2008 iStock International Inc.

/Marcela Barsse
How Sweet the Sound
Research Evidence for the Use of Music in
Alzheimers Dementia
Abstract
The purpose of this article is to provide an traditional methods of management, with
evidence-based synthesis of the research minimal risk to the client. A rating system
literature on music intervention for agitated assigning levels of evidence to support
behavior in Alzheimers dementia. A quali- these interventions was used, and implica-
tative review of the literature supported tions for nursing practice innovations and
music as a low-cost, simple alternative to further research are discussed.

Jan Witzke, RN, BSN; Rebecca A. Rhone, RN, BSN, CWS, FACCWS;
Diane Backhaus, RN, BSN; and Nanette A. Shaver, RN, BSN

Journal of Gerontological Nursing Vol. 34, No. 10, 2008 45

A
quick glance at the face of a
young nursing student try-
ing to bathe an agitated cli-
ent was the only assessment required
for the instructor to know a rapid in-
tervention was needed. The client, an
elderly man with dementia, had been
crying out repetitively all morning
but was now making threatening
gestures as well. The instructor be-
gan to sing old familiar tunes while
encouraging both the client and the
student to join her. Soon the student
took the lead and began singing one
of the most familiar songs of our
time: Amazing grace! How sweet
the sound (Bradley, 1989). Re-
markably, the clients body relaxed,
and his expression softened as he
sang along.
Challenging client behaviors such
as these are becoming more com-
mon. A recent Alzheimers Asso-
ciation (2007) report indicates that
someone develops this devastating
disease every 72 seconds, with more
than 5 million people in the United
States currently affected. Because
this disease manifests late in life,
the number of people living with its
ravaging effects is increasing as the
population ages. Symptoms are pro-
gressive and include forgetfulness,
confusion, disorientation, and agita-
tion. Agitated behaviors often inter-
fere with even the simplest activities
of daily living and may escalate from
restlessness, pacing, and disrobing to
hitting, kicking, and yelling. Cohen-
Mansfield and Billig (1986) defined
agitation as inappropriate verbal or
motor activity unrelated to needs or
confusion.
Real-life situations such as the
nursing students experience de-
scribed above prompt scientific in-
quiry. What effect, if any, did music
have in this situation? What best prac-
tice evidence is available to support
the use of music as an intervention in
decreasing agitated behaviors? Un-
fortunately, traditional management
of clients manifesting such behaviors
often results in chemical or physical
restraint (Cohen-Mansfield, Marx, &
46
Rosenthal, 1989), and because these
measures may result in numerous
detrimental side effects, there has
been a great deal of interest in finding
nonpharmacological interventions
to alleviate these symptoms. Recent
research has examined a number of
alternative interventions, including:
l Aromatherapy (Ballard,
OBrien, Reichelt, & Perry, 2002;
Holmes et al., 2002; Lin, Chan, Ng,
& Lam, 2007; Smallwood, Brown,
Coulter, Irvine, & Copland, 2001).
l Therapeutic touch and mas-
sage (Rowe & Alfred, 1999; Wang &
Hermann, 2006; Woods & Dimond,
2002).
l Animal-assisted therapy
(Churchill, Safaoui, McCabe, &
Baun, 1999; McCabe, Baun, Speich,
& Agrawal, 2002; Richeson, 2003).
l Light therapy (Ancoli-Israel
et al., 2003; Lovell, Ancoli-Israel,
& Gevirtz, 1995; Lyketsos, Lindell
Veiel, Baker, & Steele, 1999; Skjerve,
Bjorvatn, & Holsten, 2004).
The purpose of this review was to
provide an evidence-based synthesis
from the findings of previously pub-
lished literature regarding the use of
music in managing agitated behav-
iors in Alzheimers dementia.
Methods of Review
A literature search was conducted
using the computerized databases of
CINAHL, ProQuest, and Cochrane
to identify relevant studies published
between 1994 and 2007. Keywords
used in the search included music,
music therapy, dementia, Alzheimers
disease, and agitation. In addition,
hand searches were conducted from
the reference lists of retrieved stud-
ies. The criteria for study selection
included presentation of recorded
music as an intervention for agitated
behavior, published in English from
1994 to 2007, involved older adults
with dementia or Alzheimers dis-
ease, and published in peer-reviewed
journals.
Several studies were excluded
from our review that did not spe-
cifically measure agitation as an out-
come. Nevertheless, these studies
may represent important evidence
supporting music as a therapeutic
intervention for the symptoms of
dementia. Kumar et al. (1999) found
melatonin levels increased signifi-
cantly and continued to increase even
after music therapy had been dis-
continued for 6 weeks. Suzuki et al.
(2004) found a significant decrease in
salivary CgA levels (which increase
with stress) after 16 sessions of mu-
sic. Irish et al. (2006) found signifi-
cant improvement in autobiographi-
cal memory recall for individuals
with Alzheimers disease, as well as
significant reduction in state anxiety
compared with healthy older adults
also listening to background music.
In addition, four studies reviewed
were conducted by professional mu-
sic therapists (Brotons & Pickett-
Cooper, 1996; Clair & Bernstein,
1994; Kumar et al., 1999) or by a
combination of music therapists and
nursing professionals (Suzuki et al.,
2004). The term music therapy can be
defined as the use of music and/or
its musical elements (sound, rhythm,
melody and harmony) by a qualified
music therapist (Vink, Birks, Bruin-
sma, & Scholten, 2003, p. 2).
This specialized field of apply-
ing active or receptive music thera-
py involves setting specific musical
goals for the participants. Although
these studies may provide significant
findings for our topic, we chose to
exclude three of them (Brotons &
Pickett-Cooper, 1996; Kumar et al.,
1999; Suzuki et al., 2004) to broad-
en the applicability of our findings.
We chose to include Clair and Ber-
nsteins (1994) study because of the
presentation of recorded music as an
unstructured intervention.
In this review, we will join Sherratt,
Thornton, and Hatton (2004) and re-
serve the term music therapy for those
structured musical activities carried
out by a professional music therapist
and use the terms music or music in-
tervention to include the presenta-
tion of recorded music by a variety of
caregivers. It is our hope that music
JOGNonline.com

interventions may be implemented
at relatively low cost in a variety of
settings by nurses, nursing assistants,
activity staff, volunteers, and family
members (Gerdner, 2007).
Previous Literature
Reviews
The findings of seven previous
reviews of music interventions in
dementia were examined during our
search. Goodall and Etters (2005)
noted that studies conducted af-
ter 2000 appear more rigorous than
those conducted prior and discussed
the realistic barriers of sufficient
sample size and randomization of
participants in the chosen population
of interest. Koger, Chapin, and Bro-
tons (1999) provided a meta-analysis
of music/music therapy interven-
tions to update and statistically cu-
mulate the findings on this topic;
they concluded the overall results
did not provide sufficient data to de-
termine the effectiveness of specific
music interventions. Lou (2001) as-
sessed study designs and emphasized
the confounding factors of medica-
tion use and the Alzheimers disease
process itself.
In her review, Madan (2005) dis-
cussed her previously unpublished
randomized controlled trial testing
a preferred music intervention for
disruptive behaviors in dementia.
Although she reported a significant
change in scores on the Disruptive
Behavior Scale, she noted that a power
A music intervention
is easy to incorporate
into daily care, is
inexpensive, and is
noninvasive.
analysis using a sample size of 141 was
needed to determine if these results
were truly statistically significant.
Sherratt et al. (2004) focused their
qualitative review of the literature on
the outcome behaviors of engagement
and participation, not only on problem
behaviors. Notably, they discussed the
Theory of Personhood to support the
idea that well-being, as well as ill-be-
ing (as in measuring agitated behav-
iors), may provide a better measure
of interventional effect. In 2005, Sung
and Chang centered
their review on
evaluating preferred
music interventions or
comparisons of preferred
music interventions with other
kinds of music to determine effects on
agitated behaviors.
Most recently, the Cochrane De-
mentia and Cognitive Improvement
Group examined the effect of music
therapy and concluded the method-
ological quality and reporting of the
included studies were too poor to
draw any useful conclusions (Vink
et al., 2003, p. 1). It is our suggestion,
however, that the results of this rig-
orous review of music therapy inter-
ventions may be supplemented with
a broader base of evidence from the
literature. As one nursing research
expert noted, in determining the best
evidence related to care models for
patients with Alzheimers disease,
experimental and non-experimen-
tal studies may be the best evidence
available (Goode, 2003). Therefore,
the aim of our review is to synthe-
size not only the findings of primary
experimental studies as in the Co-
chrane review, but also to gather a
wider range of previously published
data and examine these findings to
propose levels of evidence that may
or may not support music as an in-
tervention to decrease agitated be-
haviors in Alzheimers dementia.

Journal of Gerontological Nursing Vol. 34, No. 10, 2008 47

 Table
Summary of Primary Research Studies Reviewed on music intervention for agitated
behavior in Alzheimers dementia
Author (Year),
Location Design, Sample LOE Intervention/Independent Variable Definition of Agitated Behavior
Clair & Bernstein Quasi-experimental, III A no music condition and two background music Pacing or wandering, screaming or
(1994), midwestern time series, within- conditions (stimulative or sedative), randomly loud persistent vocalizations, outbursts
United States participants design; played for an entire day, 5 days each week for 2 of physical combativeness, and furni-
N = 28 weeks ture moving

Denney (1997), Quasi-experimental, III Classical music selections played just above Inappropriate verbal, vocal, or motor
midwestern United time series; background noise level in dining room during activities that cannot be attributed
States N=9 lunchtime. No music was played on weeks 1 and directly to manifest needs or confusion
3. Music was played on weeks 2 and 4.

Gerdner (1997), Case study; VI Preferred music was played on an audiocassette Flat affect, pacing, repetitious verbal-
location not identi- N=1 for 30 minutes 2 days per week for a total of 15 izations regarding desire to leave, and
fied sessions. incoherent speech

Gerdner (2000), Experimental, III Individualized or classical relaxation music was Inappropriate verbal or motor activ-
midwestern United repeated measures played for 30 minutes two times per week for 6 ity that is not explained by needs or
States crossover design; weeks, with a 2-week washout period in between. confusion
N = 39

Gerdner (2005), Pilot study using re- III Individualized music played on a portable CD Inappropriate verbal or motor activ-
southern United peated measures and player at a time preceding peak level of agitation ity that is not explained by needs or
States mixed methodology; and on an as-needed basis confusion
N=8

Goddaer & Abraham Quasi-experimental, III Relaxing music defined as neutral with unrec- Inappropriate verbal, vocal, or motor
(1994), Belgium repeated measures, ognizable tunes, played during mealtime at a activities that cannot be attributed
ABAB (A = no music, decibel level just above the average noise level directly to manifest needs or confusion
B = music); on weeks 2 and 4
N = 29

Hicks-Moore (2005), Quasi-experimental; III Relaxing music played during the evening meal Inappropriate verbal or motor activi-
Canada N = 30 on weeks 2 and 4 ties that cannot be explained by needs
or confusion

Olsen et al. (2000), Quasi-experimental, III Musical Memory Lane and Video Memory Lane Agitation as one target behavior
eastern United within-participants, interventions that present nostalgic music and (examples of target behaviors include
States longitudinal design; videos in easy-to-use format smiling, laughing, agitation, wander-
N = 15 ing, sleeping, fidgeting)

Ragneskog et al. Quasi-experimental, III Intervention compared individualized music and Signs of agitation included screaming,
(2001), Sweden within-participants, classical music with a no music control; music was restlessness, aggressiveness, or fight-
time series design; played for 30 minutes in each session ing; facial expressions
N=4

Sung, Chang, & Quasi-experimental; III Preferred music provided in mid-afternoon for 30 Inappropriate verbal or motor activ-
Abbey (2006), N = 32 minutes twice per week for 6 weeks ity that is not explained by needs or
Taiwan confusion

Tabloski et al. Quasi-experimental, III Calming music selection, played for each partici- Fourteen agitated behaviors on the
(1995), eastern repeated measures; pant either in own room or a familiar lounge on Agitated Behavior Scale (ABS)
United States N = 20 two separate occasions for 15 minutes each

Note. CMAI = Cohen-Mansfield Agitation Inventory.

LOE = levels of evidence. Level I: a systematic review or meta-analysis of randomized controlled trials or clinical practice guidelines based on randomized
controlled trials; Level II: a well-designed randomized controlled trial; Level III: well-designed nonrandomized controlled trials; Level IV: well-designed case
control or cohort studies; Level V: systematic reviews of descriptive or qualitative studies; Level VI: a single descriptive or qualitative study; Level VII: the
opinion of expert authority (Melnyk & Fineout-Overholt, 2005).

48 JOGNonline.com

Measure of Outcomes
Observers counted the number of par-
ticipants exhibiting agitated behaviors
at 1-minute intervals over 30-minute
time periods (the placheck method).
CMAI as modified by Goddaer & Abra-
ham (1994) was used to record behav-
iors on the last day of each week.
Observed behavior was recorded in a
qualitative fashion.
Behaviors observed using a modified
version of the CMAI
A modified version of the CMAI; the
Agitation Visual Analog Scale (VAS);
open-ended interviews
CMAI as modified by the authors to
measure behaviors as absent or present incidence of agitated behaviors and for the dimen-
during mealtime
CMAI as modified by Goddaer & Abra-
ham (1994)
Data were collected by direct observa-
tion using hand-held computers.
Observers analyzed randomly selected
samples of videorecorded sessions.
Segment samples were analyzed using
a Facial Action Coding System.
Behaviors observed using the CMAI
ABS measured preintervention,
intervention, and postintervention
behaviors
Journal of Gerontological Nursing Vol. 34, No. 10, 2008
Results
No significant change in amount of agitated behav-
ior was displayed over the course of the study.
Incidence of all agitated behaviors was reduced.
Specific syndromes of verbally agitated behaviors
and physically nonaggressive behaviors decreased
most with the music intervention.
Participant smiled and then danced; stated, This
is fun; made no statements indicating a desire to
leave.
Significantly greater decrease in frequency of
agitated behaviors with the individualized music
intervention compared with the classical music
Agitation was significantly reduced on day shift
throughout the 8 weeks. Agitation was significantly
reduced on evening shift on weeks 5 through 8.
Significant differences were found in the cumulative
sions of physically nonaggressive behaviors and
verbally agitated behaviors.
Decreased incidence of agitated behaviors ob-
served in the weeks music was played in compari-
son to the weeks music was not played
Favorable impact on engagement, stimulated
positive affect, and activity-related talking, while
also reducing fidgeting. Clients chose a Memory
Lane activity significantly more often than other
activities and remained engaged for longer periods.
Effect of classical music was not as evident as effect
of individualized music. Two patients became calm-
er with interventions. Effect of music was minimal
for 2 patients with the most severe dementia.
Significant reduction in overall agitation and physi-
cally nonaggressive behaviors
Significant difference was found in agitation scores,
both during and after the calming music interven-
tion.
Strength of Evidence
In the 1970s, the disciplines of
nursing and medicine began viewing
their respective practices with a criti-
cal eye on the scientific rationale for
interventions (Goode, 2003; White,
2004). During this time period,
problem-oriented, research-based
interventions were developed by the
Western Interstate Commission for
Higher Education research utiliza-
tion project, which teamed a nurse
clinician and nurse educator. In 1972,
due to concern about effectiveness
and efficiency, Cochrane, a British
epidemiologist, challenged the medi-
cal community to base practice deci-
sions on rigorous research evidence
versus tradition and expert opinion
alone. This challenge eventually led to
the evidence-based medicine (EBM)
movement and the establishment of
both the Cochrane Collaboration in
1993 and the Evidence-Based Medi-
cine Working Group (Goode, 2003).
Levels of evidence, which cat-
egorize the statistical strengths and
weaknesses of individual research
or meta-analyses, vary in complex-
ity between EBM and evidence-
based nursing (EBN). The scope
of evidence to support nursing
practice is generally more inclusive
than is EBM (Goode, 2003; Stetler,
2003). Ciliska (2006) defined EBN
as the incorporation of the best
research evidence along with pa-
tient preferences, the clinical set-
ting and circumstances, and health-
care resources into decisions about
patient care (p. 38). Therefore,
EBM focuses on randomized con-
trolled trials to make recommenda-
tions for clinical practice, while the
range of EBN can include evidence
from randomized controlled trials
or quasi-experimental, descriptive,
or qualitative studies in developing
practice standards (Melnyk & Fine-
out-Overholt, 2005). Both medicine
and nursing scientific inquiry evalu-
ate authoritative opinion and expert
consensus but ascribe guarded sta-
tus to this evidence when making
recommendations for practice.
49
 validity was strengthened in all ex-
perimental and quasi-experimental
keypoints studies by the selection of a homo-
Music for Alzheimers geneous sample and the use of reli-
able diagnostic tools for level of de-
Dementia mentia. Likewise, the reliability of
data collection instruments used was
Witzke, J., Rhone, R.A., Backhaus, D., & Shaver, N.A. (2008). How Sweet the Sound: Research
Evidence for the Use of Music in Alzheimers Dementia. Journal of Gerontological
well documented; for example, the
Nursing, 34(10), 45-52. Cohen-Mansfield Agitation Inven-
tory was used to measure the out-

1 Traditional management of agitation in Alzheimers dementia in-

cludes chemical and/or physical restraint, which may result in
numerous detrimental side effects.
come of agitation (Gerdner, 2000,
2005; Hicks-Moore, 2005; Sung et
al., 2006). Methods were used to

2 Music interventions are simple, low-cost alternatives to tradi- verify observer training and inter-
tional management, may include the presentation of recorded rater agreement (Clair & Bernstein,
music by a variety of caregivers, and are supported by an evi- 1994; Gerdner, 2000, 2005; Olsen et
dence-based review of the literature. al., 2000; Sung et al., 2006). Impor-
tantly, 5 studies reported standard-

3 Evidence-based nursing incorporates the best research evi-

dence along with patient preferences, clinical circumstance,
and available health care resources to make decisions regarding
patient care.
Melnyk and Fineout-Overholts
(2005) level of evidence rating system
seems well suited for nursing practice
recommendations relating to music
interventions. Their evidence rating
system categorizes levels of evidence
as follows:
l Level I: a systematic review
or meta-analysis of randomized
controlled trials or clinical practice
guidelines based on randomized
controlled trials.
l Level II: a well-designed ran-
domized controlled trial.
l Level III: well-designed non-
randomized controlled trials.
l Level IV: well-designed case
control or cohort studies.
l Level V: systematic reviews of
descriptive or qualitative studies.
l Level VI: a single descriptive
or qualitative study.
l Level VII: the opinion of
expert authority.
Findings of This Review
Eleven of 17 studies reviewed
met our inclusion criteria and are
presented in the Table. Nine of the
included studies reported reductions
in agitation after the music interven-
tion (Denney, 1997; Gerdner, 2000,
2005; Goddaer & Abraham, 1994;
Hicks-Moore, 2005; Olsen, Hutch-
ings, & Ehrenkrantz, 2000; Rag-
neskog, Asplund, Kihlgren, & Nor-
berg, 2001; Sung, Chang, & Abbey
(2006); Tabloski, Mckinnon-Howe,
& Remington, 1995). Eight stud-
ies were quasi-experimental (Clair
& Bernstein, 1994; Denney, 1997;
Goddaer & Abraham, 1994; Hicks-
Moore, 2005; Olsen et al., 2000;
Ragneskog et al., 2001; Sung et al.
(2006); Tabloski et al., 1995), 1 was
experimental (Gerdner, 2000), 1 was
a case study (Gerdner, 1997), and 1
was a pilot study that used a mixed
methodology (Gerdner, 2005). Re-
garding the 6 studies excluded from
our findings, 5 did not specifically
measure agitation as an outcome
(Casby & Holm, 1994, Clark, Lipe,
& Bilbrey, 1998; Irish et al., 2006;
Kumar et al., 1999; Suzuki et al.,
2004), and 1 used structured musical
activities as the intervention (Bro-
tons & Pickett-Cooper, 1996).
In the studies reviewed, we found
both strengths and weaknesses re-
garding measurement tools, sample
sizes, and study designs. Internal
ization of the music intervention,
such as preferred, individualized
musical selections (Hicks-Moore,
2005; Sung et al., 2006) or the use of
an interventional protocol (Gerdner,
1997, 2000, 2005). In addition, Gerd-
ners 2000 and 2005 investigations
demonstrated convergent validity
with triangulation of data by adding
qualitative evidence in the form of
anecdotal notes.
Similarly, there were threats to
internal and external validity. Four
studies had samples of less than 10
(Denney, 1997; Gerdner, 1997, 2005;
Ragneskog et al., 2001), and 7 had
samples between 15 and 39 (Clair
& Bernstein, 1994; Gerdner, 2000;
Goddaer & Abraham, 1994; Hicks-
Moore, 2005; Olsen et al., 2000; Sung
et al., 2006; Tabloski et al., 1995). The
use of nonprobability, convenience
samples contributed to selection
bias and weakened generalizability.
Other factors, such as the presence
of observers, staff expectations, and
the novelty of the intervention, may
have exerted an effect as well.
Generally, the statistical meth-
ods used in the studies seemed to be
appropriate in relation to the tools
used to measure behavior. Two of
the studies used inferential statistics
in their analysis (Clair & Bernstein,
1994; Gerdner, 2005), whereas the
rest used nonparametric statistics to
describe their findings.

50 JOGNonline.com
Implications for Nursing
Several implications for nurs-
ing practice can be derived from the
studies reviewed:
l Music interventions may
decrease the need for physical and
chemical restraints (Hicks-Moore,
2005).
l When using music or any
intervention, continued assessment
is important. Not only should the
clients response be evaluated, but
other clients in the environment
should also be monitored as they
may find the music unpleasant
(Gerdner, 2005). Headphones may
be an important tool for the music
intervention to protect others in the
environment (Madan, 2005).
l A music intervention is easy to
incorporate into daily care, is inex-
pensive, and is noninvasive (Hicks-
Moore, 2005).
l The volume of music should
be adjusted to match the hearing
function of the individual resident
(Clair & Bernstein, 1994) and to
provide the optimal level of audi-
tory stimuli (Irish et al., 2006).
Overall, our review suggests sup-
portive evidence to recommend the
use of music as an intervention in
nursing practice. In fact, a national
guideline was recently established
outlining the use of an individual-
ized music intervention in dementia
(Gerdner, 2007). Also, the Univer-
sity of Iowa (2007) offers a quick
reference guide and consumer infor-
mation sheet describing an individu-
alized music intervention strategy in
dementia.
Opportunities for interdisciplin-
ary or collaborative practice are
available to nurses and activity ther-
apists using music as an interven-
tion. During interviews with both a
long-term care recreational coordi-
nator and a regional hospice nursing
administrator, the intentional use of
group and individual music interven-
tions for prevention and treatment of
agitated behaviors was discussed (A.
Craddick, personal communication,
November 15, 2006; S. Spillman,
Journal of Gerontological Nursing Vol. 34, No. 10, 2008
personal communication, November
15, 2006). Formalized plans of care
used in these settings involved nurs-
es, a music therapist, and an activity
therapist and included assessment of
triggering factors for agitated behav-
iors and a prescribed music interven-
tion, lasting 15 to 30 minutes, based
on client preferences.
Recommendations and
Conclusion
Although the literature has con-
tributed a great deal to the body of
knowledge regarding music inter-
ventions, there is still much to be
learned. For example:
l Is there an anxiety reduction
mechanism underlying the observed
effect of music (Irish et al., 2006)?
l Would the examination of
well-being in addition to ill-being
(as in measuring agitated behav-
iors) provide a better measure of
interventional effect (Sherratt et al.,
2004)?
l Are there direct and indirect
effects of music on the caregiver?
l What, if any, are the long-term
effects of music on clients behav-
iors?
l What is the most effective
dosage of music in regard to the
frequency and duration of the inter-
vention?
Current study findings point
toward the efficacy of individual-
ized music as a simple, low-cost al-
ternative to physical and chemical
restraints. The evidence supports
music as a therapeutic nursing inter-
vention that may serve to enhance
the quality of life for many clients
with Alzheimers dementia.
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ABOUT THE AUTHORS
Ms. Witzke is Instructor, William
Jewell College, Department of Nursing,
Liberty, Missouri; Ms. Rhone is Staff
Nurse, Wilson Medical Center, Neode-
sha, Kansas; Ms. Backhaus is Staff Nurse,
Liberty Hospital, Liberty, Missouri;
and Ms. Shaver is Assistant Professor,
Johnson County Community College,
Department of Nursing, Overland Park,
Kansas. All authors are also graduate
nursing students, University of Kansas
School of Nursing, Kansas City, Kansas.
The authors thank Geri B. Neuber-
ger, RN, MN, EdD, ARNP, Professor,
University of Kansas School of Nursing,
for her guidance in the development and
preparation of the manuscript.
Address correspondence to Rebecca A.
Rhone, RN, BSN, CWS, FACCWS, 2693
Quail, Fall River, KS 67047; e-mail:
rrhone@kumc.edu.
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