall incidence of hypertension in the sample (2.75%), the measurement of casual blood pressure, and the young study population (18 to 30 years at baseline).[38] Finally, Schnall et al.[29] reported a significant effect of cumulative job strain on increased ambulatory blood pressure over 3 years among 195 men. An additional assessment of job strain exposure made before participants entered the study revealed that ambulatory systolic blood pressure levels were 5 to 8 mm Hg higher among men who had been employed for 25 years or more and had been exposed to job strain for 50% of their working lives than among men without past exposure.[37] The larger increases observed by Schnall et al. may have been because of their use of ambulatory blood pressure measurements. Thus, the effects observed in previous longitudinal studies were most consistent with respect to systolic blood pressure, as were the effects observed in previous cross-sectional studies.[58] In our study, the systolic blood pressure increases found among men were modest but generally statistically significant, as were the risk ratios for large blood pressure increases. These effects were similar in magnitude to those associated with sedentary behavior and age, known blood pressure risk factors. In addition, similar effectsa blood pressure increment of 2.4 mm Hg (95% CI = 2.2, 7.1) and a risk ratio of 1.48 (95% CI = 0.74, 2.95)were observed among the 830 men with higher baseline blood pressure levels (130 or above; mean = 138/83 mm Hg, SD = 7/10 mm Hg). Larger increases might presumably be found over individuals' entire working life and may be associated with long-term risk of cardiovascular disease, consistent with the greater effect of life course exposure to job strain on blood pressure (58 mm Hg) found by Landsbergis et al.[37] In addition, previous studies have shown that preventive population-based approaches to reducing systolic blood pressure by 2 mm Hg are likely to decrease risks of coronary heart disease and stroke by 7% and 10%, respectively.[59,60] Such minor changes in blood pressure may thus prevent large numbers of premature deaths and disabling strokes.[59] Finally, there is no threshold (at least down to 115/75) below which decreasing blood pressure is not beneficial.[61] Several studies suggest that psychosocial factors (chronic, episodic, or acute) may influence the pathophysiological mechanisms of blood pressure increases, including activation of the autonomic nervous system and increased cardiac output.[62,63] The effect of cumulative stressors on blood

pressure may be because of the cumulative effect of multiple exposures of varying duration.[64] The larger effects of job strain found among workers with low levels of social support at the workplace are consistent with the iso-strain model (according to which job strain is an adverse psychosocial factor particularly in the case of those with low levels of social support at the workplace).[15,18,19] Furthermore, the significant interaction supports the hypothesis that reduced levels of social support enhance the effects of job strain on blood pressure. Here the overall pattern of effects tended to be similar among men and women, although magnitudes were lower among women. As was the case with men, a larger job strain effect was observed among women with low levels of social support at work. Less intense exposure because of different occupational trajectories or gender-based pathophysiological mechanisms [65] could explain these reduced effects among women. We found that men of high socioeconomic status showed effects of job strain on blood pressure that were similar to those exhibited by men of low socioeconomic status (data not shown). This result is inconsistent with that of Landsbergis et al.,[66] who observed effects only among men of low socioeconomic status. The wider occupational status range included in the Landsbergis et al. study may explain this difference. The hypothesis that decision latitude alone is associated with higher blood pressure levels [67] was not supported by this study. The effects of cumulative low decision latitude on blood pressure were weaker than those of cumulative job strain (data not shown). Furthermore, adjustment for cumulative decision latitude did not lower the effect of cumulative job strain on blood pressure (data not shown). We used another cutoff in the job strain definition (tertiles) and a continuous method (ratio of scales) to verify whether other formulations would have involved lower misclassification rates.[19] We obtained inconsistent effects using tertiles but consistent effects using the continuous method (data not shown), probably reflecting the added complexity of alternate formulations in attempts to classify exposure at 2 time points. Thus, we selected the quadrant method.[58] Baseline exposure and the 5-item psychological demand scale[46] generated consistent results (data not shown). Although this finding supports our measure, it does not rule out a nondifferential misclassification bias that probably generated an underestimation of the true effect.[68,69] Our study involved some limitations. Blood pressure measures were based on a limited number of determinations, as is true of most large epidemiological studies. Risk ratios based on a single measurement are underestimates because of regression dilution bias.[4] Thus, risk ratios for blood pressure increases would probably have been higher had the study involved multiple measurements, namely measurements involving ambulatory devices. Also, the study population was composed of white-collar workers, and thus, the results may not generalize

to other populations. However, exposure variability values (mean = 23.1, SD = 3.5, for psychological demands and mean = 70.3, SD = 10.7, for decision latitude; percentage exposed: 20.7) were similar to those of the general working population (mean = 23.9, SD = 3.8, for psychological demands and mean = 72.7, SD = 11.8, for decision latitude; percentage exposed: 21.9),[50] supporting internal validity. Other limitations included misclassification of exposure owing to dichotomized psychological demand and decision latitude scales, inclusion of intermediate exposures (active and passive)[70] for the unexposed group, and repetition of exposure misclassification at 2 time points in the cumulative assessment. Another source of nondifferential information bias could have led to an underestimation of the true effect; that is, classifying exposure according to 2 time points does not take into account the fact that workers may have temporarily changed in terms of exposure between these 2 points. No information was available on job strain stability over the 7-year period. This study also had many strengths, including being the longest and largest prospective cohort investigation, to our knowledge, to evaluate the effects of job strain on blood pressure. It enabled assessment of the effects of cumulative exposure, and the cohort involved a large proportion of women. Moreover, participation and tracking rates were high, limiting the possibility of selection bias.[69] The comparison between workers included and excluded from the analyses revealed similarities with respect to exposure and outcome variables, further minimizing the possibility of selection bias.[68] Residual confounding was improbable given that a large number of factors, including behavioral factors, and changes in these factors over follow-up were controlled for in the analyses. Missing values were imputed for workers with missing data on 2 or fewer items on a given scale. Reanalyses of the data excluding these workers generated results similar to those described here (data not shown). Adjustment for baseline blood pressure ruled out potential effects of baseline differences in blood pressure between exposure subgroups.[55] Only preplanned comparisons were tested, limiting the potential impact of multiple comparisons. Finally, robustness was supported by similar results (data not shown) obtained in reanalyses that (1) included workers treated for hypertension detected at baseline, (2) excluded workers with cardiovascular disease at follow-up, and (3) excluded workers unemployed or retired at follow-up. We found that cumulative exposure to job strain resulted in significant increases in systolic blood pressure among male white-collar workers, especially those with low levels of social support at work. Similar blood pressure effects were found among workers who became exposed during follow-up. Effect magnitudes were similar to those observed for age and sedentary behavior. Among women, the pattern of effects tended to be similar, although magnitudes were smaller. These results suggest that primary interventions aimed at reducing job strain may have

significant effects on blood pressure. Table 1. Characteristics at Baseline Among Men and Women Included and Excluded From the Analyses: Quebec City, 1991 2003 Men Included Excludeda (n=3483) (n=581) Mean age, y Percentage in age group, y 8E45 3544 <35 Baseline job strain category, % Exposed Active Passive Unexposed Low social support at work,b % Mean no. of years working for organization Education (highest level completed), % High school or less Collegec University Mean systolic blood pressure, mm 13.2 26.0 60.8 121.4 15.9 24.8 59.3 123.0 <.001 17.8 28.0 34.9 19.4 57.7 18.4 25.1 36.9 19.5 60.0 .533 31.9 46.6 21.5 39.6 30.1 30.3 .552 41.0 40.7 P .600 <.001 16.9 50.9 32.2 25.4 40.3 34.3 .949 Women Included Excludeda (n=3236) (n=802) 38.0 38.6 P .052 <.001

23.8 15.4 48.7 12.1 56.4

22.9 15.3 49.8 12.0 61.5 .172

10.6

10.3

.448

9.8

9.5

.407

.187

.009

43.6 30.4 26.1 110.8

49.6 27.6 22.8 112.2 .009

Hg Mean diastolic blood pressure, mm Hg 76.4 76.5 .037 70.3 70.8 .195

Cardiovascular risk factors, % Daily smoking Sedentary behavior Overweight d Abdominal obesitye 15.5 36.2 51.5 15.5 20.9 37.1 57.2 25.9 <.001 .701 .011 .031 19.6 46.3 27.1 14.3 27.1 46.4 31.1 13.3 <.001 .960 .025 .788

Note. P values are for Student t statistics for comparisons of means and 2 statistics for comparisons of percentages between included and excluded workers. a Excluded for technical reasons (refused to participate at follow-up, lost to follow-up, incomplete data for blood pressure or job strain). b Social support at work was measured with 1052 included and 215 excluded men and 947 included and 217 excluded women at baseline. c In the province of Quebec, college refers to preuniversity or vocational studies. d Overweight was defined as a body mass index of 25 kg/m[2] or above. e Abdominal obesity was defined as waist circumferences above 102 cm for men and 89 cm for women.

Table 2. Differences in Blood Pressure at Follow-Up and Risk Ratios for Blood Pressure Increases in the Highest Quintile Group: Cumulative Job Strain Categories Compared With the Never-Exposed Category: Quebec City, 1991 2003 Systolic Blood Pressure, Diastolic Blood Pressure, Adjusted (95% CI) Adjusted (95% CI) Difference in blood pressure at follow-up, mm Hg

Men Never exposed Exposed only at baseline Exposed only at follow-up Exposed at baseline and follow-up Women Never exposed Exposed only at baseline Exposed only at follow-up Exposed at baseline and follow-up Men Never exposed Exposed only at baseline Exposed only at follow-up Exposed at baseline and follow-up Women Never exposed Exposed only at baseline Exposed only at follow-up Exposed at baseline and follow-up 1.0 1.10 (0.94, 1.29) 1.10 (0.91, 1.32) 1.15 (0.93, 1.41) 1.0 1.08 (0.92, 1.28) 0.91 (0.74, 1.12) 1.06 (0.85, 1.31) 1.0 0.98 (0.81, 1.18) 1.40b (1.14, 1.73) 1.33b (1.01, 1.76) 1.0 1.06 (0.90, 1.24) 1.10 (0.92, 1.32) 1.07 (0.84, 1.36) 119.1 0.1 (0.9, 1.1) 0.2 (0.9, 1.4) 0.5 (0.8, 1.8) 75.5 0.3 (0.5, 1.0) 0.1 (0.9, 0.8) 0.5 (0.5, 1.4) 119.7 1.0 (0.0, 2.0) 1.5a (0.2, 2.8) 1.8a (0.1, 3.5)
a

77.7 0.8 (0.0, 1.5) 0.6 (0.3, 1.5) 0.8 (0.5, 2.0)

Risk ratio for blood pressure increase in highest quintile

Note. CI=confidence interval. Adjusted models included the following covariates: age, body mass index, social support at work,

living with a child, number of years working for the organization, and baseline systolic or diastolic blood pressure values. a Statistically significant difference (P<.05) compared with neverexposed group according to F and t statistics obtained from analysis of covariance. b Statistically significant risk ratio (P<.05) compared with neverexposed group according to overall 2 statistic obtained from binomial regression analysis. Four stress styles Look at the following descriptions in order to determine your normal reactions to stress. A. Freeze: Under pressure this individual tends to be immobilized. He/she fears making the wrong decision to such an extent that no decision is likely to be made at all. Checking with others as to what to do is a common strategy, but even then he/she may remain stuck. There is usually a deep desire for someone else to take over control and responsibility. Normal problem-solving skills are forgotten or not able to be utilized. There is a tendency to feel overwhelmed by multiple options that are being presented. This inclination may operate to such an extent that usual abilities that allow for prioritizing and weighing of options are not accessible. No answers or short answers are usually demonstrated in communication. Fear of letting go of projects because they might not be perfect is likely. Excessive checking and rechecking of figures, files or written correspondence is common. In performance circumstances this individual will have a tendency to not move, speak or remember what they are to do. Increasing pressure only immobilizes them more.

B. Flight: Stress produces a desire to run. The individual fears being trapped or attacked. Avoidance of stress-producing problems or people is his/her style of dealing with difficulties. Tendency is to leave responsibilities for others to finish. When unable to physically escape, may retreat into fantasy world or TV. May be unreliable; tendencies to have problems with absenteeism and may have an unstable work history. Procrastination with tasks and projects is common when stressed. May use smoking as an excuse to get away from people or get people to move away from him or her. Panic attacks may result if escape is thwarted. Sickness is often used as an excuse for not being involved in whatever performance in which he/she is involved. C. Fight: Under pressure the individual tends to be aggressive and become involved in conflicts. Fears produce a reaction in which he or she takes the offensive in order to get others to give way. Blame is often placed upon others before others have an opportunity to blame the fighter. Past mistakes of others are likely to be raised and gossip or undermining of the reputation or support of individuals seen as threatening to safety is often utilized. Subtle or blatant intimidation is used to find safety. Though appearing to be strong and self-assured, this individual usually has many self-doubts. In performance settings, this person will have a tendency to blame things on other people, lighting, sound system and the like. Hard to get along with, intimidating and bossy under stress. D. Submit:

A stressed submitter gives into the wishes of others in order to remove the stressful circumstances. The individual is likely to be a caretaker who wants everyone to be happy and is therefore willing to sacrifice him or herself for the sake of that perceived good. This takes a toll on the person and extended periods of stress can produce mild to severe depression. Subsequent resentment can produce passive-aggressive behavior where the individual sabotages the success of projects by "forgetting" to do one thing or another. Individuals with this style of dealing with stress want to be appreciated for their sacrifices and they get their feelings hurt if not appreciated. This style often stems from oppressive upbringing and may lead to a timid nonassertive personality. Inability to set healthy boundaries with others is a common problem. In performance, he/she is likely to go through the motions without much passion. The person becomes a follower instead of a leader which leads to chaos if this individual is looked to for leadership.

Stress Stages Alarm stage: Short term physiological mobilization. Adrenaline and cortisol increase in circulatory system, blood flows away from less essential parts of the body and toward the brain and major muscle systems, dendrites shrink back in the brain as a way of moderating the flow of information and there is a slowing or shutting down of nonessential body functions (e.g. gastrointestinal and sexual systems) that takes place. Resistance stage:

Adaptive efforts by the body to cope with or resolve stressor. Return to normal. Exhaustion stage: Initial stage - If stress persists - reserves of energy are used. Body continues in Alarm stage mode. Fatigue results. Self-medication and selfcomforting coping skills are utilized. There is increased anxiety. Decreased ability to concentrate and stay on task. Greater susceptibility to minor illnesses. Advance stage - Energy reserves are depleted. Body systems begin to malfunction and there is a much greater susceptibility to serious illnesses. Increased use of self-medication and maladaptive self-comforting methods. Normal process in which the stomach lining constantly replenishes itself to counteract digestive fluids is put on hold. Eating for comfort during this time can cause damage to the stomach. Typical appetite and eating patterns are disturbed. Increased irritability, poor judgment and personality changes. Physical and emotional problems.

The body's response to stress is generally healthy and adaptive. It functions to help an individual respond and get through unusual circumstances. This system becomes maladaptive when: The threat is psychological instead of physical The threat (the possibility of the circumstance occurring) is prolonged When distress (the actual circumstance) is prolonged

Performance Stress

Stressed, but not too stressed Professional athletes, musicians, dancers, actors and speakers realize that stress can be their best friend or their worst enemy. Too little stress and there is reduced enthusiasm and energy for the task; too much and mistakes

abound and things a person knew very well are forgotten. Excellence requires finding that right balance and being able to create it when needed.

Even people who love to be in the limelight sometimes get nervous about being scrutinized. It may be an opening night in a theater production, a band or orchestra solo, a piano or dance recital, or an important presentation or speech. They dread making mistakes or appearing foolish. If they are being evaluated or graded on what they are doing, the anxiety connected to scrutiny can be multiplied because the person or persons that sit before them (with clipboard or notebook in hand and a critical air about them) have the expressed purpose of evaluating how well the performers do at their given tasks. Scared, panicked or unnerved could be a fair description of what the one in the spotlight is feeling and that can lead to the one thing the performer dreads: mistakes. Why does it seem so easy for others? Everyone has probably known or observed the kind of people who seem to thrive and excel under stress. They may not necessarily be the most talented but they are the most consistent, and that leads to success in that which they apply their talents. Certainly they are confident in their abilities and in themselves but why is it that anxiety does not affect them in the same way it affects others? How did they get confident in the first place? The truth is that they probably learned, somewhere along the way, to manage reactivity that tendency to lose control of the emotions. Here are some resources on this website that may be or assistance to you in the area of reactivity: Four stress styles Relaxation techniques Self-guided imagery

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We are a business that specializes in helping people to master the various kinds of situational pressures that life offers. In dealing with the difficulties surrounding performances, Stress Solutions offers several approaches to helping students and professionals: Personal consultation: helping individuals to learn confidence building, relaxation techniques and ways of enlivening self when lethargic Three hour Performance Stress Solutions workshops: a cost effective way to gain and practice your newly learned knowledge and techniques Consultation with teachers and trainers: a way to learn these techniques and be able to incorporate performance stress management into their teaching Stress Stages Alarm stage: Short term physiological mobilization. Adrenaline and cortisol increase in circulatory system, blood flows away from less essential parts of the body and toward the brain and major muscle systems, dendrites shrink back in the brain as a way of moderating the flow of information and there is a slowing or shutting down of nonessential body functions (e.g. gastrointestinal and sexual systems) that takes place. Resistance stage: Adaptive efforts by the body to cope with or resolve stressor. Return to normal. Exhaustion stage: Initial stage - If stress persists - reserves of energy are used. Body continues in Alarm stage mode. Fatigue results. Self-medication and selfcomforting coping skills are utilized. There is increased anxiety. Decreased ability to concentrate and stay on task. Greater susceptibility to minor illnesses. Advance stage - Energy reserves are depleted. Body systems begin to malfunction and there is a much greater susceptibility to serious illnesses.

Increased use of self-medication and maladaptive self-comforting methods. Normal process in which the stomach lining constantly replenishes itself to counteract digestive fluids is put on hold. Eating for comfort during this time can cause damage to the stomach. Typical appetite and eating patterns are disturbed. Increased irritability, poor judgment and personality changes. Physical and emotional problems.

The body's response to stress is generally healthy and adaptive. It functions to help an individual respond and get through unusual circumstances. This system becomes maladaptive when: The threat is psychological instead of physical The threat (the possibility of the circumstance occurring) is prolonged When distress (the actual circumstance) is prolonged

Physical and mental impact of stress: 1. Increased chance of cancers 2. Rheumatoid arthritis 3. Panic attacks 4. Depression 5. Weight gain/Weight loss 6. Heart disease 7. Gastrointestinal problems 8. Circulatory problems 9. High blood pressure 10. Strokes 11. Genetically transferred diseases 12. Fibromyalgia 13. Mental illness 14. Sleep disorders 15. Infertility in men 16. Infertility in women 17. Miscarriage

18. Increased incidence of birth defects in babies born to women who have suffered severe trauma during early pregnancy 19. Low birth weight in babies born to stressed mothers 20.Poor memory 21. Poor performance 22.Decreased problem solving ability 23.Worsening of PMS symptoms 24.Immune system problems 25.Relationship problems 26.Emotional reactivity 27.Fears and phobias 28.Job burnout 29.Gene damage 30.Asthma Self-guided imagery

Self-guided Imagery Using imagery can be like taking a mini-vacation. It utilizes an individual's memory and creative imagination to take the mind out of the stress and into a relaxing scene in a way that is very physiologically similar to actually being in that place. 1. Get comfortable, breathe deeply and take inventory from your heels to your head that every part of you is as comfortable as possible. Put quiet music or nature sounds on in the background if you like. 2. Close eyes or focus on a blank wall. 3. Choose a peaceful or pleasant place that you would like to visit or revisit. 4. Be in that place: feel and see your feet planted firmly on the ground. 5. Notice what is in front of you, at your feet, to your right, to your left, above you, then, turn around and see what is behind you.

6. Walk towards a place where you would like to relax. 7. Sit or recline in that place. 8. Notice what you can see (shadows, colors, shades and hues, where the light comes from, what movement there is). 9. Notice what you can hear (wind, birds, animals, children or adult's voices, water, silence, city sounds, ships, cars and so forth). 10. What smells are in the air (flowers, perfume, cologne, fresh air, cooking aromas)? 11. Is there something that can be tasted (food, drink, salty taste in the air, a kiss, nectar from a plucked flower)? 12. What can you feel (the breeze or the movement of the air, what rough and smooth textures can you touch, what is cool and what is warm, which things are soft and which are hard, what is moist and what is dry)? 13. Sit or recline in that relaxing place, letting your mind rest. 14. Notice how you feel inside. Let the pleasantness of this place seep into any tense or uncomfortable places that you find. Tense and release Get as comfortable as possible. Take a few slow deep breaths and focus on how that feels. Start at your feet, take a deep breath, arch your feet, hold your breath while you keep the muscles tensed. Slowly breathe out as you release the tension in your feet. Repeat this. Move to your calves and tense those muscles - breathing as you tense, holding your breath and slowly breathing out as you release those muscles. Repeat. Repeat this with your thighs, abdominal muscles, stomach and back, chest

and upper back. Tense and release hands, arms and shoulders at the same time. Continue to move up your body tensing and releasing neck, then jaw and temple and scalp muscles. If you have difficulty tensing certain muscles, just focus on them as you inhale, hold and exhale. If tension remains - start at head and tense and release muscles until you are back to your feet. Breathing

When you breathe quietly and deeply you notify your stressed body that everything is okay. Picture a large triangle in front of you. Trace it with your finger as you count to yourself. Breathe in slowly from the diaphragm, counting to eight. Hold your breath for a count of eight and then slowly breathe out counting to eight. Repeat this several times, until you feel yourself getting calmer.

Managing Stress in the Workplace Communication skills training Becoming Resilient in a Demanding Business Climate workshop Individual and group consultation for business conflict resolution No one has to teach babies how to breathe in a relaxed way. When an infant calm or sleeping he or she naturally breathes in such a way that the stomach rises and falls. Lay on your back, put your hands on your stomach. Relax your abdominal muscles and take a moderately deep breath. Breathe in such a way that your stomach rises and falls along with your chest. Do not hold your breath. As soon as you have inhaled, begin to exhale. Do not try to overfill the lungs or empty them completely. Let your breathing fall into a comfortable rhythm.

Two minutes of breathing in this way has been shown to substantially reduce stress reaction in the body A self-hypnosis technique It is estimated that most people go into what is called a naturalistic trance about every 90 minutes. If you have ever gotten heavily involved in a book or a music to the point that someone had to call your name a couple of times to get your attention, you have experienced a trance state (some wives would say their husbands are in trance most of the time). Hypnosis is merely a focused state of mind and can be very relaxing if your mind is filled with worries. A few minutes in a trance state can be a mini vacation away from the hectic demands of deadlines and people's expectations. It can also help you to go to sleep more easily. The following simple self-hypnosis method is called the Betty Erickson Technique. Betty Erickson was the daughter of the hypnotherapist, Milton Erickson M.D. He taught her this method when she was a young girl. In a quiet room make yourself comfortable away from distracting movements. Name, out loud or to yourself, five things you can see (e.g. painting, curtain, window sill, telephone, etc.). Name five things you can hear (e.g. the a/c, a passing car, people talking in the hallway, a dog barking in the distance and so forth). Name five sensations that you can physically feel (e.g. "the weight of my back against the chair," "my feet against the floor," "the breeze from the air conditioner," "my arms on the arm rest," etc.). Then begin naming four things you can see, hear and feel - then three, two and finally, one. Close your eyes and enjoy this state. To quickly come out of trance, simply open your eyes, or to do it more slowly reverse the technique by naming two things that you can see, hear and feel, then move to three, four and five.

Project 3.DEMENTIA-ALZHEIMERS (Project of Dr Bhuvaneswary being conducted at the daycare center for alzheimers at Palarivattom.) Clinical dementia rating score(CDS)Hughes etal.1987. AREA ASSESSED ATTENTION COGNITIVE RESPONSES 1 Cognitive attention Cognitive responses function

2.Emotional 3.Sensory &physical(motor including)

involvement posture

1.judgement 2.consideration 3.memory 4.recognition Emotional responses Participation Sensory responses 1.sight 2.hearing 3.touch 4.smell 5.taste

How to score the impairment level with CDR IMPAIRMENT LEVEL CDR SCORE None(normal) 0 questionable 0.5 mild 1 Moderate 2 severe 3 NONE-0 1.MEMORY.no memory loss.slight inconsistent memory loss is normal . QUESTIONABLE0.5 Consistent slight forgetfulness.partial recollection of events.BENIGN FORGRTFULNESS. Fully oriented except for slight difficulty with time relationships MILD Moderate memoryloss.marked for recent events.the defect interfere with day to day activity. Moderate difficulty with time relationships.oriented for place at examinations,may have geographic dissociation elsewhere. Moderate difficulty MODERATE Severe memory loss.only highly learned material retained.New material rapidly lost Severe difficulty with time relationships.disoriented to time ,and to place.

2.ORIENTATION.fully oriented.

3.judgement and problem

Slight impairment to

Severe impairment.social

solving.solve problems ,handles life,business,finance.judgement good in relation to past performance. 4.community affairs.independent function at job,shopping,volunteer and social groups

solve problems,similarities and differences.

in handling problem situations,social judgement is maintained. Unable to function independently.(to casual inspection,appears normal and engaged in activity) Mild but definite impairment.More difficult ones are abandoned. Needs prompting

judgement impaired.

Slight impairmrnt

No pretense of independent function outside home.appears well enough at home,in family circles. Simple chores preserved.very restricted interests.Poorly maintained. Requires assistance in dressing,hygiene,keeping of personal effects

5.Home,hobbies,intellectual interests. Well maintained. 6.personal care. Fuly capable of selfcare.

Slightly impaired

Fully capable

Clinical Dementia Rating

* Score only as decline from previous usual level due to cognitive loss, not impairment due to other factors. Very Mild Impairment CDR 0.5 Consistent slight forgetfulness; partial recollection of events; "benign" forgetfulness Fully orientated except for

Healthy Score CDR 0

Mild CDR 1

Moderate CDR 2

Severe CDR 3

Memory

No memory loss or slight inconsistent forgetfulness

Severe Moderate memory memory loss; loss; only more marked highly for recent learned events; defect material interferes with retained; everyday new material activities rapidly lost

Severe memory loss, only fragments remain

Orientation

Fully orientated

Moderate Severe Orientated difficulty with difficulty with to person time time only

slight relationships; relationships; difficulty with orientated for usually time place at disorientated relationships examination; in time, often may have to place geographic disorientation elsewhere Solves Moderate everyday difficulty in problems Slight handling and impairment in problems, business solving similarities, Judgment affairs well; problems, differences; & Problem judgment similarities, social Solving good in differences judgment relation to usually past maintained performance Unable to function independently at these activities Slight though may impairment in still be these engaged in activities some; appears normal to casual inspection Severely impaired in handling problems, similarities, differences; social judgment usually impaired

Unable to make judgments or solve problems

Independent function at usual level Community in job, Affairs shopping, volunteer and social groups

No pretense No pretense of of independent independent function function outside outside home home Appears well Appears too enough to be ill to be taken to taken to functions functions outside a outside a family home family home

Home & Hobbies

Mild but definite impairment of Only simple Life at function at Life at home, chores home, home; more hobbies, preserved; hobbies, difficult intellectual very intellectual chores interests restricted interests abandoned; slightly interests, well more impaired poorly maintained complicated maintained hobbies and interests abandoned

No significant function in home

Personal Care

Fully capable of self care

Needs prompting

Requires Requires assistance in much help dressing, with hygiene, personal keeping of care; personal frequent effects incontinence

DEMENTIA-ALZHEIMERS 21.4.2006 (first visit) Clinical dementia rating score (CDS) Hughes etal.1987. Client : Fathima . AREA ASSESSED ATTENTION COGNITIVE RESPONSES 1 Cognitive attention Cognitive responses function

2.Emotional 3.Sensory &physical(motor including)

involvement posture

1.judgement 2.consideration 3.memory 4.recognition Emotional responses Participation Sensory responses 1.sight impaired 2.hearing 3.touch 4.smell 5.taste

How to score the impairment level with CDR IMPAIRMENT LEVEL CDR SCORE None(normal) 0 questionable 0.5 mild 1 Moderate 2 severe 3 NONE-0 1.MEMORY.no memory loss.slight inconsistent memory loss is normal . 0 2.ORIENTATION.fully oriented. QUESTIONABLE0.5 Consistent slight forgetfulness.partial recollection of events.BENIGN FORGRTFULNESS. Fully oriented except for slight difficulty with time MILD 1 Moderate memoryloss.marked for recent events.the defect interfere with day to day activity. Moderate difficulty with time relationships.oriented MODERATE 2 Severe memory loss.only highly learned material retained.New material rapidly lost Severe difficulty with time relationships.disoriented

relationships 0.5

3.judgement and problem solving.solve problems ,handles life,business,finance.judgement good in relation to past performance. 4.community affairs.independent function at job,shopping,volunteer and social groups

Slight impairment to solve problems,similarities and differences.

for place at examinations,may have geographic dissociation elsewhere. Moderate difficulty in handling problem situations,social judgement is maintained.

to time ,and to place.

Severe impairment.social judgement impaired.

Slight impairmrnt

5.Home,hobbies,intellectual interests. Well maintained.

6.personal care. Fuly capable of selfcare.

Unable to function independently.(to casual inspection,appears normal and engaged in activity) Inability due to oedema and arthritis -ankle (still interested in her Mild but definite home affairs etc.Not impairment.More a very intellectual difficult ones are lady by nature abandoned. )Slightly impaired Fully capable Needs prompting

No pretense of independent function outside home.appears well enough at home,in family circles.

Simple chores preserved.very restricted interests.Poorly maintained. Requires assistance in dressing,hygiene,keeping of personal effects

DEMENTIA-ALZHEIMERS Clinical dementia rating score(CDS)Hughes etal.1987.clinet 2. Lakshmykutty amma AREA ASSESSED ATTENTION COGNITIVE RESPONSES 1 Cognitive attention Cognitive responses 1.judgement function 2.consideration 3.memory 4.recognition 2.Emotional involvement Emotional responses Participation 3.Sensory posture Sensory responses 1.sight &physical(motor 2.hearing including) 3.touch 4.smell 5.taste

How to score the impairment level with CDR IMPAIRMENT LEVEL CDR SCORE None(normal) 0 questionable 0.5 mild 1 Moderate 2 severe 3 NONE-0 1.MEMORY.no memory loss.slight inconsistent memory loss is normal . QUESTIONABLE0.5 Consistent slight forgetfulness.partial recollection of events.BENIGN FORGRTFULNESS. Fully oriented except for slight difficulty with time relationships MILD Moderate memoryloss.marked for recent events.the defect interfere with day to day activity. Moderate difficulty with time relationships.oriented for place at examinations,may have geographic dissociation elsewhere. Moderate difficulty in handling problem situations,social judgement is maintained. Unable to function independently.(to casual inspection,appears normal and engaged in activity) Mild but definite impairment.More difficult ones are abandoned. Needs prompting MODERATE Severe memory loss.only highly learned material retained.New material rapidly lost Severe difficulty with time relationships.disoriented to time ,and to place.

2.ORIENTATION.fully oriented.

3.judgement and problem solving.solve problems ,handles life,business,finance.judgement good in relation to past performance. 4.community affairs.independent function at job,shopping,volunteer and social groups

Slight impairment to solve problems,similarities and differences.

Severe impairment.social judgement impaired.

Slight impairmrnt

No pretense of independent function outside home.appears well enough at home,in family circles. Simple chores preserved.very restricted interests.Poorly maintained. Requires assistance in dressing,hygiene,keeping of personal effects

5.Home,hobbies,intellectual interests. Well maintained. 6.personal care. Fuly capable of selfcare.

Slightly impaired

Fully capable

DEMENTIA-ALZHEIMERS

Clinical dementia rating score(CDS)Hughes etal.1987. client: 3. Nirmala Nambiar(MID) AREA ASSESSED ATTENTION COGNITIVE RESPONSES 1 Cognitive attention Cognitive responses 1.judgement function 2.consideration 3.memory 4.recognition 2.Emotional involvement Emotional responses Participation 3.Sensory posture Sensory responses 1.sight &physical(motor 2.hearing including) 3.touch 4.smell 5.taste How to score the impairment level with CDR IMPAIRMENT LEVEL CDR SCORE None(normal) 0 questionable 0.5 mild 1 Moderate 2 severe 3 NONE-0 1.MEMORY.no memory loss.slight inconsistent memory loss is normal . QUESTIONABLE0.5 Consistent slight forgetfulness.partial recollection of events.BENIGN FORGRTFULNESS. Fully oriented except for slight difficulty with time relationships MILD Moderate memoryloss.marked for recent events.the defect interfere with day to day activity. Moderate difficulty with time relationships.oriented for place at examinations,may have geographic dissociation elsewhere. Moderate difficulty in handling problem situations,social judgement is maintained. Unable to function independently.(to MODERATE Severe memory loss.only highly learned material retained.New material rapidly lost Severe difficulty with time relationships.disoriented to time ,and to place.

2.ORIENTATION.fully oriented.

3.judgement and problem solving.solve problems ,handles life,business,finance.judgement good in relation to past performance. 4.community affairs.independent function at

Slight impairment to solve problems,similarities and differences.

Severe impairment.social judgement impaired.

Slight impairmrnt

No pretense of independent function

job,shopping,volunteer and social groups

5.Home,hobbies,intellectual interests. Well maintained. 6.personal care. Fuly capable of selfcare.

Slightly impaired

Fully capable

casual inspection,appears normal and engaged in activity) Mild but definite impairment.More difficult ones are abandoned. Needs prompting

outside home.appears well enough at home,in family circles. Simple chores preserved.very restricted interests.Poorly maintained. Requires assistance in dressing,hygiene,keeping of personal effects

DEMENTIA-ALZHEIMERS Clinical dementia rating score (CDS) Hughes etal.1987. 4 Manavalan AREA ASSESSED ATTENTION COGNITIVE RESPONSES 1 Cognitive attention Cognitive responses 1.judgement function 2.consideration 3.memory 4.recognition 2.Emotional involvement Emotional responses Participation 3.Sensory posture Sensory responses 1.sight impaired &physical(motor 2.hearing including) 3.touch 4.smell 5.taste How to score the impairment level with CDR IMPAIRMENT LEVEL CDR SCORE None(normal) 0 questionable 0.5 mild 1 Moderate 2 severe 3 NONE-0 1.MEMORY.no memory loss.slight inconsistent memory loss is normal . QUESTIONABLE0.5 Consistent slight forgetfulness.partial recollection of events.BENIGN FORGRTFULNESS. Fully oriented except for slight difficulty MILD Moderate memoryloss.marked for recent events.the defect interfere with day to day activity. Moderate difficulty with time MODERATE Severe memory loss.only highly learned material retained.New material rapidly lost Severe difficulty with time

2.ORIENTATION.fully oriented.

with time relationships

3.judgement and problem solving.solve problems ,handles life,business,finance.judgement good in relation to past performance. 4.community affairs.independent function at job,shopping,volunteer and social groups

Slight impairment to solve problems,similarities and differences.

relationships.oriented for place at examinations,may have geographic dissociation elsewhere. Moderate difficulty in handling problem situations,social judgement is maintained. Unable to function independently.(to casual inspection,appears normal and engaged in activity) Mild but definite impairment.More difficult ones are abandoned. Needs prompting

relationships.disoriented to time ,and to place.

Severe impairment.social judgement impaired.

Slight impairmrnt

No pretense of independent function outside home.appears well enough at home,in family circles. Simple chores preserved.very restricted interests.Poorly maintained. Requires assistance in dressing,hygiene,keeping of personal effects

5.Home,hobbies,intellectual interests. Well maintained. 6.personal care. Fuly capable of selfcare.

Slightly impaired

Fully capable

DEMENTIA-ALZHEIMERS Clinical dementia rating score(CDS)Hughes etal.1987. 5 Subramanyan swamy AREA ASSESSED ATTENTION COGNITIVE RESPONSES 1 Cognitive attention Cognitive responses 1.judgement function 2.consideration 3.memory 4.recognition 2.Emotional involvement Emotional responses Participation 3.Sensory posture Sensory responses 1.sight &physical(motor 2.hearing including) 3.touch 4.smell 5.taste How to score the impairment level with CDR IMPAIRMENT LEVEL CDR SCORE None(normal) 0

questionable mild Moderate severe NONE-0 1.MEMORY.no memory loss.slight inconsistent memory loss is normal .

0.5 1 2 3 QUESTIONABLE0.5 Consistent slight forgetfulness.partial recollection of events.BENIGN FORGRTFULNESS. Fully oriented except for slight difficulty with time relationships MILD Moderate memoryloss.marked for recent events.the defect interfere with day to day activity. Moderate difficulty with time relationships.oriented for place at examinations,may have geographic dissociation elsewhere. Moderate difficulty in handling problem situations,social judgement is maintained. Unable to function independently.(to casual inspection,appears normal and engaged in activity) Mild but definite impairment.More difficult ones are abandoned. Needs prompting MODERATE Severe memory loss.only highly learned material retained.New material rapidly lost Severe difficulty with time relationships.disoriented to time ,and to place.

2.ORIENTATION.fully oriented.

3.judgement and problem solving.solve problems ,handles life,business,finance.judgement good in relation to past performance. 4.community affairs.independent function at job,shopping,volunteer and social groups

Slight impairment to solve problems,similarities and differences.

Severe impairment.social judgement impaired.

Slight impairmrnt

No pretense of independent function outside home.appears well enough at home,in family circles. Simple chores preserved.very restricted interests.Poorly maintained. Requires assistance in dressing,hygiene,keeping of personal effects

5.Home,hobbies,intellectual interests. Well maintained. 6.personal care. Fuly capable of selfcare.

Slightly impaired

Fully capable

. Suggested further reading DEMENTIA-ALZHEIMERS 21.4.2006 (first visit)

Clinical dementia rating score(CDS)Hughes etal.1987. Fathima. AREA ASSESSED ATTENTION COGNITIVE RESPONSES 1 Cognitive attention Cognitive responses function

2.Emotional 3.Sensory &physical(motor including)

involvement posture

1.judgement 2.consideration 3.memory 4.recognition Emotional responses Participation Sensory responses 1.sight impaired 2.hearing 3.touch 4.smell 5.taste

How to score the impairment level with CDR IMPAIRMENT LEVEL CDR SCORE None(normal) 0 questionable 0.5 mild 1 Moderate 2 severe 3 NONE-0 1.MEMORY.no memory loss.slight inconsistent memory loss is normal . 0 2.ORIENTATION.fully oriented. QUESTIONABLE0.5 Consistent slight forgetfulness.partial recollection of events.BENIGN FORGRTFULNESS. Fully oriented except for slight difficulty with time relationships 0.5 MILD 1 Moderate memoryloss.marked for recent events.the defect interfere with day to day activity. Moderate difficulty with time relationships.oriented for place at examinations,may have geographic dissociation elsewhere. Moderate difficulty in handling problem situations,social judgement is maintained. Unable to function MODERATE 2 Severe memory loss.only highly learned material retained.New material rapidly lost Severe difficulty with time relationships.disoriented to time ,and to place.

3.judgement and problem solving.solve problems ,handles life,business,finance.judgement good in relation to past performance. 4.community

Slight impairment to solve problems,similarities and differences.

Severe impairment.social judgement impaired.

Slight impairmrnt

No pretense of

affairs.independent function at job,shopping,volunteer and social groups

5.Home,hobbies,intellectual interests. Well maintained.

6.personal care. Fuly capable of selfcare.

independently.(to casual inspection,appears normal and engaged in activity) Inability due to oedema and arthritis -ankle (still interested in her Mild but definite home affairs etc.Not impairment.More a very intellectual difficult ones are lady by nature abandoned. )Slightly impaired Fully capable Needs prompting

independent function outside home.appears well enough at home,in family circles.

Simple chores preserved.very restricted interests.Poorly maintained. Requires assistance in dressing,hygiene,keeping of personal effects

DEMENTIA-ALZHEIMERS Clinical dementia rating score(CDS)Hughes etal.1987.2.Lakshmykutty amma AREA ASSESSED ATTENTION COGNITIVE RESPONSES 1 Cognitive attention Cognitive responses 1.judgement function 2.consideration 3.memory 4.recognition 2.Emotional involvement Emotional responses Participation 3.Sensory posture Sensory responses 1.sight &physical(motor 2.hearing including) 3.touch 4.smell 5.taste How to score the impairment level with CDR IMPAIRMENT LEVEL CDR SCORE None(normal) 0 questionable 0.5 mild 1 Moderate 2 severe 3 NONE-0 1.MEMORY.no memory loss.slight inconsistent QUESTIONABLE0.5 Consistent slight forgetfulness.partial MILD Moderate memoryloss.marked MODERATE Severe memory loss.only highly learned material

memory loss is normal .

2.ORIENTATION.fully oriented.

recollection of events.BENIGN FORGRTFULNESS. Fully oriented except for slight difficulty with time relationships

3.judgement and problem solving.solve problems ,handles life,business,finance.judgement good in relation to past performance. 4.community affairs.independent function at job,shopping,volunteer and social groups

Slight impairment to solve problems,similarities and differences.

for recent events.the defect interfere with day to day activity. Moderate difficulty with time relationships.oriented for place at examinations,may have geographic dissociation elsewhere. Moderate difficulty in handling problem situations,social judgement is maintained. Unable to function independently.(to casual inspection,appears normal and engaged in activity) Mild but definite impairment.More difficult ones are abandoned. Needs prompting

retained.New material rapidly lost Severe difficulty with time relationships.disoriented to time ,and to place.

Severe impairment.social judgement impaired.

Slight impairmrnt

No pretense of independent function outside home.appears well enough at home,in family circles. Simple chores preserved.very restricted interests.Poorly maintained. Requires assistance in dressing,hygiene,keeping of personal effects

5.Home,hobbies,intellectual interests. Well maintained. 6.personal care. Fuly capable of selfcare.

Slightly impaired

Fully capable

DEMENTIA-ALZHEIMERS Clinical dementia rating score(CDS)Hughes etal.1987. 3. Nirmala nambiar(MID) AREA ASSESSED ATTENTION COGNITIVE RESPONSES 1 Cognitive attention Cognitive responses 1.judgement function 2.consideration 3.memory 4.recognition 2.Emotional involvement Emotional responses Participation 3.Sensory posture Sensory responses 1.sight &physical(motor 2.hearing including) 3.touch 4.smell

5.taste How to score the impairment level with CDR IMPAIRMENT LEVEL CDR SCORE None(normal) 0 questionable 0.5 mild 1 Moderate 2 severe 3 NONE-0 1.MEMORY.no memory loss.slight inconsistent memory loss is normal . QUESTIONABLE0.5 Consistent slight forgetfulness.partial recollection of events.BENIGN FORGRTFULNESS. Fully oriented except for slight difficulty with time relationships MILD Moderate memoryloss.marked for recent events.the defect interfere with day to day activity. Moderate difficulty with time relationships.oriented for place at examinations,may have geographic dissociation elsewhere. Moderate difficulty in handling problem situations,social judgement is maintained. Unable to function independently.(to casual inspection,appears normal and engaged in activity) Mild but definite impairment.More difficult ones are abandoned. Needs prompting MODERATE Severe memory loss.only highly learned material retained.New material rapidly lost Severe difficulty with time relationships.disoriented to time ,and to place.

2.ORIENTATION.fully oriented.

3.judgement and problem solving.solve problems ,handles life,business,finance.judgement good in relation to past performance. 4.community affairs.independent function at job,shopping,volunteer and social groups

Slight impairment to solve problems,similarities and differences.

Severe impairment.social judgement impaired.

Slight impairmrnt

No pretense of independent function outside home.appears well enough at home,in family circles. Simple chores preserved.very restricted interests.Poorly maintained. Requires assistance in dressing,hygiene,keeping of personal effects

5.Home,hobbies,intellectual interests. Well maintained. 6.personal care. Fuly capable of selfcare.

Slightly impaired

Fully capable

DEMENTIA-ALZHEIMERS Clinical dementia rating score(CDS)Hughes etal.1987.4 Manavalan AREA ASSESSED ATTENTION COGNITIVE RESPONSES 1 Cognitive attention Cognitive responses 1.judgement function 2.consideration 3.memory 4.recognition 2.Emotional involvement Emotional responses Participation 3.Sensory posture Sensory responses 1.sight impaired &physical(motor 2.hearing including) 3.touch 4.smell 5.taste How to score the impairment level with CDR IMPAIRMENT LEVEL CDR SCORE None(normal) 0 questionable 0.5 mild 1 Moderate 2 severe 3 NONE-0 1.MEMORY.no memory loss.slight inconsistent memory loss is normal . QUESTIONABLE0.5 Consistent slight forgetfulness.partial recollection of events.BENIGN FORGRTFULNESS. Fully oriented except for slight difficulty with time relationships MILD Moderate memoryloss.marked for recent events.the defect interfere with day to day activity. Moderate difficulty with time relationships.oriented for place at examinations,may have geographic dissociation elsewhere. Moderate difficulty in handling problem situations,social judgement is maintained. Unable to function MODERATE Severe memory loss.only highly learned material retained.New material rapidly lost Severe difficulty with time relationships.disoriented to time ,and to place.

2.ORIENTATION.fully oriented.

3.judgement and problem solving.solve problems ,handles life,business,finance.judgement good in relation to past performance. 4.community

Slight impairment to solve problems,similarities and differences.

Severe impairment.social judgement impaired.

Slight impairmrnt

No pretense of

affairs.independent function at job,shopping,volunteer and social groups

5.Home,hobbies,intellectual interests. Well maintained. 6.personal care. Fuly capable of selfcare.

Slightly impaired

Fully capable

independently.(to casual inspection,appears normal and engaged in activity) Mild but definite impairment.More difficult ones are abandoned. Needs prompting

independent function outside home.appears well enough at home,in family circles. Simple chores preserved.very restricted interests.Poorly maintained. Requires assistance in dressing,hygiene,keeping of personal effects

DEMENTIA-ALZHEIMERS Clinical dementia rating score(CDS)Hughes etal.1987. 5 Subramanyan swamy AREA ASSESSED ATTENTION COGNITIVE RESPONSES 1 Cognitive attention Cognitive responses 1.judgement function 2.consideration 3.memory 4.recognition 2.Emotional involvement Emotional responses Participation 3.Sensory posture Sensory responses 1.sight &physical(motor 2.hearing including) 3.touch 4.smell 5.taste How to score the impairment level with CDR IMPAIRMENT LEVEL CDR SCORE None(normal) 0 questionable 0.5 mild 1 Moderate 2 severe 3 NONE-0 1.MEMORY.no memory loss.slight inconsistent memory loss is normal . QUESTIONABLE0.5 Consistent slight forgetfulness.partial recollection of events.BENIGN FORGRTFULNESS. Fully oriented except MILD Moderate memoryloss.marked for recent events.the defect interfere with day to day activity. Moderate difficulty MODERATE Severe memory loss.only highly learned material retained.New material rapidly lost Severe difficulty with

2.ORIENTATION.fully

oriented.

for slight difficulty with time relationships

3.judgement and problem solving.solve problems ,handles life,business,finance.judgement good in relation to past performance. 4.community affairs.independent function at job,shopping,volunteer and social groups

Slight impairment to solve problems,similarities and differences.

with time relationships.oriented for place at examinations,may have geographic dissociation elsewhere. Moderate difficulty in handling problem situations,social judgement is maintained. Unable to function independently.(to casual inspection,appears normal and engaged in activity) Mild but definite impairment.More difficult ones are abandoned. Needs prompting

time relationships.disoriented to time ,and to place.

Severe impairment.social judgement impaired.

Slight impairmrnt

No pretense of independent function outside home.appears well enough at home,in family circles. Simple chores preserved.very restricted interests.Poorly maintained. Requires assistance in dressing,hygiene,keeping of personal effects

5.Home,hobbies,intellectual interests. Well maintained. 6.personal care. Fuly capable of selfcare.

Slightly impaired

Fully capable

Smith, Georgia H. "A Comparison of the Effect of Three Treatment Interventions on Cognitive Functioning of Alzheimers Patients." Music Therapy The Journal of the American Association for Music Therapy. Vol. 6A, No. 1. (1986). Pg. 41-56. For this study, 12 women aged 71-92 were placed into groups of three. Each group received sessions of musically cued reminiscence (using familiar songs and questions to encourage discussion), verbally cued reminiscence (using questions to encourage discussion), and musical activity (using familiar songs without encouraging discussion). It was found that musically cued reminiscence and verbally cued reminiscence increased language scores, but only musical activities increased total cognition scores. Dementia Lipe, Anne W. "Using Music Therapy to Enhance the Quality of Life in a Client with Alzheimers Dementia: A Case Study." Music Therapy Perspectives. National Association for Music Therapy, Inc. Vol. 9. (1991). Pg. 102-105. This case study examined a 69-year-old white woman who had played the piano when she was younger.

Through the music therapy sessions, she was able to hum melodies after given the name of a song. Her general attitude was "brightened" and she was able to better express herself through music after the sessions.

Clair, Alicia A. and Bernstein, Barry. "A Comparison of Singing, Vibrotactile and Nonvibrotactile Instrumental Playing Responses in Severely Regressed Persons with Dementia of the Alzheimers Type." Journal of Music Therapy. National Association for Music Therapy, Inc. Vol. 27, No. 3. (Fall 1990). Pg. 119-125. Six men aged 62-73 were chosen for this study. Vibrotactile portions of the sessions involved placing a hand drum in the lap of the patient. Nonvibrotactile portions involved the music therapist holding the drum in front of the patient. Singing was led by the music therapist, and the patients were encouraged to join in singing. Participation was highest when the drum was placed in patient laps, whereas there was little to no participation in singing exercises. Only one patient sang, and he had sung with a band as an adult. His participation decreased as his dementia progressed.

Groene, Robert W. II. "The Effectiveness of Music Therapy 1:1 Intervention with Individuals Having Senile Dementia of the Alzheimers Type." Journal of Music Therapy. National Association for Music Therapy, Inc. Vol. 30, No. 3. (Fall 1993). Pg. 138-157. Sessions were conducted to measure wandering during reading sessions for 16 women and 14 men aged 60-91. The presence of music during the reading sessions increased seating/proximity and decreased wandering in the patients.

http://www.mediconsult.com/mc/mcsite.nsf/condition/alzheimers~journal+articles~GYC G-47UT6D "Influence of Dinner Music on Food Intake and Symptoms Common in Dementia." Ragneskog H., Brane G., Karlsson I., Kihlgren M. This article examined the effect of music on the food intake of 25 patients in a nursing home. First, the patients ate with no music of any type during their mealtime. Next, there was soothing music played while they ate. After that, folk songs likely to be known to the patients were used. Finally, contemporary pop music was played. The soothing music, followed by the pop music, showed the greatest effect on the food intake, as well as on the overall mood of the patients.

http://wkweb5.cableinet.co.uk/garyblatch/music.html "The Use of Music Therapy with the Elderly Diagnosed with Dementia or Depression." Dunn, J. This site recommends

using passive techniques to aid in relaxation and sleep, and using active techniques for enjoyment and socialization.

http://www.alznsw.asn.au/library/demmang.htm#home "Dementia Management Principles." This site provides general information about dementia. The information in this article can be applied when using music as therapy for enjoyment, memory recall, and in other therapeutic arenas.

Bergener, Manfred, MD, and Finkel, Sanford I., MD. Treating Alzheimer's and Other Dementia's. Springer Publishing Company, Inc., 1995. Location-Main Stacks. Understanding exactly what you are treating is important. This book contains an excellent overview of Alzheimers Disease. Dementia of Alzheimer's, the most common form type (DAT) is the most common disturbance of mental functioning in the later years of life. This is an excellent resource for music therapists.

Arnst, Catherine. "Songs that lead down memory lane." Business Week, October 6, issue 3547, (1997): 75. Location-journals microfilm. This article discussed Alzheimers disease in elderly patients. It also described the effect of this disease on memories. However, in many Alzheimers patients it is not the memories that are gone, but rather the ability to retrieve them. The study described the effectiveness of music for retrieval. It found that dementia patients could recall long-term memories after hearing familiar tunes. The study compared the outcome of memory retrieval in two groups, one that was oriented with music and the other with verbalization. Results concluded that music therapy is a valuable tool to enhance the quality of life for patients with dementia.

Rabins, P.V. "Developing treatment guidelines for Alzheimers disease and other dementia." Journal of Clinical Psychiatry, 57 Suppl. 14 (1996): 37-38. Location- journals microfilm. This article contains a review of literature that revealed a variety of treatments are effective in reducing symptoms associated with Alzheimers disease. Environmental and behavioral therapies aimed at reducing cognitive or behavioral symptoms of Alzheimers disease were noted. Music therapy was included in this discussion of therapies.

Casy, J., and Holm, M. "The effects of music on repetitive disruptive vocalizations of persons with dementia." American Journal of Occupational Therapy, 48 No. 10 (1994): 883-889. Location- journals microfilm. The objective of this study was to examine the

effect of classical music and favorite music on the repetitive disruptive vocalizations of long-term facility residents with Alzheimers disease. The study included three subjects. Results showed classical music and favorite music decreased the number of vocalizations in 2/3 of the subjects. The findings support a method that was effective in decreasing the disruptive vocalization pattern common in people with this disease, in the least restrictive manor. In particular, both classical and favorite music decreased frequency of RDV. The article also concluded that the decrease in frequency was due to the subjects appreciation and enjoyment of the music.

Lipe, Anne and Nahama, Glynn. "Musical debatethe music therapy assessment tool." Journal of Gerontological Nursing, 18 No. 7 (1992): 3-4. Location- journals microfilm. This editorial reviewed research in the use of music therapy with Alzheimers patients and explained how it is beginning to develop more. It reviews research studies and results of two previous investigations. It was found that Alzheimer dementia patients could continue to function successfully in structured music group experiences. The article also reviewed the use of the music therapy assessment tool and explains how it was designed to facilitate research aimed at defining particular nursing interventions. This networking would then maximize the Alzheimers disease patients quality of life.

Thomas, D., Heitman, R., and Alexander, T. "The effects of music on bathing cooperation for residents with dementia." Journal of Music Therapy, 34 No. 7 (1997): 247-253. Location- journals microfilm. The purpose of this study was to evaluate musics effect on bathing cooperation among a group of patients diagnosed with Alzheimers disease. Music was used to reduce anxiety by creating an atmosphere that was interpreted as safe and non-threatening. The type of music used in this study was individualized for each subject. A tape of music to be played during the study was developed by the help of family members with the information they provided. Results suggested that the discretionary use of music while bathing might have some effect on delaying the onset of the more severe forms of agitation. This source also gives guidance for caregivers to implement while bathing a client.

Christie, Mary Ella. "The Influence of a Highly Participatory Peer Motivating Group Behaviors of Lower Functioning Persons Who Have Probable Alzheimers Type Dementia: A Feasible Study." Music Therapy Perspectives, 13 No.2 (1997): 87. Location Current. This clinical study shows that strong participators in a group music program can highly increase the behaviors of lower functioning members of the group. ' Music Therapy for Parkinson's and Dementia

Music therapy holds so many promises for so many types of diseases, not only for memory loss but also for working with people who have movement disorders, especially Parkinson's. Research at Beth Abraham Hospital shows that "Parkinson's Disease patients regain some ability to organize and perform movements that were lost due to the disease. Not just any melody will do. The music must evoke a response in each patient, which is used by Tomaino to help the patient enact a specific physiological movement, such as walking. For the patient to move physically, the rhythm must be stimulating and the music familiar enough to allow for carry-over outside the music therapy session." Michael Thaut, AoA Grant Project Director of Colorado State University, in the bulletin on the White House Mini-Conference on Aging and Music Therapy, 1994, states: "The results of this study impact neurological rehabilitation because they demonstrate that particular elements of music have a specific effect on motor systems. After three weeks, the patients with Parkinson's disease demonstrated longer stride length and improved gait velocity by an average of 25 per cent. These data validate the effectiveness of auditory rhythm to improve gait through the rhythmic coupling of auditory and motor systems." In working with persons who have dementia, certain cautions need to be taken, as certain types of music may cause agitation. Two example come to mind: 1. one psychologist told me that in his Alzheimer special care unit, their least successful "musical session" involved live bagpipe music: this session was not meant to be retreive memories (the audience had no special association with the music and therefore could not access long-term memories) but meant as more of a quality of life occasion, but the results were increased agitation and outbursts. Their most successful sessions (audience was relaxed and peaceful) were with classical music and hymns. 2. Be prepared that people may retrieve both positive and negative memories. Connie Tomaino of Beth Abraham told the story of the time she played a waltz to a women who broke out in sobs, only to find out later that the woman had been in a concentration camp (unknown to Connie at the time) and hearing waltz music was a traumatic event for her. For those interested in learning more about the effects of music therapy on memory and gait, I would suggest contacting the National Association for Music Therapy at 301.598.3300. You can contact them for additional

information on specific music research. Their brochure also lists specific federally funded studies and one of the responsibilities of the recipients is the dissemination of their study's results: many will have write-ups in brochures, booklets, books, magazines, etc. Here is a partial list of recipients from the National Association for Music Therapy: TITLE: Music Therapy for Alzheimer's and Dementia Individuals: Recipient: University of Iowa, Kate Gfeller, School of Music 319.335.2611 TITLE: Music Therapy in Alzheimer's Disease Recipient: University of Miami, Ted Tims 305.284.3943 TITLE: A Rhythmic Sensorimotor Music Therapy Program to Improve Gait Ability in Parkinsonian Patients and Healthy Elderly Recipient: Colorado State University, Michael Thaut 303.491.7384 You may also want to contact the Institute for Music and Neurologic Function at 718.519.4164 and ask for their booklet "Music has Power" -it is good write-up of the overall picture on the therapeutic benefits of music. They are also conducting research in five catorgories: music and hearing, music and language, music and memory, music and learning, and music and recovery from nerve injury. Other comments about the use of music: Rosemary Bakker Gerontologist/Interior Designer smartage@msn.com The best type music? I have seen the best results with using the music that was popular in the patient's "prime" time of life. That is if you have the luxury of knowing what the individual enjoyed. Our recreational therapist was familiar with our above mentioned gentleman and realized what he needed. Some good old fashioned swing music was wonderful. For a 50-year-old patient, R&B might do the trick. Soft, or "elevator music" is never inappropriate. Most older patients, especially here in the Bible Belt, respond well to instrumental hymns and spirituals. Poor choices would obviously be rock, jazz, polkas, lively spirited songs and oddly enough patriotic music (especially with veterans). You want to avoid "getting the juices flowing,"' so to speak.

MUSIC THERAPY IN BRAIN DAMAGE A literature search at Indiana University, Bloomington, Indiana

MEDLINE EXPRESS (R) 1/96-1/97 1 of 23 TI: Models of music therapy intervention in stroke rehabilitation. AU: Purdie-H; Baldwin-S AD: Grampian Healthcare NHS Trust, Maidencraig House, Woodend Hospital, Eday Road, Aberdeen, Scotland. SO: Int-J-Rehabil-Res. 1995 Dec; 18(4): 341-50 ISSN: 0342-5282 PY: 1995 LA: ENGLISH CP: ENGLAND MESH: Adult-; Middle-Age MESH: *Cerebrovascular-Disorders-rehabilitation; *Music-Therapy TG: Human; Male PT: JOURNAL-ARTICLE; REVIEW; REVIEW-LITERATURE AN: 96342315 UD: 9701 MEDLINE EXPRESS (R) 1/96-1/97 2 of 23 TI: Influence of dinner music on food intake and symptoms common in dementia. AU: Ragneskog-H; Brane-G; Karlsson-I; Kihlgren-M SO: Scand-J-Caring-Sci. 1996; 10(1): 11-7 ISSN: 0283-9318 PY: 1996 LA: ENGLISH CP: NORWAY

AB: The influence of dinner music on food intake and symptoms common in dementia such as depressed mood, irritability and restlessness was studied. The study was carried out in a nursing-home ward in Sweden. Soothing music was played as dinner music for weeks, Swedish tunes form the 1920s and 1930s for two weeks and pop music for two weeks. Prior to these periods, there was one week without music, and at the end of the intervention there was a two-week control period. The effects of the intervention were assessed by psychological ratings and by weighing the food helpings. It was found that during all three music periods the patients ate more in total. The difference was particularly significant for the dessert. The staff were thought to be influenced by the music, as they served the patients more food, both main course and dessert, whenever music was played. The patients were less irritable, anxious and depressed during the music periods. The results of the study suggest that dinner music, particularly soothing music, can reduce irritability, fear-panic and depressed mood and can stimulate demented patients in a nursing-home ward into eating more. MESH: Affect-; Aged-; Aged,-80-and-over; Dementia-nursing; Geriatric-Assessment; Nursing-Homes MESH: *Dementia-psychology; *Eating-; *Food-Services; *Music-Therapy-methods TG: Human; Support,-Non-U.S.-Gov't PT: CLINICAL-TRIAL; CONTROLLED-CLINICAL-TRIAL; JOURNAL-ARTICLE AN: 96361200 UD: 9611 SB: NURSING MEDLINE EXPRESS (R) 1/96-1/97 3 of 23 TI: A harmonious atmosphere. AU: Roberts-J SO: Nurs-Times. 1996 Jan 24-30; 92(4): 60-1 ISSN: 0029-6589 PY: 1996 LA: ENGLISH CP: ENGLAND

MESH: Aged-; Dementia-psychology MESH: *Dementia-nursing; *Geriatric-Nursing; *Music-Therapy-methods TG: Human PT: JOURNAL-ARTICLE AN: 96193580 UD: 9611 SB: NURSING MEDLINE EXPRESS (R) 1/96-1/97 4 of 23 TI: [Music therapy single case research--a qualitative approach] TO: Musiktherapeutische Einzelfallforschung--ein qualitativer Ansatz. AU: Langenberg-M; Frommer-J; Tress-W AD: Hochschule der Kunste Berlin. SO: Psychother-Psychosom-Med-Psychol. 1995 Dec; 45(12): 418-26 ISSN: 0173-7937 PY: 1995 LA: GERMAN; NON-ENGLISH CP: GERMANY AB: A qualitative approach for describing music psychotherapy treatment is developed. For this purpose we employ the methodological principle of triangulation of perspectives (patient, therapist, independent observers, composers). Our approach is based on the concept of the resonator function describing the perceptive capacity of all participants for effective and relationship-referred significance of the work produced during the treatment. The qualitative method importing and extending the knowledge of the inner context of the case is illustrated by two musical improvisations from the treatment of a female patient suffering from chronic migraine. MESH: Adult-; English-Abstract; Migraine-psychology; Migraine-therapy; Psychoanalytic-Interpretation; Psychophysiologic-Disorders-psychology; Psychophysiologic-Disorders-therapy

MESH: *Music-Therapy-methods; *Psychoanalytic-Therapy-methods TG: Case-Report; Female; Human PT: JOURNAL-ARTICLE AN: 96137655 UD: 9605 MEDLINE EXPRESS (R) 1/96-1/97 5 of 23 TI: Leaving concert hall for clinic, therapists now test music's 'charms' [news] AU: Marwick-C SO: JAMA. 1996 Jan 24-31; 275(4): 267-8 ISSN: 0098-7484 PY: 1996 LA: ENGLISH CP: UNITED-STATES MESH: Adult-; Autism-therapy; Cerebrovascular-Disorders-therapy; Child-; Labor-; Neoplasms-rehabilitation; Parkinson-Disease-therapy; PregnancyMESH: *Music-Therapy TG: Female; Human PT: NEWS AN: 96144519 UD: 9604 SB: AIM MEDLINE EXPRESS (R) 1991-1995 6 of 23 TI: Music as a nursing intervention for residents with Alzheimer's disease in long-term care.

AU: Sambandham-M; Schirm-V SO: Geriatr-Nurs. 1995 Mar-Apr; 16(2): 79-83 ISSN: 0197-4572 PY: 1995 LA: ENGLISH CP: UNITED-STATES MESH: Aged-; Aged,-80-and-over; Alzheimer's-Disease-psychology; MemoryMESH: *Alzheimer's-Disease-nursing; *Long-Term-Care; *Music-Therapy TG: Human PT: CLINICAL-TRIAL; JOURNAL-ARTICLE AN: 95293239 UD: 9509 SB: NURSING MEDLINE EXPRESS (R) 1991-1995 7 of 23 TI: [Establishing contact in the early stage of severe craniocerebral trauma: sound as the bridge to mute patients] TO: Kontaktaufnahme im Fruhstadium schwerer Schadel-Hirn-Traumen: Klang als Brucke zum verstummten Menschen. AU: Jochims-S SO: Rehabilitation-Stuttg. 1994 Feb; 33(1): 8-13 ISSN: 0034-3536 PY: 1994 LA: GERMAN; NON-ENGLISH CP: GERMANY

AB: Both from a theoretical perspective and by means of several case examples, the article focuses on the issue of overcoming the disturbed pre-verbal communication behaviour presented by patients in the early stage following severe craniocerebral trauma. In patients with brain lesion, a pre-verbal, emotionally-focussed tonal language almost invariably is capable of reaching the still healthy sections of the person. Hence, it is possible for music therapy to both establish contact with the seemingly non-responsive patient and re-stimulate the person's fundamental communication competencies and experience at the emotional, social and cognitive levels. MESH: Adult-; Aphasia-psychology; Aphasia-rehabilitation; Brain-Damage,-Chronicpsychology; Brain-Injuries-psychology; Coma-psychology; English-Abstract; Mutismpsychology; Sick-Role MESH: *Brain-Damage,-Chronic-rehabilitation; *Brain-Injuries-rehabilitation; *Comarehabilitation; *Communication-Methods,-Total; *Music-Therapy; *Mutismrehabilitation TG: Case-Report; Human; Male; Support,-Non-U.S.-Gov't PT: JOURNAL-ARTICLE AN: 94218528 UD: 9407 MEDLINE EXPRESS (R) 1991-1995 8 of 23 TI: Alzheimer's disease: rhythm, timing and music as therapy. AU: Aldridge-D AD: Medizinische Fakultat, Universitat Witten Herdecke, Germany. SO: Biomed-Pharmacother. 1994; 48(7): 275-81 ISSN: 0753-3322 PY: 1994 LA: ENGLISH CP: FRANCE AB: Active music-making provides a form of therapy for the Alzheimer's patient which may stimulate cognitive activities such that areas subject to progressive failure are maintained. Anecdotal evidence suggests that quality of life of Alzheimer's patients is

significantly improved with music therapy, accompanied by the overall social benefits of acceptance and sense of belonging gained by communicating with others. Music therapy, when based on clear treatment objectives can reduce the individual prescription of tranquilizing medication, reduce the use of hypnotics and help overall goals of rehabilitation. Mood improvement and self-expression, the stimulation of speech and organisation of mental processes; and sensory stimulation and motor integration are promoted. Given that the rate of deterioration in Alzheimer's disease is not predictable, a series of single case experimental designs would generate valuable empirical data concerning treatment outcome and promote basic research into the timing functions required for the co-ordination of cognition, physiology, motor ability and the integrity of behaviour. MESH: Alzheimer's-Disease-diagnosis; Intelligence-Tests; Language-; Middle-Age; Quality-of-Life MESH: *Alzheimer's-Disease-therapy; *Music-Therapy TG: Case-Report; Female; Human PT: JOURNAL-ARTICLE AN: 95161637 UD: 9505 MEDLINE EXPRESS (R) 1991-1995 9 of 23 TI: The effect of music on repetitive disruptive vocalizations of persons with dementia. AU: Casby-JA; Holm-MB AD: California Children's Service, Health Department, San Jose 95128. SO: Am-J-Occup-Ther. 1994 Oct; 48(10): 883-9 ISSN: 0272-9490 PY: 1994 LA: ENGLISH CP: UNITED-STATES AB: OBJECTIVE. This study examined the effect of classical music and favorite music on the repetitive disruptive vocalizations of long-term-care facility (LTCF) residents with dementia of the Alzheimer's type (DAT). METHOD. Three subjects diagnosed with DAT

who had a history of repetitive disruptive vocalizations were selected for the study. Three single-subject withdrawal designs (ABA, ACA, and ABCA) were used to assess subjects' repetitive disruptive vocalizations during each phase: no intervention (A); relaxing, classical music (B); and favorite music (C). RESULTS. Classical music and favorite music significantly decreased the number of vocalizations in two of the three subjects (p < .05). CONCLUSION. These findings support a method that was effective in decreasing the disruptive vocalization pattern common in those with DAT in the least restrictive manner, as mandated by the Omnibus Budget Reconciliation Act of 1987. MESH: Aged-; Aged,-80-and-over; Alzheimer's-Disease-physiopathology; Dementiaphysiopathology; Skilled-Nursing-Facilities; Treatment-Outcome MESH: *Alzheimer's-Disease-therapy; *Dementia-therapy; *Music-Therapy; *VerbalBehavior TG: Female; Human; Male PT: JOURNAL-ARTICLE AN: 95126243 UD: 9504 MEDLINE EXPRESS (R) 1991-1995 10 of 23 TI: Behavioral training of a young women with Rett syndrome. AU: Bat-Haee-MA AD: O'Berry Center, Goldsboro, NC 27533. SO: Percept-Mot-Skills. 1994 Feb; 78(1): 314 ISSN: 0031-5125 PY: 1994 LA: ENGLISH CP: UNITED-STATES MESH: Activities-of-Daily-Living-psychology; Adult-; Body-Weight; Feeding-Behavior; Leisure-Activities; Music-Therapy; Occupational-Therapy; Psychomotor-Performance; Rett-Syndrome-psychology MESH: *Behavior-Therapy-methods; *Rett-Syndrome-rehabilitation

TG: Case-Report; Female; Human PT: JOURNAL-ARTICLE AN: 94232754 UD: 9408 MEDLINE EXPRESS (R) 1991-1995 11 of 23 TI: Communicating with brain-impaired palliative care patients through music therapy. AU: O'Callaghan-CC AD: Music Therapy Department, Caritas Christi Hospice, Kew, Australia. SO: J-Palliat-Care. 1993 Winter; 9(4): 53-5 ISSN: 0825-8597 PY: 1993 LA: ENGLISH CP: CANADA AB: Language is mainly a function of the left hemisphere of the brain; music is mainly a function of the right hemisphere. Using language and music together therapeutically with brain-impaired patients offers a greater chance of activating intact neurological pathways than using language alone. Music therapy also offers an alternate and creative way of communicating with these patients. MESH: Brain-Damage,-Chronic-psychology; Counseling-methods; Family-Therapymethods MESH: *Brain-Damage,-Chronic-therapy; *Communication-; *Music-Therapy-methods; *Palliative-Care-methods TG: Human PT: JOURNAL-ARTICLE AN: 94180268 UD: 9406

MEDLINE EXPRESS (R) 1991-1995 12 of 23 TI: Effects of individualized music on confused and agitated elderly patients. AU: Gerdner-LA; Swanson-EA AD: University of Iowa, College of Nursing, Iowa City 52242. SO: Arch-Psychiatr-Nurs. 1993 Oct; 7(5): 284-91 ISSN: 0883-9417 PY: 1993 LA: ENGLISH CP: UNITED-STATES AB: The Progressively Lowered Stress Threshold Model in conjunction with an identified theoretical basis provides a framework for the use of individualized music in individuals with Dementia of the Alzheimer's Type (DAT). The effects of individualized music is explored in five elderly patients who are confused and agitated and residing in a long-term care facility. The Modified Cohen-Mansfield Agitation Inventory is used to measure the outcome. The immediate and 1-hour residual effects suggest the potential of individualized music as an alternative approach to the management of agitation in confused elderly patients. MESH: Aged-; Aged,-80-and-over; Alzheimer's-Disease-nursing; Alzheimer's-Diseasepsychology; Confusion-nursing; Confusion-psychology; Individuality-; Mental-StatusSchedule; Nurse-Patient-Relations; Psychomotor-Agitation-nursing; PsychomotorAgitation-psychology MESH: *Alzheimer's-Disease-therapy; *Confusion-therapy; *Music-Therapy; *Psychomotor-Agitation-therapy TG: Case-Report; Female; Human; Male PT: JOURNAL-ARTICLE AN: 94079424 UD: 9403 SB: NURSING MEDLINE EXPRESS (R) 1991-1995 13 of 23

TI: [A music therapy workshop for demented persons] TO: Un atelier de musicotherapie pour personnes dementes. AU: Bellet-M; Berta-J SO: Soins-Psychiatr. 1993 Feb(148): 31-3 ISSN: 0241-6972 PY: 1993 LA: FRENCH; NON-ENGLISH CP: FRANCE MESH: AgedMESH: *Dementia,-Senile-therapy; *Music-Therapy-organization-and-administration TG: Human PT: JOURNAL-ARTICLE AN: 94053904 UD: 9402 SB: NURSING MEDLINE EXPRESS (R) 1991-1995 14 of 23 TI: Music and Alzheimer's disease--assessment and therapy: discussion paper. AU: Aldridge-D AD: Medizinische Fakultat, Universitat Witten Herdecke, Germany. SO: J-R-Soc-Med. 1993 Feb; 86(2): 93-5 ISSN: 0141-0768 PY: 1993 LA: ENGLISH

CP: ENGLAND MESH: Alzheimer's-Disease-physiopathology; Alzheimer's-Disease-therapy; Cognition-; Music-Therapy; PerceptionMESH: *Alzheimer's-Disease-psychology; *MusicTG: Human PT: JOURNAL-ARTICLE AN: 93164167 UD: 9305 MEDLINE EXPRESS (R) 1991-1995 15 of 23 TI: Music debate continues [letter] AU: MacLean-B SO: J-Gerontol-Nurs. 1993 Feb; 19(2): 5-6 ISSN: 0098-9134 PY: 1993 LA: ENGLISH CP: UNITED-STATES MESH: Alzheimer's-Disease-nursing MESH: *Alzheimer's-Disease-therapy; *Music-Therapy; *Nursing-Assessment-standards TG: Human PT: LETTER AN: 93155447 UD: 9305 SB: NURSING MEDLINE EXPRESS (R) 1991-1995 16 of 23

TI: [Assisting disabled elderly people to live to the best of their abilities. Music therapy for the elderly with dementia at Belland General Hospital in Osaka] AU: Sakata-A SO: Kango. 1992 Feb; 44(2): 37-46 ISSN: 0022-8362 PY: 1992 LA: JAPANESE; NON-ENGLISH CP: JAPAN MESH: Aged-; Dementia,-Senile-rehabilitation; Hospitals,-General; JapanMESH: *Dementia,-Senile-therapy; *Disabled-rehabilitation; *Geriatric-Nursing; *Music-Therapy TG: Human PT: JOURNAL-ARTICLE AN: 93287480 UD: 9309 SB: NURSING MEDLINE EXPRESS (R) 1991-1995 17 of 23 TI: A song for Mrs Smith. AU: Braben-L SO: Nurs-Times. 1992 Oct 7-13; 88(41): 54 ISSN: 0029-6589 PY: 1992 LA: ENGLISH CP: ENGLAND

MESH: Aged-; Alzheimer's-Disease-therapy MESH: *Alzheimer's-Disease-nursing; *Music-Therapy-methods TG: Case-Report; Female; Human PT: JOURNAL-ARTICLE AN: 93149798 UD: 9305 SB: NURSING MEDLINE EXPRESS (R) 1991-1995 18 of 23 TI: Musical debate [letter] AU: Lipe-A SO: J-Gerontol-Nurs. 1992 Jul; 18(7): 3-4 ISSN: 0098-9134 PY: 1992 LA: ENGLISH CP: UNITED-STATES MESH: AgedMESH: *Alzheimer's-Disease-therapy; *Music-Therapy-methods TG: Human PT: LETTER AN: 92332942 UD: 9210 SB: NURSING MEDLINE EXPRESS (R) 1991-1995 19 of 23

TI: The music therapy assessment tool in Alzheimer's patients. AU: Glynn-NJ SO: J-Gerontol-Nurs. 1992 Jan; 18(1): 3-9 ISSN: 0098-9134 PY: 1992 LA: ENGLISH CP: UNITED-STATES AB: 1. Empirical research is needed to evaluate immediate and sustained physiological, psychological, and psychosocial therapeutic effects, if any, of music therapy on behavioral patterns of elderly institutionalized Alzheimer's patients. 2. The Music Therapy Assessment Tool (MTAT) was specifically designed and developed to assess the effects of music therapy on behavioral patterns of Alzheimer's disease patients. 3. Preliminary testing of the MTAT suggests that it has fairly high internal consistency and inter-rater reliability and warrants consideration as a research tool. 4. Musical intervention included familiar music to facilitate communication and socialization, ethnic and nostalgic music to stimulate reminiscence, and melodies with distinctive rhythmic patterns to enhance movement and behavioral repatterning. MESH: Aged-; Aged,-80-and-over MESH: *Alzheimer's-Disease-therapy; *Geriatric-Assessment; *Music-Therapy; *Nursing-Assessment-methods TG: Female; Human; Male PT: JOURNAL-ARTICLE AN: 92156556 UD: 9205 SB: NURSING MEDLINE EXPRESS (R) 1991-1995 20 of 23 TI: [Senile dementia. Music as a bridge between the past and the present] TO: Senil demens. Musik som en bro mellem fortid og nutid.

AU: Wellendorf-B SO: Sygeplejersken. 1991 Dec 11; 91(50): 22-4 ISSN: 0106-8350 PY: 1991 LA: DANISH; NON-ENGLISH CP: DENMARK MESH: Aged-; Aged,-80-and-over; Nursing-Homes MESH: *Dementia,-Senile-rehabilitation; *Interpersonal-Relations; *Music-Therapy TG: Case-Report; Female; Human PT: JOURNAL-ARTICLE AN: 92285855 UD: 9209 SB: NURSING MEDLINE EXPRESS (R) 1991-1995 21 of 23 TI: Songs that soothe. AU: Cooper-J SO: N-Z-Nurs-J. 1991 Apr; 84(3): 22-3 ISSN: 0028-8535 PY: 1991 LA: ENGLISH CP: NEW-ZEALAND MESH: Aged-; Dementia-nursing; Music-Therapy-methods MESH: *Dementia-therapy; *Music-Therapy-standards

TG: Case-Report; Female; Human; Male PT: JOURNAL-ARTICLE AN: 91226870 UD: 9108 SB: NURSING MEDLINE EXPRESS (R) 1990 22 of 23 TI: Spark of life. AU: Jones-CP AD: VA Medical Center, Lexington, Kentucky. SO: Geriatr-Nurs. 1990 Jul-Aug; 11(4): 194-6 ISSN: 0197-4572 PY: 1990 LA: ENGLISH CP: UNITED-STATES MESH: Adult-; Coma-nursing; Head-Injuries-nursing; Motivation-; Music-Therapy MESH: *Coma-rehabilitation; *Head-Injuries-rehabilitation TG: Case-Report; Human; Male PT: JOURNAL-ARTICLE AN: 90306798 UD: 9010 SB: NURSING MEDLINE EXPRESS (R) 1990 23 of 23 TI: [Coping with illness in the early phase of severe neurologic diseases. A contribution of music therapy to psychological management in selected neurologic disease pictures]

TO: Krankheitsverarbeitung in der Fruhphase schwerer neurologischer Erkrankungen. Ein Beitrag der Musiktherapie zur psychischen Betreuung bei ausgewahlten neurologischen Krankheitsbildern. AU: Jochims-S SO: Psychother-Psychosom-Med-Psychol. 1990 Mar-Apr; 40(3-4): 115-22 ISSN: 0173-7937 PY: 1990 LA: GERMAN; NON-ENGLISH CP: GERMANY,-WEST AB: In many cases neurological diseases become traumatic because of their abrupt appearance resulting in physical and/or mental impairment, which is often experienced as deep narcicistic offence. Assumpting that there exist a correlation between successful functional rehabilitation and emotional coping strategies and because the factor "time" is as well relevant for the full development of potential early support in the sense of guiding through morning and grief to be necessary. By two case studies, one in the field of physical handicap and one in the field of severe head injury by road accident, it is tried to point out the special possibilities of music therapy including the question of induction. MESH: Adult-; Brain-Damage,-Chronic-diagnosis; English-Abstract; Music-Therapymethods MESH: *Adaptation,-Psychological; *Brain-Damage,-Chronic-psychology; *MusicTherapy; *Sick-Role TG: Case-Report; Human; Male PT: JOURNAL-ARTICLE AN: 90245923 UD: 9008

go to Shufflebrain main menu pietsch@indiana.edu

(THESE REFERENCES WERE GIVEN TO G .BHUVANESWARY FOR CONTINUING HER RESEARCH FURTHER .)

5 FOR MONITORING THE QUALITY OF MUSIC THERAPY 1.Suggestions for developing a pioneer music therapy education center, a pioneer music therapy center (a hospital), and a university center, and preferably a laboratory where one can standardize the results (lab results in research and treatment).These 4 centers can function in different districts but with a coordinating function. 1 Apex body 2.The governing body consisting of 16 member executive board (elected and appointed officers) Board meetings 2/3 times an year. Policies are set by an assembly of delegates consisting of representatives from each of the associations regional chapters. 3.There are 10 or more standing committees which represent 1.the area of clinical training(doctors) 2.Education(educationists,musicologists) 3.Government relations 4.Research and development 5.Standards and special target population 6.professional advocacy 7.employment/public relations 8.continuing education 9.international relations 10.application relations. 4 PUBLICATION WING 1BOOKS/LEAFLETS/BROCHURES 2.TEXT BOOKS NEEDED 3.JOURNALS 4.UPTODATE INFORMATION ON WEBSITE 5.CONFERENCE PROGRAMMES,MONOGRAPHS,VIDEOS,FACT SHEETS,BIBLIOGRAPHY,

5.Continueing education . Regional periodical National ,international Workshops symposium

6 AFFILIATED INSTITUTIONS

1.University-medical colleges,music colleges 2.Hospitals govt,private.allopathy,ayurveda,others 7 For educational institutions Infrastructure and facilities assessment 1.campus area 2.builtup area 3.computers in the school(number) 4.total number of students in the school. 5.Number of classrooms 6.Number of OHP 7.Number of slide projectors 8.Number of LCD projectors 9.Number of books in the library 10.Number of journals available in library 11.Electronic database 12.Residential facility 13.School bus 8.Intellectual capital

1.Number of books 2.Number of books authored by the faculty 3.Papers published in Indian journals 4.Papers published in regional journals 5.Papers published in international journals 6.Number of journals subscribed 7.Faculty /student ratio 8.Faculty less than 10 yr experience/student ratio 9.Faculty with 10 /more yrs experience /students ratio 10.Faculty with PhD/Mphil/students ratio 9 Industry interface

1.How many personality development programmes conducted per year For students For teachers/parents 2002 2002 2003 2003 2004 2004 2005 2005 2006 2006

2.How many seminars per year 3.How many workshops per year 4. How many projects per year by students

extracurricular activities 1.number of regional level events organized number of students participated in it 2.number of national level events organized number of students participated 3.international level events organized number of students participated 4.number of international exchange programmes for students and faculty number of students and faculty participated satisfaction survey score. Do you take satisfaction survey scores If yes, Student satisfaction score Faculty satisfaction score Parent satisfaction score Placement/performance/incentives Number of teachers Maximum salary to teacher Minimum salary to teacher ROI index(average salary/fee )in India ROI index in other countries(abroad) QUESTIONNAIRE for school children 2. age 3. class 4.rank

1.Name 5. mark

6.Extracurricular activities/hobbies(list in the order of priority)

7.Participation in school festivals/arts/sports

8.Mothers hobbies/profession

9.Fathers hobbies/profession

10.Are you interested in music?

Yes

no

11.If yes,what type of music you like? Vocal Hindustani classical devotional/nondevotional 12.Best male voice you like? 13.Best female voice you like? 14.Have you learned music? Yes no Instrumental south Indian classical light music

popular film music others/specify

15.If yes upto which level?(specify) 16.Can you identify Raagas? Yes no 17.If yes which are the raagaas you can identify?and which of them you like best?(list the raagaas you know,and put a tick mark against the ones you like.)

18.Did your parents/siblings sing to you while you were a child to put you to sleep? Yes no 19.can you remember them?If yes,which were they?

20.Which of those songs you liked best? 21.what are your best childhood memories associated with that music/lullabies which you would like to share with your family,friends and the world?

22.Do any particular music produce sad memories in you?Do any particular song produce nostalgia,happiness,and feelings of love and compassion?

23.What is the effect of your favourite music sung by your favourite singer on your body,mind and mood?

24.Did your parents/grandparents tell you stories in childhood?If yes what type of stories?

25.What type of books you read? Stories/fiction/fairytales/spiritual Poetry Essays Science books Newspapers/periodicals Horror/crime stories None other than textbooks 26.What type of TV programmes you watch/like best?(if you love more than one,number them accordingly) Music/dance/cultural Serials/soap operas Films/filmbased comedies News Educational Debates/discussions/current affairs Political analysis Sports 27.Do you go to bed with your favourite music yes no 28.Do you wake up with a melodious soft devotional music? Yes no

29.Which programme your mother watch on TV? 30.Which programme your father watch on TV? 31.Do your parents discuss music/arts/etc with you? Yes no

32.Do you share your musical experiences with your classmates/friends? Yes no 33.Do your friends communicate to you their best musical experiences? Yes no.

34.Narrate the best musical experiences you had/or heard in your lifetime.

35.Have you heard of a discipline called music therapy?What is your opinion about it?Can music have effects on the physical,mental,intellectual and spiritual wellbeing of individuals? .HOW TO START YOUR RESEARCH WORK(A GUIDELINE) Research Subject

Put the research subject in the center. Draw arrows in different directions and write down the different ideas I generated on the subject ,from my own observations,life experiences. For example ,the subject is music therapy. The ideas I generate are the effect of music on normal children, on retarded children, on normal adults,on geriatrics with dementia ,the type of music best suited,the techniques best suited,the voice liked by all,the effects of music both subjective and objective on patients,data accumulation ,and many others. Put all these in order,and then learn the different perspectives on each of these ideas from other people,from other works,from other disciplines so that it becomes an interdisciplinary approach with proper references and alterations of my own method or improvisations on it if necessary. This is an enormous responsibility because you are trying to find out the truth,purging off the false informations and the illfated.When I accept an information I am trusting the sources on the way and if I go wrong in that procedure I may loose my track.So that verification of the data from other sources and matching them with my own data is very important . When I study music therapy with the Indian classical music and melakartharaaga system and when I depend upon the music of yesudas for that purpose,I am depending upon the fact that he is one person who can sing all the melakartharaagaas and his voice is the best for interpersonal intrapersonal relationship with patients from all the south Indian languages.That is for understanding the critical and noncritical circumstances the surroundings of people ,places ,things surrounding the topic has to be researched and I should know that when I start to explore these circumstances surrounding yesudas I can come across both negative and positive informations which can either negatively or positively shift the outcome of my research.Therefore initial research is important .For that I will have to watch every bit of information available about him (on TV/video/film/music/and talk to or hear opinions of as many people as possible who know him ,read as many clippings from media on him and then have close contact with him and talk to him ).This initial research is over .It is important to be your own jury /and

judge in several matters because otherwise the negative opinions of unwanted elements may creep into the research project and spoil it.For this I always keep an established set of research standards and always hold myself responsible and accountable for what I am doing.I am selective to avoid nonestimated projects and take only what is meaningful to me as a researcher.For example if I didnt have the knowledge that yesudas is capable of rendering all the 72 melakartharaagaas and give peace of mind to people of India speaking different languages I would never have started this research.It is a question of what your inner voice tells you and the verification of it from various other sources. Usually when someone talks about a research project ,it is very boring and everyone in the room including your own family members leave the room,but with the project of music therapy with yesudas it is the otherway round.People want to hear more about it and like the subject well.A very welcome change for any researcher.

.Music psychology references

Machleidts experience process starts with interest, is followed by anxiety, then anger occurs and afterwards sadness, which is finally followed by joy, the hedonic end of this process. In the manner of the main stream of recent emotion psychology Machleidt describes a special shift in that process, which occurs in the stage of anger, as the acting treshold (acting shift, Machleidt, 1994, 353 & 359). But on the other hand he names this process the experience process (Machleidt, 1994, 353), so he seems to be very near to the above mentioned being touched-definition. In my study of the music- and verbalanalysis within the context of the affect of anger, this stage seems not to be an acting threshold. It became an object-relationship-threshold (Wosch, 2002, 253). The client follows in the first improvisations the affects or musical structures of the therapist. Within the stage of anger the client separates from the therapist very clearly, also with his own music elements. Afterwards, the client begins a long period of sadness with different developments. During that period of time different affects were evaluated for client and therapist. The individuality of the client and a separation-process to inner objectrelationship could start then within the stage of anger. Therefore, interest seems to show a tendency in the direction of the object, anxiety a tendency away from the object, anger the fight for separation from the object, with elements of moving toward the object and away from the object. After that, sadness continues separation from the object, including separation from the self of the experienced person. Last but not least, joy turns toward the self as the hedonic end stage of the experience being touched by something. In these senses it was possible to add 21 further emotions to these five categories. The emotion psychologist Philipp Mayring characterized these further emotions in a very similar way, also as emotions in the sense of being touched (Mayring, 1992). We were able to evaluate short excerpts of music therapy improvisation using these different emotion based on the five basic affects. It was also necessary to understand emotion in music as an on-going process, not as a static experience. It seems that emotion can be studied only as an on-going process of being touched and of object-relationship even within short pieces of music of only two or three minutes in music therapy improvisations. References

Berlyne, D.E. (1971). Aesthetics and psychobiology. New York Bonny, H. (1986). Music and Healing. In: Music Therapy, 6A, I, 3-12 Brggenwerth, G.; Gutjahr, L.; Kulka, T.; Machleidt, W. (1994). EEG-Vernderungen emotionaler Reaktionen auf Musik. In: Z. EEG-EMG, 25, 117-125 Bruscia, K. (1987). Improvisational models of music therapy. Springfield Bunt, L.; Pavlicevic, M. (2001). Music and emotion:perspectives from music therapy. In: Sloboda, J.A.; Juslin, P.N. (Ed.) (2001a). Music and Emotion: theory and research. New York, pp. 181-205. Gerdner, L. (2000). Effects of individudualized versus classical relaxation music on the frequency of agitation in elderly persons with AD disease and related disorders. In: Intern. Psychogeriatrics, 12,1,49-65 Gutjahr, L.; Brggenwerth, G.; Gvenec, O.; Wilcken, C.; Machleidt, W.; Hinrichs, H. (1994). Die Wirkung altorientalischer Musik im EEG. In: Z. EEG-EMG, 25, 126-129. Izard, C. (1994). Die Emotionen des Menschen. Weinheim. Kernberg, O.F. (1988). Schwere Persnlichkeitsstrungen. Stuttgart. Lungwitz, H. (1970). Lehrbuch der Psychobiologie. Berlin. Machleidt, W.; Gutjahr, L.; Mgge, A. (1989). Grundgefhle. Berlin. Machleidt, W. (1994). Ist Schizophrenie eine emotionale Erkrankung? Affektpsychologisches Verstndnis und integrative Behandlungsanstze der Schizophrenie. In: Psychologische Beitrge, 36, 348-378. Mkel, T. (1995). Musikanalyse und sozialpsychologische Interaktionstheorie. In: Interdisciplinary studies in musicology. Poznan, 179-196. Mayring, P. (1992). Eine Klassifikation der Gefhle. In: Ulich, D.; Mayring, P. (1992). Psychologie der Emotionen, Stuttgart, pp. 136-164. Meyer, L.B. (1956). Emotion and meaning in music. Chicago. Priestley, M. (1994). Analytical Music Therapy. Phoenixville. Schwabe, C.; Rhrborn, H. (Ed.) (1996). Regulative Musiktherapie. Entwicklung, Stand und Perspektiven in der psychotherapeutischen Medizin. Stuttgart.

Sloboda, J.A. (1992). Empirical studies of musical affect. In: Riess-Jones, M.; Hollerman, S. (Ed.). Cognitive bases of musical communication. Washington, 33-45. Sloboda, J.A.; Juslin, P.N. (2001). Psychological perspectives on music and emotion. In: Sloboda, J.A.; Juslin, P.N. (Ed.) (2001a). Music and Emotion: theory and research. New York, pp. 71-105. Sloboda, J.A.; Juslin, P.N. (Ed.) (2001a). Music and Emotion: theory and research. New York Ulich, D.; Mayring, P. (1992). Psychologie der Emotionen. Stuttgart. Vink, A. (2001). Music and Emotion. Living apart together: a relationship between music psychology and music therapy. In: Nordic Journal of Music Therapy, 10(2), 144-158. Wigram, T. (1999). Assessment methods in music therapy: a humanistic or natural science framework? In: Nordic Journal of Music Therapy, 8(1), 6-24. Wosch, T. (2002). Emotionale Mikroprozesse musikalischer Interaktionen. Eine Einzelfallanalyse zur Untersuchung musiktherapeutischer Improvisationen. Mnster. Wosch, T. (2002a). Emotion process measurement of music therapy improvisation. In: Aldridge, D.; Fachner, J. (Ed.): Info CD-Rom IV, Conferences, Naples/Italy 2001, [CDRom], Witten Herdecke. Wosch, T. (2003). NEoM a research-network on emotion in music therapy. In: Aldgidge, D.; Fachner, J. (Ed.): Info CD-Rom V, Conferences, Oxford, UK 2002, Witten Herdecke.

NEAR DEATH EXPERIENCES.

Near death experience in survivors of cardiac arrest :A prospective study in the Netherlands (Lancet 2001;358:2039-45) Pim van Lommel,Ruud van Wees,Vincent Meyers,Ingrid Elfferich The lancet.Vol 358.December 15,2001. The cause of this experience and its aftereffects were studied in a prospective study of 344 cases,the demographic ,medical,pharmacological and psychological data compared in patients whom had NDE and who didnt have it.In a longitudinal study of life changes after NDE ,these groups were studied 2 and 8 years after. Theories of origin: 1.physiological changes in the brain. Brain celldeath due to cerebral anoxia 2.psychological reaction to approaching death 3.A combination of such reaction and anoxia.

4.Changing states of consciousness (transcendance)in which perception ,cognitive function,emotion ,and sense of identity function independently from normal bodylinked waking consciousness. 5.People who have an NDE are psychologically healthy ,although some show nonpathological signs of dissociation. The patients transformational processes are very similar after an experience of neardeath,and encompass lifechanging insight,heightened intuition,and disappearance of fear of death.Assimilation and acceptance of these changes is thought to take at least several years. Definition of NDE by these group of doctors as:The reported memory of all impressions during a special state of consciousness,including specific elements such as out of body experience ,pleasant feelings,and seeing a tunnel,light ,deceased relatives,or a life review. Depth of NDE measured as 1.superficial,2.core experiences and 3.deep experiences.If there is some recollection only it is superficial NDE.Core NDE can be including moderately deep and deep NDE and the very deep NDE with clear picture of the exact experience. Elements of NDE (frequency of 10 elements of NDE) ELEMENTS OF NDE 1.awareness of being dead 2.positive emotions 3.out of body experience 4.moving through a tunnel 5.communication with light 6.observation of colours 7.observation of celestial landscapes 8.meeting with deceased persons 9.life review 10 presence of border FREQUENCY (n=62) 31(50%) 35(56%) 15(24%) 19(31%) 14(23%) 14(23%) 18(29%) 20(32%) 8(13%) 5(8%)

Lifechange inventory questionnaire(2 year follow up)

1.Social attitude Showing own feelings Acceptance of others More loving,empathic Understanding others Involvement of family 2.Religious/spiritual attitude Understand purpose of life Sense the inner meaning of life Interest in spirituality 3.attitude to death fear of death belief in life after death 4..others interest in the meaning of life. Understanding oneself 3.appreciation of ordinary things People with NDE have a significant increase in belief in an afterlife and decrease in the fear of death compared to people who had not this experience.Depth of NDE was linked to high scores in spiritual items such as interest in the meaning of ones own life,and social items such as showing love and accepting others.Selfassurance,social awareness and religious nature increased in all patients irrespective of NDE. TOTAL SUM OF INDIVIDUAL LIFE-CHANGE INVENTORY SCORES OF PATIENTS AT 2 YEAR AND 8 YEAR FOLLOW UP.

Lifechange inventory scores Showing own feelings Acceptance of others More loving ,empathetic Understanding others Involvement in family Understanding purpose of life Sense inner

TWO YEAR FOLLOWUP 8 YEAR FOLLOW UP NDE (23) NO NDE(15) NDE(23) NO NDE(15)

42 42 52 36 47 52 52

16 16 25 8 33 33 25

78 78 68 73 78 57 57

58 41 50 75 58 66 25

meaning of life Interest in spirituality Fear of death Belief in lifeafter death Interest in meaning of life Understanding oneself Appreciation of ordinary things

15 -47 36 52 58

-8 -16 16 33 8

42 -63 42 89 63

-41 -41 16 66 58

78

41

84

50

The authors say that the medical factors cannot account for the occurance of NDE since all patients who are clinically dead do not have NDE. Good shortterm memory is needed to remember the near death experiences.(also sleep experiences,naadalayayoga experiences)Forgetting or repressing such experiences was not the reason for the people who have not reported NDE.because eeven in those who remembered ,the first interview could not elicit the memory .With timepass ,after 2 to 8 year follow up,they could remember the core NDE more clearly and they consisted only positive emotions ,showing that the transient memory defects immeadiately after the episode were over and they can remember it more clearly after sometime,if they survived.Women have deeper experiences than men.There is an inverse relation to foreknowledge of the NDE and frequency of NDE.(two scoring systems of NDE 1.Rings classification(Ring.K.life at death.A scientific investigation of the neardeath experience.New york:Coward Mccann and Geoghenan,1980.) 2.Greysons NDE scale(Greyson .B.The neardeath experience scale:construction,reliability and validity .J Nervous Mental Dis 1982:171:369-75) The denial of such experiences come from social rejection and ridicule.It is this social conditioning which causes NDE to be traumatic ,although in itself it is not a psychotraumatic experience.As a result the effects of this experience can be delayed for years,and only gradually and with difficulty is an NDE accepted and integrated.Furthermore ,the longlasting transformational effects of an experience that lasts for only a few minutes of cardiac arrest is a surprising and unexpected finding. Sabom reported a young woman during brain surgery for a cerebral aneurysm showing an EEG of cortex and brainstem totally flat.After the surgery,which was successful,the patient reported to have a very deep NDE,including an out of the body experience ,with subsequently verified observations during the period of the flat EEG. There are some induced experiences with electrical,chemical ,experimental stimulation of temporal lobe,hippocampus etc,which also have unconsciousness,out of body experiences,perception of light,flashes of recollection from the past.These recollections ,however consist of fragmented and random memories unlike the panoramic life-review that can occur in NDE.Transformational processes ,with changing life-insight and

disappearance of fear of death are not seen after such artificial means of induction of NDE.Thus induced experiences are not the same as NDE .The question raised is ,if brain is the seat of memory and consciousness ,how can the clear consciousness outside ones body be experienced at the moment that the brain has no function during a perod of clinical death with flat EEG?In cardiac arrest also the EEG become flat .Blind people describe also have reported the veridical perception during out of body experiences.NDE pushes at the limits of medical ideas about the range of human consciousness and the midbrain relation.NDE could be a changing state of consciousness(the transcendence)or the BARDO ,in which identity,cognition,emotion function independently from the unconscious body ,but retain the possibility of nonsensory perception. A case history of Alzheimers disease.

Male 84, suffering from Alzheimer. He had a cerebral stroke in 1990 at Chennai. Initially he went into situation where his speech and co-ordination were affected. He was treated by Dr. Logamuthu Krishnan, neuro surgeon, by medicines and traction. This continued for one year. The response was only partially and as his condition was diagnosed as Alzheimer nothing more could be done. My fathers memory was affected and his behaviour started becoming strange and irrational. Physically he could not even lift a cup of coffee, and his speech became impaired. At that time a family of ours, Ayurveda practioner suggested Ayurveda treatment. Hiring a Paathi we started Dhaara and Oil massage every day. This continued for 3 months. He did recover to the limit where he could walk on his own, but with difficulty, eat on his own and speak coherently. But he did tend to wander off in his thoughts and imaginations (hallucinating). In the mean time my parents shifted to Trivandrum to be near my sister. In the preceding years Dads condition started deteriorating rapidly. He lost his sense of direction, started urinating in public, arguing on trivial matters etc. His character became quite childish being stubborn, sulking, refusing to go to the bathroom etc. Started removing his clothes most times and developed a tendency to be nude. Going back to the beginning of this letter, started playing music to him daily 3 weeks back. The response was startling and even other who looked askance at my attempt started noticing the change. Like I said before I have no medical or scientific training or knowledge in this subject. It was just a desperate attempt. The music I played were 1Marvellous Marva by Pt.Shivkumar Sharma (Raag Marva) 2Mohan Veena by Pt.Viswamohan Bhatt (Raag Yaman. Raag Basant) 3Chaurasias Choice by Pt.Hariprasad Chaurasia (Raag Ahir bhairav, Multani,Kafi) 4Evening Ragas by Pt.Hariprasad Chaurasia (Raag Bageshri) 5The Genius of Pt.Ravi Shanker (Raag Sanjf Kalyan, Yaman)

67891011121314-

15-

Sundown Ragas by Pt.Jitendra Abhishek (Raag Madhuwanti, Dharbar Kannada) Moon Magic by Pt.Hariprasad Chaurasia (Fusion of Indian, Indonesian and African music0 Singing Strings Vol 4 By Pt.Giriraj Sitar (Raag Lalit) and Pt.Budhadev Dasgupta Sarod (Raag Kaunshi Kanada) Indian Classical on Swarmandal by Shrikant Thackerey (Raag Yaman, Patdeep, Madhuwanti, Bhairavi) Kafi Thaat by Shruti Amonkar (Raag Hamsakinkikini), Kishori Amonkar (Raag Suha) Pt.Harprasad Chaurasia (Raag Bageshri) Golden Raaga Collection 3 by Krishna Hangal (Raag Miyan ki Malhar, Shankara) Golden Raaga Collection by Pt.C.R.Vyas (Raag Dev Gandhar, Salang, Dhani, Bhairavi) Saptarishi by Pt.Bhimsen Joshi (Raag Patdeep) Music for Relaxation by Viswa Mohan Bhatt (Indian Fusion of Mohana Veena, Flute, Piano, Violin, Sarod, Sitar, Guitar, Keyboard, Tabla, Mridangam) The Silent Path of a Vocal Genius Kollegal Subramanyam (Raag Nata, Amruthavarshini, Charukeshi, Neetimati, Revathi, Vasanta)

All these I have only on audio tape form. I have on cds 1 Life Spring Happiness Karunesh 2 Tales of a Dancing River Prem Joshua 3 Collection of Ghazals Persian & Indian improvisations Ustad Shujaat Hussain Khan Sitar & vocal The Rain, Fire, Dawn, Eternity 4 Relaxation Body Mind & Spirit Sambodhi Prem 5 Two cd on Chinese music played on traditional instruments I play mostly the instrumentals on the audio tape as they are convenient to play on my portable audio stereo player. If you do require any of these for your research and treatment do let me know and I will make copies and send it to you. I only require the time to copy them as I am lazy by nature. I am getting some cds on Sopanam music which I am planning to try out. Hope this will help you I your work. Please do send me any further information on this subject for my own knowledge and also to help others who are in this situation. Thanking you (This is a letter received from a dutiful son ,who remembered what his father liked during his early years.The problem with the old age people and the new generation is that they do not know each other well.probably due to lack of communication between them In old age homes this is a major problem

.Music can induce better communication and understanding between people ) See : Music Therapy for education,administration and management : Dr Suvarna Nalapat ; Readworthy Publication New Delhi 2008 .