Impact of Multisensory Environments on Behavior for People With Dementia: A Systematic Literature Review

Impact of Multisensory Environments on Behavior for People With Dementia: A Systematic Literature... Abstract Purpose of the Study Behavioral and psychological symptoms of dementia (BPSD) affect quality of life for people with dementia. Nonpharmacological interventions are the preferred first line of treatment, and it is theorized that BPSD are directly influenced by sensory imbalance and improved by sensory equilibrium. The purpose of this article is to investigate the evidence regarding the use of multisensory environments (MSEs) as treatment for BPSD. Design and Methods A systematic literature review was performed using the PICO framework within PsycINFO, Web of Science, ERIC, PubMED, and Cinahl databases, as well as additional hand-searched documents. Included articles were published during 1990 to 2015 and report empirical studies of MSE BPSD interventions that include furniture, fixtures, and equipment to provide visual, auditory, tactile, and olfactory stimulation. Desired elements include ergonomic vibroacoustic furniture, bubble tubes, color-changing lights, and fiber optics. Results Twelve articles met the inclusion criteria for review. Evidence supports the positive impact of sensory stimulation as a nonpharmacological behavioral treatment for dementia. Many studies investigated both behavior and mood, and several investigated biomedical parameters including heart rate and cognition. Significant differences were not found in the between-group studies when MSE was compared with other one-to-one interventions. Results on long-term effects were mixed. Variations can be seen in terms of research methods, types of environmental interventions, duration, and specific characteristics of participants, thus confounding the reliability of findings. Implications Key findings and directions for future research are discussed including primary outcomes, study design, environmental intervention types, and relevant assessment tools. Multisensory environment, Sensory stimulation, Behavior, Sensoristasis, MSE Hitting, screaming, and wandering are just a few of the behavioral and psychological symptoms of dementia (BPSD) that may place a heavy burden on caregivers of persons living with dementia. Therapeutic interventions include both pharmacological and nonpharmacological treatments. Although some people with dementia benefit from pharmacological treatment, many drugs have been shown to provide only modest benefits, are not tolerated by a wide number of patients, and may even be harmful (Borson et al., 2013; Gitlin, Kales, & Lyketsos, 2012; Tinklenberg et al., 2007). Therefore, there is an increasing focus on nonpharmacological interventions. There are many types of nonpharmacological approaches to reducing BPSD. Although there is no consensus on how to categorize these interventions (Kales, Gitlin, & Lyketsos, 2015), Cabrera and colleagues (2015) categorized these approaches into one of five groups: (i) psychosocial and educational (either with individuals or in groups); (ii) physical activity; (iii) sensorial (light, music, therapeutic touch, and multisensory stimuli); (iv) staff-focused interventions; or, (v) complex interventions. Our review focuses on sensorial interventions. The theory supporting sensorial interventions posits that cognitive and functional declines associated with dementia are further aggravated by psychosomatic distress caused by a decrease in one’s ability to regulate sensory stimulation. This has been described using the Model of Imbalances in Sensoristasis (Kovach, 2000). People with dementia experience sensory imbalance due to many factors, including disturbances in circadian rhythm, neurophysiological weakening, or environmental factors (Kovach, 2000; Milev et al., 2008). Problem behaviors may occur as a result of sensory imbalance, and research indicates that environmental factors aimed at restoring equilibrium, such as multisensory environments (MSEs), may improve the quality of life (QoL) for persons with dementia and their caregivers. Multisensory environments are also referred to as multisensory stimulation environments or Snoezelen rooms. “Snoezelen,” a registered trademark of ROMPA/Flaghouse that originated in the Netherlands in the 1970s, combines the Dutch words “snuffelen” meaning to explore and “doezelen” meaning to relax (Jamshidi Manesh, Kalati, & Hosseini, 2015). Snoezelen rooms are purposefully designed, technologically integrated environments utilizing specific furniture, fixtures, and equipment (FF&E) to provide a controlled sensory experience. In our review, all of these types of interventions will be referred to as MSEs. Sensory equilibrium may be accomplished within an MSE through controlled visual, auditory, tactile, and olfactory stimuli designed to mitigate overactive (anxious, agitated, or aggressive) or underactive (apathetic, depressed, or anergic) behaviors. This may include interactive LED lighting elements that can be controlled by the participant, vibroacoustic furniture that provides the ability to feel musical vibrations, and aromatherapy, which gives desired scents. This type of environmental therapy has been shown to have a positive impact on BPSD by reducing wandering (Yao & Algase, 2006), lowering agitation during the bathing process (Cohen-Mansfield & Parpura-Gill, 2007), and increasing positive engagement. This leads to an improvement in cognition and function (Baker et al, 2001; Collier, McPherson, Ellis-Hill, Staal, & Bucks, 2010), perhaps reducing caregiver burden (Baker et al., 2001; Collier et al., 2010; Yao & Algase, 2006; Brennan, Su, & Horowitz, 2006). Unfortunately, there is limited research investigating the efficacy of MSEs. In this paper, we (i) provide a systematic review of the efficacy of MSEs and variations in its application; (ii) identify important gaps in knowledge; and (iii) offer recommendations for improving future MSE investigations and other environmental interventions. Methods A systematic literature review was performed using the PICO search model (Figure 1) which included studies identified in the following databases: PubMed, CINAHL, PsycINFO, Web of Science, and ERIC. Figure 1. View largeDownload slide Explanation of PICO search model (Centre for Evidence-Based Medicine, 2016). Figure 1. View largeDownload slide Explanation of PICO search model (Centre for Evidence-Based Medicine, 2016). Abstracts and reference lists of reviewed articles were also hand searched and included in the review. The assistance of a specialized research librarian was used to strengthen the quality of the search and validate the pertinence of databases and keywords used. Thesaurus, MeSH, and truncated terms were used where appropriate. A detailed explanation of the complete search strategy can be seen in Supplementary Appendix. A flowchart of the search strategy and organization of the Journal Citation Report (JCR) can be seen in Figure 2. Figure 2. View largeDownload slide Literature review search strategy. Based on Moher, Liberati, Tetzlaff, and Altman (2009). Figure 2. View largeDownload slide Literature review search strategy. Based on Moher, Liberati, Tetzlaff, and Altman (2009). Titles and abstracts of manuscripts were assessed for relevance to the topic of MSEs for reducing BPSD using the following inclusion criteria: Empirical quantitative, qualitative, or mixed-methods studies published in peer-reviewed journals between 1990 and 2015, written in English; Study participants were clinically diagnosed with dementia; The impact of MSE interventions on behavior of people with dementia was measured; and, MSE intervention incorporated at least three FF&E items including ergonomic vibroacoustic furniture, bubble tubes, color-changing lighting solutions, music, and/or fiber optics. If relevance was not clearly evident based on the initial review, the full article was read to determine whether it should be included. Once the initial group of articles was gathered, the full texts were read to ascertain final inclusion in the review. Twelve articles met the inclusion criteria. Data were extracted into a JCR to review study characteristics and rate levels of evidence for each article. We conducted an analysis of the existing evidence and an evaluation of the quality of the research identified (Table 1). Following this model, articles assigned levels of evidence 1 (systematic reviews), 4 (professional standards), and 6 (recommendations) were not included in this study, because the purpose of this review is to investigate original, empirical studies. Table 1. Levels of Evidence for Health Care Design (Marquardt, Bueter, & Motzek, 2014) adapted from Stichler (2010) Level Description of quality Included 1 Systematic reviews of multiple randomized controlled trials or nonrandomized studies; meta-analysis of multiple experimental or quasi-experimental studies; meta-synthesis of multiple qualitative studies leading to an integrative interpretation No 2 Well-designed experimental (randomized) or quasi-experimental (nonrandomized) studies with a low attrition rate, intention to treat analysis, blinding, masked randomization, and consistent results compared with other similar studies Yes 3a Observational studies with a cohort design; experimental or quasi-experimental studies that did not fulfill the criteria of Level 2 Yes 3b Cross-sectional studies or case–control studies; qualitative research that, based on a literature review, on a theoretical framework, reports a clear method and considers a diversity of views Yes 4 Professional standards or guidelines with studies to support recommendations No 5 Qualitative research that did not meet the criteria of Level 3b Yes 6 Recommendations from manufacturers or consultants who may have a financial interest or bias No Level Description of quality Included 1 Systematic reviews of multiple randomized controlled trials or nonrandomized studies; meta-analysis of multiple experimental or quasi-experimental studies; meta-synthesis of multiple qualitative studies leading to an integrative interpretation No 2 Well-designed experimental (randomized) or quasi-experimental (nonrandomized) studies with a low attrition rate, intention to treat analysis, blinding, masked randomization, and consistent results compared with other similar studies Yes 3a Observational studies with a cohort design; experimental or quasi-experimental studies that did not fulfill the criteria of Level 2 Yes 3b Cross-sectional studies or case–control studies; qualitative research that, based on a literature review, on a theoretical framework, reports a clear method and considers a diversity of views Yes 4 Professional standards or guidelines with studies to support recommendations No 5 Qualitative research that did not meet the criteria of Level 3b Yes 6 Recommendations from manufacturers or consultants who may have a financial interest or bias No View Large Table 1. Levels of Evidence for Health Care Design (Marquardt, Bueter, & Motzek, 2014) adapted from Stichler (2010) Level Description of quality Included 1 Systematic reviews of multiple randomized controlled trials or nonrandomized studies; meta-analysis of multiple experimental or quasi-experimental studies; meta-synthesis of multiple qualitative studies leading to an integrative interpretation No 2 Well-designed experimental (randomized) or quasi-experimental (nonrandomized) studies with a low attrition rate, intention to treat analysis, blinding, masked randomization, and consistent results compared with other similar studies Yes 3a Observational studies with a cohort design; experimental or quasi-experimental studies that did not fulfill the criteria of Level 2 Yes 3b Cross-sectional studies or case–control studies; qualitative research that, based on a literature review, on a theoretical framework, reports a clear method and considers a diversity of views Yes 4 Professional standards or guidelines with studies to support recommendations No 5 Qualitative research that did not meet the criteria of Level 3b Yes 6 Recommendations from manufacturers or consultants who may have a financial interest or bias No Level Description of quality Included 1 Systematic reviews of multiple randomized controlled trials or nonrandomized studies; meta-analysis of multiple experimental or quasi-experimental studies; meta-synthesis of multiple qualitative studies leading to an integrative interpretation No 2 Well-designed experimental (randomized) or quasi-experimental (nonrandomized) studies with a low attrition rate, intention to treat analysis, blinding, masked randomization, and consistent results compared with other similar studies Yes 3a Observational studies with a cohort design; experimental or quasi-experimental studies that did not fulfill the criteria of Level 2 Yes 3b Cross-sectional studies or case–control studies; qualitative research that, based on a literature review, on a theoretical framework, reports a clear method and considers a diversity of views Yes 4 Professional standards or guidelines with studies to support recommendations No 5 Qualitative research that did not meet the criteria of Level 3b Yes 6 Recommendations from manufacturers or consultants who may have a financial interest or bias No View Large Results Participants Participants in the reviewed studies were predominantly 65 years and older, and all had a medical diagnosis of moderate-to-severe dementia. Sample sizes range from 4 to 136, and the gender of participants was predominantly female. To quantify participants’ level of dementia, five studies used the Mini-Mental State Examination (MMSE) (Baillon et al., 2005; Baker et al., 2001; 2003; Cornell, 2004; Staal et al., 2007), two used the Global Deterioration Scale (GDS) (Maseda et al., 2014a), two used the Short Portable Mental Status Questionnaire (SPMSQ) (Riley-Doucet, 2009; Riley-Doucet & Dunn, 2013), one used the Diagnostic Statistical Manual of Mental Disorders 4th Edition (DSM IV) (Milev et al., 2008), one used the Clinical Dementia Rating Scale (CDR) (Baillon et al., 2005), one used the Behavior Rating Scale (BRS), Cognitive Assessment Scale (CAS), and Clifton Assessment Procedures for the Elderly (CAPE) in conjunction with the MMSE (Cornell, 2004), and two used a medical diagnosis of dementia without an additional assessment (Minner, Hoffstetter, Casey, & Jones, 2004; Ward-Smith et al., 2009). Settings The reviewed studies were conducted in Europe, Canada, and the United States (Figure 3). One out of 12 of the studies was conducted within a residential setting (Riley-Doucet, 2009), whereas the majority were conducted within institutional health care facilities. The type of institutional health care facilities varied, including adult day care centers, also known as day hospitals in the United Kingdom (Baker et al., 2001; Cornell, 2004; Riley-Doucet & Dunn, 2013; Ward-Smith et al., 2009), and skilled nursing facilities (Baillon et al., 2005; Maseda et al., 2014a; 2014b; Milev et al., 2008; Minner et al., 2004; Staal et al., 2007). One study included in the review used data from a mixed setting sample, that is, some participants were from an adult day center and some were from skilled nursing facilities (Baker et al., 2003). Figure 3. View largeDownload slide Global settings of included studies. Figure 3. View largeDownload slide Global settings of included studies. Approaches to MSE Therapy In order to understand the effect of MSE therapy for elders, it is important to clarify the defining factors that differentiate it from other therapies. Baker and colleagues (2001) define MSE therapy as a (i) purposefully designed environment offering visual, auditory, tactile, and olfactory stimulation, (ii) where staff follows the lead of the participants during therapy sessions in a nondirective approach where patients are encouraged to interact with sensory stimuli of their choice, and (iii) sensory stimuli are nonsequential and therefore place very low cognitive demands on participants. Of these three factors, the nondirective approach is critical. This differs from one-on-one activity sessions that do not involve MSEs where a staff member may actively participate in a card game or puzzle solving activity with the participant, because in the case of MSE therapy, the staff member takes on a passive role allowing the participant to independently engage with sensory stimuli. All studies identified within this review followed the three guidelines outlined, however, the approaches were varied in terms of approach. Some studies followed the protocol outlined by Baker and colleagues (1998) for a randomized, controlled trial that compared the effects of eight MSE sessions with control sessions (Baillon et al., 2005; Baker et al., 2001; 2003; Maseda et al., 2014a; 2014b). Some studies offered sessions at regular intervals during the week, commencing at the same time of day and for the same duration each week (Cornell, 2004; Milev et al., 2008; Staal et al., 2007), whereas others administered the therapy intermittently (Ward-Smith et al., 2009). Some studies administered the MSE therapy specifically when the BPSD occurred (Minner et al., 2004; Riley-Doucet & Dunn, 2013). Overall, the approach to data collection varied widely between 2 weeks to 1 year, and MSE intervention sessions lasted between 8 and 40 minutes. None of the studies evaluated demonstrated whether the MSE therapy specifically addressed either under- or over-stimulation. Study Design Of the 12 studies included, seven were randomized controlled studies (Baillon et al., 2005; Baker et al., 2001; 2003; Maseda et al., 2014a; 2014b; Milev et al., 2008; Ward-Smith et al., 2009), one within-subjects repeated-measures design (Riley-Doucet & Dunn, 2013), one mixed-design, between-groups study (Staal et al., 2007), one outcome-based quality improvement study (Minner et al., 2004), one single-case design study (Cornell, 2004), and one qualitative study (Riley-Doucet, 2009). Of the randomized controlled trial studies, a variety of designs and comparators were reported in the included studies. Baillon and colleagues (2005) used a crossover design with reminiscence therapy as the control group for two different groups undergoing two intervention sessions, each lasting 2 weeks. Ward-Smith and colleagues (2009) conducted a retrospective medical chart review of patients with documented BPSD receiving routine antipsychotic medication and either MSE therapy or not. Comparators reported in the between-group studies included care as usual (Milev et al., 2008) with activities including card playing, quizzes, or viewing photographs (Baker et al., 2001; 2003; Maseda et al., 2014a; 2014b). Some reviewed studies followed a pre-post design (Riley-Doucet & Dunn, 2013; Staal et al., 2007). Although the studies included in this review were innovative in approach, some weaknesses were identified. Overall, sample sizes were very low. Although this is not a concern in Cornell’s (2004) single-case design study, where each participant was assessed at a large number of intervals throughout the course of the study and became their own control (Kazdin, 2011), it is a concern for the randomized, pre-post and between-group studies. In these designs, a smaller sample size does not provide an adequately generalizable result to the larger population. Baker and colleagues’ study (2001) occurred over a two-and-a-half-year period, and consistent management of the intervention and procedures could be questioned. Baker and colleagues’ study (2003) included data from three adult day centers in the United Kingdom, the Netherlands, and Sweden between 1996 and 2001. The variance in settings, staff, application of the MSE therapy, and follow-up assessments could have confounded findings. Additional details for each of the 12 studies reviewed are shown in Table 2. Table 2. Characteristics of Included Studies First author (year) Level Methods Participants Intervention Outcomes Setting Assessments Results Baillon et al (2005) 2 RCT n = 20, Dementia diagnosis with significant levels of agitation and consistent levels of antipsychotic medication intake MSSE: Snoezelen Room, bubble tubes, projected lights, music, aromatherapy, and tactile objects selected based on individual sensory preferences, RT: Conversational activity, reflect on past experiences using cues relevant to participants’ individual interests Mood, behavior, heart rate SCU & ALF (Geri-psych), UK Dementia: MMSE (mod-severe) & CDR Both interventions: +Mood effect +Behavior effect ↔ Diff(s) BG ↓Heart rate Crossover randomized trial, 3 sessions of Snoezelen or RT for 2 weeks, 1 week off, then 3 sessions with either therapy for 2 weeks, 1-to-1 sessions up to 40 min Agitation: ABMI & CMAI Heart rate: heart rate monitor Mood & behavior: Interact Short Scale Baker et al (2003) 2 RCT n = 136, Dementia diagnosis without other major psychiatric issues MSSE: Room with bubble tubes, fiber optic sprays, gel and image projections, music, tactile stimulation, and aromatherapy Mood, behavior, cognition Day hospital (UK); Geri-psych ward (Netherlands, Sweden) Short Term: Behavior/ mood: Interact, Interact Short (UK/ Netherlands), GIP (Sweden) Long term: Cognition: MMSE Behavior: BRS, CAPE, BMD, REHAB All 3 sites, both groups: +Mood, +Behavior, ↔ Diff(s) BG; MSS Groups: UK & Netherlands ↓Bored/ inactive ↑Interpersonal ↑Memory recall Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks Activity: playing cards, quizzes, looking at photographs All activity groups: ↑ADL over MSS ↔ LT Effect BG Baker et al (2001) 2 RCT Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks, nondirective, enabling approach, generalization of effects over time n = 50, Dementia diagnosis, attending a day hospital 2+ times per week, no other major psychiatric issues, previous MSSE exposure within 3 months MSSE: Purposefully designed auditory, tactile, and olfactory stimulation with varied lighting, music, aromas, and textural objects, nonsequential stimuli, Activity: individually selected (e.g., puzzles) Mood, behavior, cognition Day hospital, UK Short-term assess: Behavior/mood: Interact (during sessions), Interact Short (10 min before and after) Long-term assess: Cognition: MMSE, Behavior: BRS, CAPE, BMD, REHAB, CAS Both groups: ↑Speech ↑Interpersonal ↑Env Engagement ↑Initiative, alert ↓Bored/inactive;MSS group: ↑Attentive to Env +Mood effect AH +Behavior effect AH No lasting LT effect Cornell (2004) 3a Single-case design, Snoezelen sessions, 2× per week for 4 weeks, 30-min sessions, Behavior/mood assessed 30 min before and after each session n = 4, Women with dementia diagnosis, attending day hospital MSSE: Snoezelen room, bubble tubes, mirrors, color-changing fiber optic sprays, music, image and gel projector for walls, mirror ball to project colored patterns, fiber optic carpet, and tactile objects Mood, behavior, response to equipment Day hospital, UK Dementia: Medical diagnosis with BRS, CAS, CAPE, & MMSE less than 10 (moderate stage) ↑Mood, ↑Behavior; Positive mood/behavior lasted at least 30 min, some reported effects lasted 24 h Individual characteristics: medical records Mood/behavior: Interact and Interact Short Response to equipment: PI generated tool Maseda et al (2014a) 2 RCT n = 30, 3 groups: MSSE, Activity, control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, i.e., cards, quiz, photos, Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Biomedical: Heart Rate and SpO2 Specialized residential elderly center, Spain Dementia: GDS Biomedical: Finger pulse oximeters Mood & Behavior: Interact Scale & Interact Short Scale ↑Mood, ↑Positive behavior, ↓Heart rate ↑SpO2 ↔ Diff(s) BG Controlled longitudinal, between-group study, 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, Design followed protocol suggested by Baker et al. (1998) Maseda et al (2014b) 2 RCT n = 30, 3 groups: MSSE, Activity, Control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, tactile board Activity: 1-to-1 individually selected (e.g., cards, quiz, photos) Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Emotional, Cognitive and Functional levels on ADLs, Agitation Specialized residential elderly center, Spain Dementia: GDS Agitation: CMAI MSSE/Activity: ↑Mood ↔Cog Level, ↑Pos Beh Diff(s) BG: MSSE Group ↑F(x) ADL, ↓CMAI Non Ag, Activity/Control ↔F(x) ADL Controlled longitudinal, between-group study; 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, protocol by Baker et al. (1998) Behavior: NPI-NH Mood: CSDD Cognitive Status: MMSEFunctional status with ADLs: Barthel Index Milev et al (2008) 2 RCT n = 21, 7 in each group: control, 1 session per week MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, (e.g., cards) Behavior LTC, CAN Dementia: Medical diagnosis (DSM IV) Behavior: DOS, CGI-I MSE groups: ↓DOS, ↑Pos Beh, Results increased with session intensity, results maintained over 12 weeks Pilot study, 24-week single-blind study, 30-min sessions, 1-3× per week for 12 weeks, no MSE for 12 additional weeks Minner et al (2004) 3a Outcome-based quality improvement study, Single facilitator model, duration varied, Behavior assessed before, during, and after for 1 year period n = 19, Residents with frequent behavior problems MSSE: Snoezelen Room, bubble tubes, rocker, bean bag chair, lightning ball, hanging plastic beads, vibrating pillow, lava lamp, aromatherapy diffuser, music, colored lights, and mirror Problem behaviors: Noisy breathing, Negative vocalization, Sad/frightened expression, Tense body language, and Fidgeting Residential nursing facility, USA CDS/DS-DAT ↓Neg behavior, ↑Pos behavior Riley-Doucet (2009) 4 Pilot study, qualitative research Design, number, and length of sessions varied, Avg 2× per week for 28 min over a total of 3 weeks n = 10, Participants: Aged 65+, dementia diagnosis; n = 10, Caregivers: aged 18+ MSE: Quiet room in home and portable Snoezelen kit: Bubble tube, evening breeze fan, chase light string, plasma ball, solar effects projector, music, vibrating tube, and aroma diffuser Participant and caregiver perceptions of MSE, Level of cognitive impairment, Participant use of MSE, Participant’s behavioral response/ apparent enjoyment Private homes, USA Dementia: Confirmed medical diagnosis & SPMSQ (mod-severe) Caregiver & participant MSE perceptions: semi- structured interviews Demographics: self- report questionnaire Themes: +PT satisfaction w/ MSE, ↑positive affective state, ↑PT cog, ↓CG burden, +CG satisfaction, +Interpersonal PT & CG relationships Use of MSE: COR Riley-Doucet (2013) 3a Pilot study, within- subjects, repeated- measures design, 4 weeks, Number and length of intervention sessions varied, Avg 5× per week for 15 min per session for 4 weeks, total 42 collective sessions, Intervention occurred when PT exhibited BPSD n = 8, Participants: Aged 65+, dementia diagnosis, BPSD history at DCC, attend DCC at least 2× week; n = 4, Caregivers: Aged 18+ MSE: Corner of large activity room enclosed with room dividers, Comfortable chair placed in area, portable Snoezelen kit: aroma diffuser, chase light string, evening breeze fan, fiber optic string light, plasma ball, solar effects projector, music, and vibrating tube Participant: Agitation, Reaction to MSE Caregivers: Satisfaction with MSE to manage BPSD Adult day care center, USA Dementia: Confirmed medical diagnosis & SPMSQ (mostly severe) Demographics: DCC records and questionnaire Length of time in and enjoyment of MSE & engagement time: Obs record Agitation: ABS Caregiver satisfaction: Caregiver exit survey ↓Agitation, +Reaction to MSE, +CG satisfaction; Hierarchy of preferred stimuli: Vibrating tube, music, fiber optic string light, chase light string, solar effects projector, aroma diffuser, plasma ball, and evening breeze Staal et al (2007) 2 RCT Between-group comparison, 2–3 sessions to assess sensory preferences, 6 sessions of MSBT at FT intervals of FT15, FT20-25, FT30 n = 24, MSBT group Avg age 80, Control group Avg age 72 MSBT: Individualized, 1-to-1 administered sensory stimulation (visual, auditory, olfactory, and tactile) Agitation, Apathy, ADL Acute care Geri-psych unit Dementia: Medical diagnosis with BPSD (mod-severe) Cognitive F(x): MMSE MSBT Group: ↓Agitation ↓Apathy ↑ADL Agitation: PAS Physical health: MAI ↔RADL, BDP Behavior: SANS-AD ADL: KI-ADL & RADL & BDP Ward-Smith et al (2009) 2 Between-group comparison study, controlled, not randomized, Intervention between 1 and 4 pm after antipsychotic meds, 84 s essions over 3 months n = 14, 7 in each group, 12/14 female, Avg PT age 81 MSSE: MSE Room, reclining bench, dimmable lights, bubble tubes, light wheel, vibrating pillows, fiber optic lights, aromatherapy, DVDs, comfortable seating, and wind chimes Incidences of problematic behavior SCU within a LTC, USA Dementia: Medical diagnosis MSE Group: ↓PsyB incidence ↔PsyB range; Control group: ↑PsyB incidence Behavior: PBAR and medical records First author (year) Level Methods Participants Intervention Outcomes Setting Assessments Results Baillon et al (2005) 2 RCT n = 20, Dementia diagnosis with significant levels of agitation and consistent levels of antipsychotic medication intake MSSE: Snoezelen Room, bubble tubes, projected lights, music, aromatherapy, and tactile objects selected based on individual sensory preferences, RT: Conversational activity, reflect on past experiences using cues relevant to participants’ individual interests Mood, behavior, heart rate SCU & ALF (Geri-psych), UK Dementia: MMSE (mod-severe) & CDR Both interventions: +Mood effect +Behavior effect ↔ Diff(s) BG ↓Heart rate Crossover randomized trial, 3 sessions of Snoezelen or RT for 2 weeks, 1 week off, then 3 sessions with either therapy for 2 weeks, 1-to-1 sessions up to 40 min Agitation: ABMI & CMAI Heart rate: heart rate monitor Mood & behavior: Interact Short Scale Baker et al (2003) 2 RCT n = 136, Dementia diagnosis without other major psychiatric issues MSSE: Room with bubble tubes, fiber optic sprays, gel and image projections, music, tactile stimulation, and aromatherapy Mood, behavior, cognition Day hospital (UK); Geri-psych ward (Netherlands, Sweden) Short Term: Behavior/ mood: Interact, Interact Short (UK/ Netherlands), GIP (Sweden) Long term: Cognition: MMSE Behavior: BRS, CAPE, BMD, REHAB All 3 sites, both groups: +Mood, +Behavior, ↔ Diff(s) BG; MSS Groups: UK & Netherlands ↓Bored/ inactive ↑Interpersonal ↑Memory recall Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks Activity: playing cards, quizzes, looking at photographs All activity groups: ↑ADL over MSS ↔ LT Effect BG Baker et al (2001) 2 RCT Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks, nondirective, enabling approach, generalization of effects over time n = 50, Dementia diagnosis, attending a day hospital 2+ times per week, no other major psychiatric issues, previous MSSE exposure within 3 months MSSE: Purposefully designed auditory, tactile, and olfactory stimulation with varied lighting, music, aromas, and textural objects, nonsequential stimuli, Activity: individually selected (e.g., puzzles) Mood, behavior, cognition Day hospital, UK Short-term assess: Behavior/mood: Interact (during sessions), Interact Short (10 min before and after) Long-term assess: Cognition: MMSE, Behavior: BRS, CAPE, BMD, REHAB, CAS Both groups: ↑Speech ↑Interpersonal ↑Env Engagement ↑Initiative, alert ↓Bored/inactive;MSS group: ↑Attentive to Env +Mood effect AH +Behavior effect AH No lasting LT effect Cornell (2004) 3a Single-case design, Snoezelen sessions, 2× per week for 4 weeks, 30-min sessions, Behavior/mood assessed 30 min before and after each session n = 4, Women with dementia diagnosis, attending day hospital MSSE: Snoezelen room, bubble tubes, mirrors, color-changing fiber optic sprays, music, image and gel projector for walls, mirror ball to project colored patterns, fiber optic carpet, and tactile objects Mood, behavior, response to equipment Day hospital, UK Dementia: Medical diagnosis with BRS, CAS, CAPE, & MMSE less than 10 (moderate stage) ↑Mood, ↑Behavior; Positive mood/behavior lasted at least 30 min, some reported effects lasted 24 h Individual characteristics: medical records Mood/behavior: Interact and Interact Short Response to equipment: PI generated tool Maseda et al (2014a) 2 RCT n = 30, 3 groups: MSSE, Activity, control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, i.e., cards, quiz, photos, Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Biomedical: Heart Rate and SpO2 Specialized residential elderly center, Spain Dementia: GDS Biomedical: Finger pulse oximeters Mood & Behavior: Interact Scale & Interact Short Scale ↑Mood, ↑Positive behavior, ↓Heart rate ↑SpO2 ↔ Diff(s) BG Controlled longitudinal, between-group study, 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, Design followed protocol suggested by Baker et al. (1998) Maseda et al (2014b) 2 RCT n = 30, 3 groups: MSSE, Activity, Control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, tactile board Activity: 1-to-1 individually selected (e.g., cards, quiz, photos) Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Emotional, Cognitive and Functional levels on ADLs, Agitation Specialized residential elderly center, Spain Dementia: GDS Agitation: CMAI MSSE/Activity: ↑Mood ↔Cog Level, ↑Pos Beh Diff(s) BG: MSSE Group ↑F(x) ADL, ↓CMAI Non Ag, Activity/Control ↔F(x) ADL Controlled longitudinal, between-group study; 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, protocol by Baker et al. (1998) Behavior: NPI-NH Mood: CSDD Cognitive Status: MMSEFunctional status with ADLs: Barthel Index Milev et al (2008) 2 RCT n = 21, 7 in each group: control, 1 session per week MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, (e.g., cards) Behavior LTC, CAN Dementia: Medical diagnosis (DSM IV) Behavior: DOS, CGI-I MSE groups: ↓DOS, ↑Pos Beh, Results increased with session intensity, results maintained over 12 weeks Pilot study, 24-week single-blind study, 30-min sessions, 1-3× per week for 12 weeks, no MSE for 12 additional weeks Minner et al (2004) 3a Outcome-based quality improvement study, Single facilitator model, duration varied, Behavior assessed before, during, and after for 1 year period n = 19, Residents with frequent behavior problems MSSE: Snoezelen Room, bubble tubes, rocker, bean bag chair, lightning ball, hanging plastic beads, vibrating pillow, lava lamp, aromatherapy diffuser, music, colored lights, and mirror Problem behaviors: Noisy breathing, Negative vocalization, Sad/frightened expression, Tense body language, and Fidgeting Residential nursing facility, USA CDS/DS-DAT ↓Neg behavior, ↑Pos behavior Riley-Doucet (2009) 4 Pilot study, qualitative research Design, number, and length of sessions varied, Avg 2× per week for 28 min over a total of 3 weeks n = 10, Participants: Aged 65+, dementia diagnosis; n = 10, Caregivers: aged 18+ MSE: Quiet room in home and portable Snoezelen kit: Bubble tube, evening breeze fan, chase light string, plasma ball, solar effects projector, music, vibrating tube, and aroma diffuser Participant and caregiver perceptions of MSE, Level of cognitive impairment, Participant use of MSE, Participant’s behavioral response/ apparent enjoyment Private homes, USA Dementia: Confirmed medical diagnosis & SPMSQ (mod-severe) Caregiver & participant MSE perceptions: semi- structured interviews Demographics: self- report questionnaire Themes: +PT satisfaction w/ MSE, ↑positive affective state, ↑PT cog, ↓CG burden, +CG satisfaction, +Interpersonal PT & CG relationships Use of MSE: COR Riley-Doucet (2013) 3a Pilot study, within- subjects, repeated- measures design, 4 weeks, Number and length of intervention sessions varied, Avg 5× per week for 15 min per session for 4 weeks, total 42 collective sessions, Intervention occurred when PT exhibited BPSD n = 8, Participants: Aged 65+, dementia diagnosis, BPSD history at DCC, attend DCC at least 2× week; n = 4, Caregivers: Aged 18+ MSE: Corner of large activity room enclosed with room dividers, Comfortable chair placed in area, portable Snoezelen kit: aroma diffuser, chase light string, evening breeze fan, fiber optic string light, plasma ball, solar effects projector, music, and vibrating tube Participant: Agitation, Reaction to MSE Caregivers: Satisfaction with MSE to manage BPSD Adult day care center, USA Dementia: Confirmed medical diagnosis & SPMSQ (mostly severe) Demographics: DCC records and questionnaire Length of time in and enjoyment of MSE & engagement time: Obs record Agitation: ABS Caregiver satisfaction: Caregiver exit survey ↓Agitation, +Reaction to MSE, +CG satisfaction; Hierarchy of preferred stimuli: Vibrating tube, music, fiber optic string light, chase light string, solar effects projector, aroma diffuser, plasma ball, and evening breeze Staal et al (2007) 2 RCT Between-group comparison, 2–3 sessions to assess sensory preferences, 6 sessions of MSBT at FT intervals of FT15, FT20-25, FT30 n = 24, MSBT group Avg age 80, Control group Avg age 72 MSBT: Individualized, 1-to-1 administered sensory stimulation (visual, auditory, olfactory, and tactile) Agitation, Apathy, ADL Acute care Geri-psych unit Dementia: Medical diagnosis with BPSD (mod-severe) Cognitive F(x): MMSE MSBT Group: ↓Agitation ↓Apathy ↑ADL Agitation: PAS Physical health: MAI ↔RADL, BDP Behavior: SANS-AD ADL: KI-ADL & RADL & BDP Ward-Smith et al (2009) 2 Between-group comparison study, controlled, not randomized, Intervention between 1 and 4 pm after antipsychotic meds, 84 s essions over 3 months n = 14, 7 in each group, 12/14 female, Avg PT age 81 MSSE: MSE Room, reclining bench, dimmable lights, bubble tubes, light wheel, vibrating pillows, fiber optic lights, aromatherapy, DVDs, comfortable seating, and wind chimes Incidences of problematic behavior SCU within a LTC, USA Dementia: Medical diagnosis MSE Group: ↓PsyB incidence ↔PsyB range; Control group: ↑PsyB incidence Behavior: PBAR and medical records Note: ↑ = increase, ↓ = decrease, ↔ = no change, + = positive effect. ADL = activities of daily living; AH = at home; ABMI = Agitation Behavior Mapping Instrument; ABS = Agitated Behavior Scale; Ag = aggressive; ALF = assisted living facility; Assess = assessment(s); Avg = average; BDP = Beck Dressing Performance Scale; Beh = behavior; BPSD = behavioral and psychological symptoms of dementia; BG = between group; BMD = Behavior and Mood Disturbance Scale; BRS = Behavior Rating Scale; CAN = Canada; CAPE = Clifton Assessment Procedures for the Elderly; CAS = Cognitive Assessment Scale; CDR = Clinical Dementia Rating; CDS = Comfort/Discomfort Scale; CG = caregiver; CGI-I = Clinical Global Impression-Improvement; CMAI = Cohen-Mansfield Agitation Inventory; Cog = cognition; COR = Caregiver Observation Record; CSDD = Cornell Scale for Depression in Dementia; DCC = Day Care Center; Diff(s) = differences; DOS = Daily Observation Scale; DS-DAT = Discomfort Scale-Dementia of the Alzheimer’s Type; DSM IV = Diagnostic Statistical Manual of Mental Disorders 4th Edition; Env = environment; F(x) = functioning; FT = fixed time; Geri-psych = geriatric psychiatry; GDS = Global Deterioration Scale; GIP = Swedish Behavior Observation Scale for Intramural Psycho-geriatrics; KI-ADL = Katz Index of Activities of Daily Living; LT = long term; LTC = long-term care facility; MAI = Multi-level Assessment Instrument; MMSE = Mini-Mental State Examination; Mod-severe = moderate to severe; MSBT = multisensory behavioral therapy; MSE = multisensory environment; MSS = multisensory stimulation; MSSE = multisensory stimulation environment; Neg behavior = negative behavior; Non Ag = nonaggressive behavior; NPI-NH = Neuropsychiatric Inventory-Nursing Home; Obs = observation; PAS = Pittsburg Agitation Scale; PBAR = Psychotic Behavior Assessment Record; PI = principle investigator; Pos behavior = positive behavior; PsyB = psychotic behavior; PT = participant; RADL = Refined Activities of Daily Living Assessment Scale; RCT = randomized controlled trial; REHAB = Rehabilitation Evaluation Hall and Baker Tool; RT = reminiscence therapy; SANS-AD = Scale for the Assessment of Negative Symptoms in Alzheimer’s Disease; SCU = specialty care unit; SPMSQ = Short Portable Mental Status Questionnaire; SpO2 = arterial oxygen saturation; SR = self-report. View Large Table 2. Characteristics of Included Studies First author (year) Level Methods Participants Intervention Outcomes Setting Assessments Results Baillon et al (2005) 2 RCT n = 20, Dementia diagnosis with significant levels of agitation and consistent levels of antipsychotic medication intake MSSE: Snoezelen Room, bubble tubes, projected lights, music, aromatherapy, and tactile objects selected based on individual sensory preferences, RT: Conversational activity, reflect on past experiences using cues relevant to participants’ individual interests Mood, behavior, heart rate SCU & ALF (Geri-psych), UK Dementia: MMSE (mod-severe) & CDR Both interventions: +Mood effect +Behavior effect ↔ Diff(s) BG ↓Heart rate Crossover randomized trial, 3 sessions of Snoezelen or RT for 2 weeks, 1 week off, then 3 sessions with either therapy for 2 weeks, 1-to-1 sessions up to 40 min Agitation: ABMI & CMAI Heart rate: heart rate monitor Mood & behavior: Interact Short Scale Baker et al (2003) 2 RCT n = 136, Dementia diagnosis without other major psychiatric issues MSSE: Room with bubble tubes, fiber optic sprays, gel and image projections, music, tactile stimulation, and aromatherapy Mood, behavior, cognition Day hospital (UK); Geri-psych ward (Netherlands, Sweden) Short Term: Behavior/ mood: Interact, Interact Short (UK/ Netherlands), GIP (Sweden) Long term: Cognition: MMSE Behavior: BRS, CAPE, BMD, REHAB All 3 sites, both groups: +Mood, +Behavior, ↔ Diff(s) BG; MSS Groups: UK & Netherlands ↓Bored/ inactive ↑Interpersonal ↑Memory recall Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks Activity: playing cards, quizzes, looking at photographs All activity groups: ↑ADL over MSS ↔ LT Effect BG Baker et al (2001) 2 RCT Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks, nondirective, enabling approach, generalization of effects over time n = 50, Dementia diagnosis, attending a day hospital 2+ times per week, no other major psychiatric issues, previous MSSE exposure within 3 months MSSE: Purposefully designed auditory, tactile, and olfactory stimulation with varied lighting, music, aromas, and textural objects, nonsequential stimuli, Activity: individually selected (e.g., puzzles) Mood, behavior, cognition Day hospital, UK Short-term assess: Behavior/mood: Interact (during sessions), Interact Short (10 min before and after) Long-term assess: Cognition: MMSE, Behavior: BRS, CAPE, BMD, REHAB, CAS Both groups: ↑Speech ↑Interpersonal ↑Env Engagement ↑Initiative, alert ↓Bored/inactive;MSS group: ↑Attentive to Env +Mood effect AH +Behavior effect AH No lasting LT effect Cornell (2004) 3a Single-case design, Snoezelen sessions, 2× per week for 4 weeks, 30-min sessions, Behavior/mood assessed 30 min before and after each session n = 4, Women with dementia diagnosis, attending day hospital MSSE: Snoezelen room, bubble tubes, mirrors, color-changing fiber optic sprays, music, image and gel projector for walls, mirror ball to project colored patterns, fiber optic carpet, and tactile objects Mood, behavior, response to equipment Day hospital, UK Dementia: Medical diagnosis with BRS, CAS, CAPE, & MMSE less than 10 (moderate stage) ↑Mood, ↑Behavior; Positive mood/behavior lasted at least 30 min, some reported effects lasted 24 h Individual characteristics: medical records Mood/behavior: Interact and Interact Short Response to equipment: PI generated tool Maseda et al (2014a) 2 RCT n = 30, 3 groups: MSSE, Activity, control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, i.e., cards, quiz, photos, Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Biomedical: Heart Rate and SpO2 Specialized residential elderly center, Spain Dementia: GDS Biomedical: Finger pulse oximeters Mood & Behavior: Interact Scale & Interact Short Scale ↑Mood, ↑Positive behavior, ↓Heart rate ↑SpO2 ↔ Diff(s) BG Controlled longitudinal, between-group study, 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, Design followed protocol suggested by Baker et al. (1998) Maseda et al (2014b) 2 RCT n = 30, 3 groups: MSSE, Activity, Control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, tactile board Activity: 1-to-1 individually selected (e.g., cards, quiz, photos) Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Emotional, Cognitive and Functional levels on ADLs, Agitation Specialized residential elderly center, Spain Dementia: GDS Agitation: CMAI MSSE/Activity: ↑Mood ↔Cog Level, ↑Pos Beh Diff(s) BG: MSSE Group ↑F(x) ADL, ↓CMAI Non Ag, Activity/Control ↔F(x) ADL Controlled longitudinal, between-group study; 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, protocol by Baker et al. (1998) Behavior: NPI-NH Mood: CSDD Cognitive Status: MMSEFunctional status with ADLs: Barthel Index Milev et al (2008) 2 RCT n = 21, 7 in each group: control, 1 session per week MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, (e.g., cards) Behavior LTC, CAN Dementia: Medical diagnosis (DSM IV) Behavior: DOS, CGI-I MSE groups: ↓DOS, ↑Pos Beh, Results increased with session intensity, results maintained over 12 weeks Pilot study, 24-week single-blind study, 30-min sessions, 1-3× per week for 12 weeks, no MSE for 12 additional weeks Minner et al (2004) 3a Outcome-based quality improvement study, Single facilitator model, duration varied, Behavior assessed before, during, and after for 1 year period n = 19, Residents with frequent behavior problems MSSE: Snoezelen Room, bubble tubes, rocker, bean bag chair, lightning ball, hanging plastic beads, vibrating pillow, lava lamp, aromatherapy diffuser, music, colored lights, and mirror Problem behaviors: Noisy breathing, Negative vocalization, Sad/frightened expression, Tense body language, and Fidgeting Residential nursing facility, USA CDS/DS-DAT ↓Neg behavior, ↑Pos behavior Riley-Doucet (2009) 4 Pilot study, qualitative research Design, number, and length of sessions varied, Avg 2× per week for 28 min over a total of 3 weeks n = 10, Participants: Aged 65+, dementia diagnosis; n = 10, Caregivers: aged 18+ MSE: Quiet room in home and portable Snoezelen kit: Bubble tube, evening breeze fan, chase light string, plasma ball, solar effects projector, music, vibrating tube, and aroma diffuser Participant and caregiver perceptions of MSE, Level of cognitive impairment, Participant use of MSE, Participant’s behavioral response/ apparent enjoyment Private homes, USA Dementia: Confirmed medical diagnosis & SPMSQ (mod-severe) Caregiver & participant MSE perceptions: semi- structured interviews Demographics: self- report questionnaire Themes: +PT satisfaction w/ MSE, ↑positive affective state, ↑PT cog, ↓CG burden, +CG satisfaction, +Interpersonal PT & CG relationships Use of MSE: COR Riley-Doucet (2013) 3a Pilot study, within- subjects, repeated- measures design, 4 weeks, Number and length of intervention sessions varied, Avg 5× per week for 15 min per session for 4 weeks, total 42 collective sessions, Intervention occurred when PT exhibited BPSD n = 8, Participants: Aged 65+, dementia diagnosis, BPSD history at DCC, attend DCC at least 2× week; n = 4, Caregivers: Aged 18+ MSE: Corner of large activity room enclosed with room dividers, Comfortable chair placed in area, portable Snoezelen kit: aroma diffuser, chase light string, evening breeze fan, fiber optic string light, plasma ball, solar effects projector, music, and vibrating tube Participant: Agitation, Reaction to MSE Caregivers: Satisfaction with MSE to manage BPSD Adult day care center, USA Dementia: Confirmed medical diagnosis & SPMSQ (mostly severe) Demographics: DCC records and questionnaire Length of time in and enjoyment of MSE & engagement time: Obs record Agitation: ABS Caregiver satisfaction: Caregiver exit survey ↓Agitation, +Reaction to MSE, +CG satisfaction; Hierarchy of preferred stimuli: Vibrating tube, music, fiber optic string light, chase light string, solar effects projector, aroma diffuser, plasma ball, and evening breeze Staal et al (2007) 2 RCT Between-group comparison, 2–3 sessions to assess sensory preferences, 6 sessions of MSBT at FT intervals of FT15, FT20-25, FT30 n = 24, MSBT group Avg age 80, Control group Avg age 72 MSBT: Individualized, 1-to-1 administered sensory stimulation (visual, auditory, olfactory, and tactile) Agitation, Apathy, ADL Acute care Geri-psych unit Dementia: Medical diagnosis with BPSD (mod-severe) Cognitive F(x): MMSE MSBT Group: ↓Agitation ↓Apathy ↑ADL Agitation: PAS Physical health: MAI ↔RADL, BDP Behavior: SANS-AD ADL: KI-ADL & RADL & BDP Ward-Smith et al (2009) 2 Between-group comparison study, controlled, not randomized, Intervention between 1 and 4 pm after antipsychotic meds, 84 s essions over 3 months n = 14, 7 in each group, 12/14 female, Avg PT age 81 MSSE: MSE Room, reclining bench, dimmable lights, bubble tubes, light wheel, vibrating pillows, fiber optic lights, aromatherapy, DVDs, comfortable seating, and wind chimes Incidences of problematic behavior SCU within a LTC, USA Dementia: Medical diagnosis MSE Group: ↓PsyB incidence ↔PsyB range; Control group: ↑PsyB incidence Behavior: PBAR and medical records First author (year) Level Methods Participants Intervention Outcomes Setting Assessments Results Baillon et al (2005) 2 RCT n = 20, Dementia diagnosis with significant levels of agitation and consistent levels of antipsychotic medication intake MSSE: Snoezelen Room, bubble tubes, projected lights, music, aromatherapy, and tactile objects selected based on individual sensory preferences, RT: Conversational activity, reflect on past experiences using cues relevant to participants’ individual interests Mood, behavior, heart rate SCU & ALF (Geri-psych), UK Dementia: MMSE (mod-severe) & CDR Both interventions: +Mood effect +Behavior effect ↔ Diff(s) BG ↓Heart rate Crossover randomized trial, 3 sessions of Snoezelen or RT for 2 weeks, 1 week off, then 3 sessions with either therapy for 2 weeks, 1-to-1 sessions up to 40 min Agitation: ABMI & CMAI Heart rate: heart rate monitor Mood & behavior: Interact Short Scale Baker et al (2003) 2 RCT n = 136, Dementia diagnosis without other major psychiatric issues MSSE: Room with bubble tubes, fiber optic sprays, gel and image projections, music, tactile stimulation, and aromatherapy Mood, behavior, cognition Day hospital (UK); Geri-psych ward (Netherlands, Sweden) Short Term: Behavior/ mood: Interact, Interact Short (UK/ Netherlands), GIP (Sweden) Long term: Cognition: MMSE Behavior: BRS, CAPE, BMD, REHAB All 3 sites, both groups: +Mood, +Behavior, ↔ Diff(s) BG; MSS Groups: UK & Netherlands ↓Bored/ inactive ↑Interpersonal ↑Memory recall Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks Activity: playing cards, quizzes, looking at photographs All activity groups: ↑ADL over MSS ↔ LT Effect BG Baker et al (2001) 2 RCT Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks, nondirective, enabling approach, generalization of effects over time n = 50, Dementia diagnosis, attending a day hospital 2+ times per week, no other major psychiatric issues, previous MSSE exposure within 3 months MSSE: Purposefully designed auditory, tactile, and olfactory stimulation with varied lighting, music, aromas, and textural objects, nonsequential stimuli, Activity: individually selected (e.g., puzzles) Mood, behavior, cognition Day hospital, UK Short-term assess: Behavior/mood: Interact (during sessions), Interact Short (10 min before and after) Long-term assess: Cognition: MMSE, Behavior: BRS, CAPE, BMD, REHAB, CAS Both groups: ↑Speech ↑Interpersonal ↑Env Engagement ↑Initiative, alert ↓Bored/inactive;MSS group: ↑Attentive to Env +Mood effect AH +Behavior effect AH No lasting LT effect Cornell (2004) 3a Single-case design, Snoezelen sessions, 2× per week for 4 weeks, 30-min sessions, Behavior/mood assessed 30 min before and after each session n = 4, Women with dementia diagnosis, attending day hospital MSSE: Snoezelen room, bubble tubes, mirrors, color-changing fiber optic sprays, music, image and gel projector for walls, mirror ball to project colored patterns, fiber optic carpet, and tactile objects Mood, behavior, response to equipment Day hospital, UK Dementia: Medical diagnosis with BRS, CAS, CAPE, & MMSE less than 10 (moderate stage) ↑Mood, ↑Behavior; Positive mood/behavior lasted at least 30 min, some reported effects lasted 24 h Individual characteristics: medical records Mood/behavior: Interact and Interact Short Response to equipment: PI generated tool Maseda et al (2014a) 2 RCT n = 30, 3 groups: MSSE, Activity, control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, i.e., cards, quiz, photos, Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Biomedical: Heart Rate and SpO2 Specialized residential elderly center, Spain Dementia: GDS Biomedical: Finger pulse oximeters Mood & Behavior: Interact Scale & Interact Short Scale ↑Mood, ↑Positive behavior, ↓Heart rate ↑SpO2 ↔ Diff(s) BG Controlled longitudinal, between-group study, 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, Design followed protocol suggested by Baker et al. (1998) Maseda et al (2014b) 2 RCT n = 30, 3 groups: MSSE, Activity, Control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, tactile board Activity: 1-to-1 individually selected (e.g., cards, quiz, photos) Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Emotional, Cognitive and Functional levels on ADLs, Agitation Specialized residential elderly center, Spain Dementia: GDS Agitation: CMAI MSSE/Activity: ↑Mood ↔Cog Level, ↑Pos Beh Diff(s) BG: MSSE Group ↑F(x) ADL, ↓CMAI Non Ag, Activity/Control ↔F(x) ADL Controlled longitudinal, between-group study; 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, protocol by Baker et al. (1998) Behavior: NPI-NH Mood: CSDD Cognitive Status: MMSEFunctional status with ADLs: Barthel Index Milev et al (2008) 2 RCT n = 21, 7 in each group: control, 1 session per week MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, (e.g., cards) Behavior LTC, CAN Dementia: Medical diagnosis (DSM IV) Behavior: DOS, CGI-I MSE groups: ↓DOS, ↑Pos Beh, Results increased with session intensity, results maintained over 12 weeks Pilot study, 24-week single-blind study, 30-min sessions, 1-3× per week for 12 weeks, no MSE for 12 additional weeks Minner et al (2004) 3a Outcome-based quality improvement study, Single facilitator model, duration varied, Behavior assessed before, during, and after for 1 year period n = 19, Residents with frequent behavior problems MSSE: Snoezelen Room, bubble tubes, rocker, bean bag chair, lightning ball, hanging plastic beads, vibrating pillow, lava lamp, aromatherapy diffuser, music, colored lights, and mirror Problem behaviors: Noisy breathing, Negative vocalization, Sad/frightened expression, Tense body language, and Fidgeting Residential nursing facility, USA CDS/DS-DAT ↓Neg behavior, ↑Pos behavior Riley-Doucet (2009) 4 Pilot study, qualitative research Design, number, and length of sessions varied, Avg 2× per week for 28 min over a total of 3 weeks n = 10, Participants: Aged 65+, dementia diagnosis; n = 10, Caregivers: aged 18+ MSE: Quiet room in home and portable Snoezelen kit: Bubble tube, evening breeze fan, chase light string, plasma ball, solar effects projector, music, vibrating tube, and aroma diffuser Participant and caregiver perceptions of MSE, Level of cognitive impairment, Participant use of MSE, Participant’s behavioral response/ apparent enjoyment Private homes, USA Dementia: Confirmed medical diagnosis & SPMSQ (mod-severe) Caregiver & participant MSE perceptions: semi- structured interviews Demographics: self- report questionnaire Themes: +PT satisfaction w/ MSE, ↑positive affective state, ↑PT cog, ↓CG burden, +CG satisfaction, +Interpersonal PT & CG relationships Use of MSE: COR Riley-Doucet (2013) 3a Pilot study, within- subjects, repeated- measures design, 4 weeks, Number and length of intervention sessions varied, Avg 5× per week for 15 min per session for 4 weeks, total 42 collective sessions, Intervention occurred when PT exhibited BPSD n = 8, Participants: Aged 65+, dementia diagnosis, BPSD history at DCC, attend DCC at least 2× week; n = 4, Caregivers: Aged 18+ MSE: Corner of large activity room enclosed with room dividers, Comfortable chair placed in area, portable Snoezelen kit: aroma diffuser, chase light string, evening breeze fan, fiber optic string light, plasma ball, solar effects projector, music, and vibrating tube Participant: Agitation, Reaction to MSE Caregivers: Satisfaction with MSE to manage BPSD Adult day care center, USA Dementia: Confirmed medical diagnosis & SPMSQ (mostly severe) Demographics: DCC records and questionnaire Length of time in and enjoyment of MSE & engagement time: Obs record Agitation: ABS Caregiver satisfaction: Caregiver exit survey ↓Agitation, +Reaction to MSE, +CG satisfaction; Hierarchy of preferred stimuli: Vibrating tube, music, fiber optic string light, chase light string, solar effects projector, aroma diffuser, plasma ball, and evening breeze Staal et al (2007) 2 RCT Between-group comparison, 2–3 sessions to assess sensory preferences, 6 sessions of MSBT at FT intervals of FT15, FT20-25, FT30 n = 24, MSBT group Avg age 80, Control group Avg age 72 MSBT: Individualized, 1-to-1 administered sensory stimulation (visual, auditory, olfactory, and tactile) Agitation, Apathy, ADL Acute care Geri-psych unit Dementia: Medical diagnosis with BPSD (mod-severe) Cognitive F(x): MMSE MSBT Group: ↓Agitation ↓Apathy ↑ADL Agitation: PAS Physical health: MAI ↔RADL, BDP Behavior: SANS-AD ADL: KI-ADL & RADL & BDP Ward-Smith et al (2009) 2 Between-group comparison study, controlled, not randomized, Intervention between 1 and 4 pm after antipsychotic meds, 84 s essions over 3 months n = 14, 7 in each group, 12/14 female, Avg PT age 81 MSSE: MSE Room, reclining bench, dimmable lights, bubble tubes, light wheel, vibrating pillows, fiber optic lights, aromatherapy, DVDs, comfortable seating, and wind chimes Incidences of problematic behavior SCU within a LTC, USA Dementia: Medical diagnosis MSE Group: ↓PsyB incidence ↔PsyB range; Control group: ↑PsyB incidence Behavior: PBAR and medical records Note: ↑ = increase, ↓ = decrease, ↔ = no change, + = positive effect. ADL = activities of daily living; AH = at home; ABMI = Agitation Behavior Mapping Instrument; ABS = Agitated Behavior Scale; Ag = aggressive; ALF = assisted living facility; Assess = assessment(s); Avg = average; BDP = Beck Dressing Performance Scale; Beh = behavior; BPSD = behavioral and psychological symptoms of dementia; BG = between group; BMD = Behavior and Mood Disturbance Scale; BRS = Behavior Rating Scale; CAN = Canada; CAPE = Clifton Assessment Procedures for the Elderly; CAS = Cognitive Assessment Scale; CDR = Clinical Dementia Rating; CDS = Comfort/Discomfort Scale; CG = caregiver; CGI-I = Clinical Global Impression-Improvement; CMAI = Cohen-Mansfield Agitation Inventory; Cog = cognition; COR = Caregiver Observation Record; CSDD = Cornell Scale for Depression in Dementia; DCC = Day Care Center; Diff(s) = differences; DOS = Daily Observation Scale; DS-DAT = Discomfort Scale-Dementia of the Alzheimer’s Type; DSM IV = Diagnostic Statistical Manual of Mental Disorders 4th Edition; Env = environment; F(x) = functioning; FT = fixed time; Geri-psych = geriatric psychiatry; GDS = Global Deterioration Scale; GIP = Swedish Behavior Observation Scale for Intramural Psycho-geriatrics; KI-ADL = Katz Index of Activities of Daily Living; LT = long term; LTC = long-term care facility; MAI = Multi-level Assessment Instrument; MMSE = Mini-Mental State Examination; Mod-severe = moderate to severe; MSBT = multisensory behavioral therapy; MSE = multisensory environment; MSS = multisensory stimulation; MSSE = multisensory stimulation environment; Neg behavior = negative behavior; Non Ag = nonaggressive behavior; NPI-NH = Neuropsychiatric Inventory-Nursing Home; Obs = observation; PAS = Pittsburg Agitation Scale; PBAR = Psychotic Behavior Assessment Record; PI = principle investigator; Pos behavior = positive behavior; PsyB = psychotic behavior; PT = participant; RADL = Refined Activities of Daily Living Assessment Scale; RCT = randomized controlled trial; REHAB = Rehabilitation Evaluation Hall and Baker Tool; RT = reminiscence therapy; SANS-AD = Scale for the Assessment of Negative Symptoms in Alzheimer’s Disease; SCU = specialty care unit; SPMSQ = Short Portable Mental Status Questionnaire; SpO2 = arterial oxygen saturation; SR = self-report. View Large Effects of MSE Therapy Generally, the studies reported positive results regarding the impact of MSE therapy on BPSD. Specific results included a decrease in the number of BPSD incidences (Maseda et al., 2014a; Minner et al., 2004; Riley-Doucet & Dunn, 2013; Staal et al., 2007; Ward-Smith et al., 2009), positive changes in mood/behavior (Baillon et al., 2005; Baker et al., 2001; 2003; Cornell, 2004; Maseda et al., 2014b), and positive changes in engagement (Milev et al., 2008). Significant differences were not found in the between-group studies when MSEs were compared with other one-to-one interventions (Maseda et al., 2014a; Staal et al., 2007; Ward-Smith et al., 2009). Results on long-term effects were mixed, as some found that observed positive effects did not last significantly beyond the treatment sessions (Baker et al., 2001; 2003; Cornell, 2004). Although one study demonstrated long-term benefits of MSE therapy at 12 weeks after treatment (Milev et al., 2008), no other studies found long-term effects. Three studies examined how participants responded to the MSE equipment: one in a qualitative self-reporting format (Riley-Doucet, 2009) and two with an observational tool developed by the principal investigators (Cornell, 2004; Riley-Doucet & Dunn, 2013). Behavior and Mood Behavior and/or mood were the most commonly assessed outcome variables across the 12 studies included within this review. Several investigators used the Interact and Interact Short (Maseda et al., 2014a) to evaluate behavior and/or mood. The Interact is an observational assessment tool designed to measure the impact of the intervention on people with dementia using a mood/behavior rating scale. Other tools used to assess behaviors and mood included the Cohen-Mansfield Agitation Index (CMAI) (Baillon et al., 2005; Sánchez et al., 2013), Neuropsychiatric Inventory-Nursing Home (NPI-NH), Cornell Scale for Depression in Dementia (CSDD) (Maseda et al., 2014b), Psychotic Behavior Assessment Record (PBAR) (Ward-Smith et al., 2009), Daily Observation Scale (DOS) (Milev et al., 2008), and Clinical Global Impression-Improvement (CGI-I) (Milev et al., 2008). Activities of daily living, such as feeding or dressing one’s self, were assessed using the Barthel Index (Maseda et al., 2014b), Katz Index of Activities of Daily Living (KI-ADL), Refined Activities of Daily Living Assessment Scale (RADL), and Beck Dressing Performance Scale (BDP) (Staal et al., 2007). Trained staff and researchers completed the standardized assessments, whereas participants and family members completed preference assessments. Six of the included studies examined MSE impact on both behavior and mood (Baillon et al., 2005; Baker et al., 2001; 2003; Cornell, 2004; Maseda et al., 2014a; Sánchez et al., 2013). Two evaluated MSE impact on agitation (Riley-Doucet & Dunn, 2013; Staal et al., 2007), two studied incidences of problematic behavior alone (Milev et al., 2008; Ward-Smith et al., 2009), and two incorporated caregiver perceptions of the MSE intervention among family caregivers (Riley-Doucet, 2009) and dementia-care staff members (Riley-Doucet & Dunn, 2013). Overall, the studies showed consistent improvement in mood, an increase in positive behaviors, and/or a reduction of BPSD (Baillon et al., 2005; Baker et al., 2001; 2003; Cornell, 2004; Maseda et al., 2014a; 2014b; Milev et al., 2008; Minner et al., 2004), either during or following MSE therapy. Although all of the included studies demonstrated a positive impact of MSE therapy on BPSD, several showed no difference in impact compared with a one-on-one control activity, thus reporting that the study and control interventions were equally effective. Alternative therapies shown to be equally effective were reminiscence therapy (Baillon et al., 2005) and directive activities requiring intellectual/physical demands (i.e., playing cards, quizzes, and looking at photographs) (Baker et al., 2001; 2003; Maseda et al., 2014a; 2014b). One study reported that the impact of MSE therapy increased with more sessions per week (over 8 weeks) and a longer duration of therapy over time (Milev et al., 2008). Biomedical Response As an adjunct to behavior, several studies investigated biomedical parameters including heart rate (Baillon et al., 2005; Maseda et al., 2014a) and cognition (Baker et al., 2001; 2003; Maseda et al., 2014a). Baillon and colleagues (2005) demonstrated that both the MSE and reminiscence therapy showed a decrease in the mean heart rate by the end of each session, with more post-session carryover effect after MSE therapy. Other researchers (Baker et al., 2001; 2003) found that differences in cognition between MSE group versus activity groups without MSE were not significant in either study. Quality of the Evidence Eight out of 12 studies were rated Level 2 evidence, three were Level 3a, and one was Level 4 evidence, indicating that the majority of articles were of relatively high levels of quality, as seen in Figure 4. Figure 4. View largeDownload slide Levels of evidence of reviewed studies. Figure 4. View largeDownload slide Levels of evidence of reviewed studies. Discussion Summary of Efficacy and Gaps in the Literature Overall, published studies support efficacy of MSEs in reducing BPSD, potentially improving QoL for participants and caregivers. However, the studies do not offer conclusions on the timing of MSE therapy (i.e., when to use it), the frequency with which it should be used, or how to identify candidates who would likely benefit from MSE therapy. Furthermore, reviewed studies do not show that the intervention was more effective than other potentially less expensive therapies, such as reading to and talking with an individual. Results were mixed regarding whether the MSE interventions provided lasting effects for participants. This systematic review of MSE interventions revealed several gaps in the literature. The topic has been researched widely since 1990, as evidenced by the 1,226 articles found after the original database search. However, only 12 of the 1,226 articles identified shared a comparable level of intervention design and analogous empirical quality. A weakness in the studies using activities as comparators is the level of cognition required to complete the tasks. For example, activity-based sessions require higher levels of cognitive functioning in order for the participant to understand instructions and complete tasks, such as playing cards or completing puzzles. This is a major weakness in studies comparing MSE therapy with activity sessions and should be abandoned in further research. Recommendations for the Design of Future Studies An examination of the study designs reveals inconsistencies and provides directions for future research. For instance, the physical locations of the settings, duration of therapy sessions, and duration of the data collection period varied widely, ranging from temporary MSEs made by placing room dividers in the back corner of a therapy room, to rooms in people’s homes, to specifically designated rooms within a medical facility. Not all studies reported whether MSE interventions were provided consistently on the same day of each week, at the same time of day, and for the same duration each day, which should be made clear in future studies. There is a need for more research that follows a controlled, longitudinal investigation of the impact of MSE environments on behavior in a methodologically transparent, rigorous, and organized way that can be replicated. Furthermore, future studies should meet the criteria for higher levels of evidence quality. Important questions that have not yet been studied include the identification of the specific equipment that is most impactful, the role of participants’ sensory preference on the effectiveness of MSE therapy, and the use of study methods that are specifically designed to evaluate small sample sizes. Another important question to address is whether there are specific rooms where problem behaviors typically occur for people living with dementia (i.e., the bathroom) where interventions might be implemented to achieve more significant results. Investigations pursuing these questions can potentially help establish the value of MSE therapy in the future. Another important question is whether taking people to an MSE to achieve sensoristasis, then placing them back in the environment that may have contributed to their sensory disequilibrium, is an appropriate therapeutic approach. It is conceivable that, instead, more effort should be directed toward finding design solutions that allow individuals to have greater control at all times over the sensory conditions of their immediate surroundings, assuming that they could understand how their actions might alter their environment in a manner that is beneficial for them. Evidence About Other Environmental Interventions There is additional evidence regarding the impact of purposefully built environments as behavioral interventions for people with dementia. Clark, Lipe, and Bilbrey (1998) investigated the impact of music as a nonpharmacological behavioral intervention for people with dementia. The music condition demonstrated significant decrease in a majority of aggressive behaviors, and hitting. It was observed that the participants’ moods were significantly better during the music condition and they were overall more cooperative during assisted bathing. Whall and colleagues (1997) and Cohen-Mansfield and Parpura-Gill (2007) investigated the impact of natural elements within the bathing room on acts of agitated, aggressive behavior by patients with dementia. The natural elements used as positive distractions included sounds of birds, babbling brooks, corresponding images, and food. The study revealed decreased agitation during the natural element intervention. Environmental cues such as signs, labels, and color coding can be used as effective environmental interventions to support wayfinding and decrease wandering (Kincaid & Peacock, 2003; Marquardt, 2011; Passini, Pigot, Rainville, & Tétreault, 2000). These studies support the role of the environment as a behavioral intervention leading to reduced BPSD for people with dementia which can lead to improved care outcomes (Marquardt et al., 2014). It should be noted that environmental interventions should be implemented with careful consideration to the individual preferences and sensitivities of participants so as not to induce BPSD through unintended overstimulation. Feasibility of Implementation in Practice Settings Although MSE was not shown to have a greater effect on BPSD than other types of one-on-one activities, e-searchers and care providers must consider whether regular and consistent one-on-one interaction is feasible in adult day care facilities, special care units, and assisted living facilities, as this is not congruent with typical staff-to-patient ratios that impede the regular one-to-one interaction within an assisted living situation. But, it is important to remember that there are other ways to provide one-on-one therapy interactions that do not involve staff, such as those that are between different patients, between patients and volunteers, and between patients and family members. One-on-one activities with persons other than clinical staff may provide similar results in a relatively low-cost, purposeful manner. These activities might be as simple as peeling and eating a tangerine together to engage multiple senses (tactile, visual, olfactory, taste, and sound). When regularly occurring one-on-one multisensory activities are not feasible, other sensorial activities, such as group music interventions, may help reduce BPSD. Group activities may be led by staff, volunteers, or other residents. Although the innovative nature of multisensory environments piques the interest of caregivers, an often cited barrier to implementing MSE is cost. Specific MSE equipment can range in price from $995.00 to $6,495.00 for a mobile sensory cart, and a built MSE room that is approximately 120 square feet can cost an estimated $28,000.00 to $30,000.00 for equipment, shipping, and installation. Because of the cost of the equipment, it would be beneficial to discern if there are specific pieces of equipment that are preferred more than others to help decision makers selecting MSE equipment make the most efficient use of available resources. For instance, if research shows that the most impactful types of MSE equipment are the bubble tube, projector, and fiber optic cables, each can be purchased a-la-cart and used purposefully within a smaller interior space. Limitations Some limitations to this study are acknowledged. First, only empirical quantitative or qualitative studies from 1990 to 2015 written in English were included. Empirical research within this review was considered to be studies that were based on either experimentation or observation to address a question or evaluate a hypothesis. Although some qualitative studies did emerge within this criteria, the overwhelming results were skewed toward quantitative research. Second, the authors sought articles for review that incorporated at least three sensory-based items including ergonomic virbroacoustic furniture, bubble tubes, color-changing lights, music, and fiber optics. The intention for this specific requirement was to compile a list of studies that were as homogenous as possible for in-depth comparison of assessments and outcomes. However, this may have excluded multisensory stimulation studies that used informal yet relevant modes of sensory stimulation. Despite these limitations, all effort was made by the authors to conduct a thorough investigation of the available literature in a way that allowed for in-depth comparison of intervention, assessment, and outcome measures to aid the development of future research of MSE therapy. Conclusion According to this literature review, there is evidence that MSE interventions have a positive impact on mood and behavior (e.g., independence in ADLs), reduce BPSD, and therefore likely improve QoL for patients and caregivers. However, much of the focus of the studies has been on one-to-one interaction with people with moderate-to-severe dementia using a wide variety of study designs and assessment tools. Furthermore, the use of pre-post studies using impersonalized MSE therapy solutions with activity comparators should be abandoned in future research. Single-case design study methods, well validated in the field of applied behavioral research, should be investigated in future studies because they align well with the person-centered approach at the core of MSE interventions and are controlled. Also, direct participant preference should be systematically evaluated before the intervention begins and comparators that do not require any more cognitive ability than MSE therapy should be used. None of the studies included in this review focused on the impact of MSE therapy during assisted bathing which is an area of critical need in dementia care. Sensorial deprivation or overload can result in behavior problems including agitation and aggression and tend to occur during times of personal care assistance (Cipriani, Vedovello, Nuti, & Di Fiorino, 2011; Sloane et al., 2004; Teri, Larson, & Reifler, 1988). In fact, it is believed that 86% of nursing home residents with dementia display problem behaviors during times of bathing and toileting assistance (Baker, Hanley, & Mathews, 2006; Sloane et al., 2004). Purposefully designed, person-centered MSE bathing environments have the potential to reduce aggression for people with dementia in a specific area of critical need, where a majority of BPSD occur. These future studies will greatly benefit the QoL of the rising number of people with dementia and their caregivers through a methodologically sound research design and systematic preference assessment. Results from these studies will not only benefit people living with dementia, but potentially a broader population of people with cognitive impairments ranging from developmental to trauma-related disabilities. Supplementary Material Please visit the article online at http://gerontologist.oxfordjournals.org/ to view supplementary material. References References marked with an asterisk (*) were included in the review. * Baillon S. van Diepen E. Prettyman R. Rooke N. Redman J. & Campbell R . ( 2005 ). Variability in response of older people with dementia to both Snoezelen and Reminiscence . 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The effect of multisensory stimulation on persons residing in an extended care facility . American Journal of Alzheimer’s Disease & Other Dementias , 24 , 450 – 455 . doi:10.1177/1533317509350153 Google Scholar CrossRef Search ADS Whall A. L. Black M. E. Groh C. J. Yankou D. J. Kupferschmid B. J. & Foster N. L . ( 1997 ). The effect of natural environments upon agitation and aggression in late stage dementia patients . American Journal of Alzheimer’s Disease and Other Dementias , 12 , 216 – 220 . doi:10.1177/153331759701200506 Google Scholar CrossRef Search ADS Yao L. & Algase D . ( 2006 ). Environmental ambiance as a new window on wandering . Western Journal of Nursing Research , 28 , 89 – 104 . doi:10.1177/0193945905282355 © The Author(s) 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. 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Impact of Multisensory Environments on Behavior for People With Dementia: A Systematic Literature Review

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© The Author(s) 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
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Abstract

Abstract Purpose of the Study Behavioral and psychological symptoms of dementia (BPSD) affect quality of life for people with dementia. Nonpharmacological interventions are the preferred first line of treatment, and it is theorized that BPSD are directly influenced by sensory imbalance and improved by sensory equilibrium. The purpose of this article is to investigate the evidence regarding the use of multisensory environments (MSEs) as treatment for BPSD. Design and Methods A systematic literature review was performed using the PICO framework within PsycINFO, Web of Science, ERIC, PubMED, and Cinahl databases, as well as additional hand-searched documents. Included articles were published during 1990 to 2015 and report empirical studies of MSE BPSD interventions that include furniture, fixtures, and equipment to provide visual, auditory, tactile, and olfactory stimulation. Desired elements include ergonomic vibroacoustic furniture, bubble tubes, color-changing lights, and fiber optics. Results Twelve articles met the inclusion criteria for review. Evidence supports the positive impact of sensory stimulation as a nonpharmacological behavioral treatment for dementia. Many studies investigated both behavior and mood, and several investigated biomedical parameters including heart rate and cognition. Significant differences were not found in the between-group studies when MSE was compared with other one-to-one interventions. Results on long-term effects were mixed. Variations can be seen in terms of research methods, types of environmental interventions, duration, and specific characteristics of participants, thus confounding the reliability of findings. Implications Key findings and directions for future research are discussed including primary outcomes, study design, environmental intervention types, and relevant assessment tools. Multisensory environment, Sensory stimulation, Behavior, Sensoristasis, MSE Hitting, screaming, and wandering are just a few of the behavioral and psychological symptoms of dementia (BPSD) that may place a heavy burden on caregivers of persons living with dementia. Therapeutic interventions include both pharmacological and nonpharmacological treatments. Although some people with dementia benefit from pharmacological treatment, many drugs have been shown to provide only modest benefits, are not tolerated by a wide number of patients, and may even be harmful (Borson et al., 2013; Gitlin, Kales, & Lyketsos, 2012; Tinklenberg et al., 2007). Therefore, there is an increasing focus on nonpharmacological interventions. There are many types of nonpharmacological approaches to reducing BPSD. Although there is no consensus on how to categorize these interventions (Kales, Gitlin, & Lyketsos, 2015), Cabrera and colleagues (2015) categorized these approaches into one of five groups: (i) psychosocial and educational (either with individuals or in groups); (ii) physical activity; (iii) sensorial (light, music, therapeutic touch, and multisensory stimuli); (iv) staff-focused interventions; or, (v) complex interventions. Our review focuses on sensorial interventions. The theory supporting sensorial interventions posits that cognitive and functional declines associated with dementia are further aggravated by psychosomatic distress caused by a decrease in one’s ability to regulate sensory stimulation. This has been described using the Model of Imbalances in Sensoristasis (Kovach, 2000). People with dementia experience sensory imbalance due to many factors, including disturbances in circadian rhythm, neurophysiological weakening, or environmental factors (Kovach, 2000; Milev et al., 2008). Problem behaviors may occur as a result of sensory imbalance, and research indicates that environmental factors aimed at restoring equilibrium, such as multisensory environments (MSEs), may improve the quality of life (QoL) for persons with dementia and their caregivers. Multisensory environments are also referred to as multisensory stimulation environments or Snoezelen rooms. “Snoezelen,” a registered trademark of ROMPA/Flaghouse that originated in the Netherlands in the 1970s, combines the Dutch words “snuffelen” meaning to explore and “doezelen” meaning to relax (Jamshidi Manesh, Kalati, & Hosseini, 2015). Snoezelen rooms are purposefully designed, technologically integrated environments utilizing specific furniture, fixtures, and equipment (FF&E) to provide a controlled sensory experience. In our review, all of these types of interventions will be referred to as MSEs. Sensory equilibrium may be accomplished within an MSE through controlled visual, auditory, tactile, and olfactory stimuli designed to mitigate overactive (anxious, agitated, or aggressive) or underactive (apathetic, depressed, or anergic) behaviors. This may include interactive LED lighting elements that can be controlled by the participant, vibroacoustic furniture that provides the ability to feel musical vibrations, and aromatherapy, which gives desired scents. This type of environmental therapy has been shown to have a positive impact on BPSD by reducing wandering (Yao & Algase, 2006), lowering agitation during the bathing process (Cohen-Mansfield & Parpura-Gill, 2007), and increasing positive engagement. This leads to an improvement in cognition and function (Baker et al, 2001; Collier, McPherson, Ellis-Hill, Staal, & Bucks, 2010), perhaps reducing caregiver burden (Baker et al., 2001; Collier et al., 2010; Yao & Algase, 2006; Brennan, Su, & Horowitz, 2006). Unfortunately, there is limited research investigating the efficacy of MSEs. In this paper, we (i) provide a systematic review of the efficacy of MSEs and variations in its application; (ii) identify important gaps in knowledge; and (iii) offer recommendations for improving future MSE investigations and other environmental interventions. Methods A systematic literature review was performed using the PICO search model (Figure 1) which included studies identified in the following databases: PubMed, CINAHL, PsycINFO, Web of Science, and ERIC. Figure 1. View largeDownload slide Explanation of PICO search model (Centre for Evidence-Based Medicine, 2016). Figure 1. View largeDownload slide Explanation of PICO search model (Centre for Evidence-Based Medicine, 2016). Abstracts and reference lists of reviewed articles were also hand searched and included in the review. The assistance of a specialized research librarian was used to strengthen the quality of the search and validate the pertinence of databases and keywords used. Thesaurus, MeSH, and truncated terms were used where appropriate. A detailed explanation of the complete search strategy can be seen in Supplementary Appendix. A flowchart of the search strategy and organization of the Journal Citation Report (JCR) can be seen in Figure 2. Figure 2. View largeDownload slide Literature review search strategy. Based on Moher, Liberati, Tetzlaff, and Altman (2009). Figure 2. View largeDownload slide Literature review search strategy. Based on Moher, Liberati, Tetzlaff, and Altman (2009). Titles and abstracts of manuscripts were assessed for relevance to the topic of MSEs for reducing BPSD using the following inclusion criteria: Empirical quantitative, qualitative, or mixed-methods studies published in peer-reviewed journals between 1990 and 2015, written in English; Study participants were clinically diagnosed with dementia; The impact of MSE interventions on behavior of people with dementia was measured; and, MSE intervention incorporated at least three FF&E items including ergonomic vibroacoustic furniture, bubble tubes, color-changing lighting solutions, music, and/or fiber optics. If relevance was not clearly evident based on the initial review, the full article was read to determine whether it should be included. Once the initial group of articles was gathered, the full texts were read to ascertain final inclusion in the review. Twelve articles met the inclusion criteria. Data were extracted into a JCR to review study characteristics and rate levels of evidence for each article. We conducted an analysis of the existing evidence and an evaluation of the quality of the research identified (Table 1). Following this model, articles assigned levels of evidence 1 (systematic reviews), 4 (professional standards), and 6 (recommendations) were not included in this study, because the purpose of this review is to investigate original, empirical studies. Table 1. Levels of Evidence for Health Care Design (Marquardt, Bueter, & Motzek, 2014) adapted from Stichler (2010) Level Description of quality Included 1 Systematic reviews of multiple randomized controlled trials or nonrandomized studies; meta-analysis of multiple experimental or quasi-experimental studies; meta-synthesis of multiple qualitative studies leading to an integrative interpretation No 2 Well-designed experimental (randomized) or quasi-experimental (nonrandomized) studies with a low attrition rate, intention to treat analysis, blinding, masked randomization, and consistent results compared with other similar studies Yes 3a Observational studies with a cohort design; experimental or quasi-experimental studies that did not fulfill the criteria of Level 2 Yes 3b Cross-sectional studies or case–control studies; qualitative research that, based on a literature review, on a theoretical framework, reports a clear method and considers a diversity of views Yes 4 Professional standards or guidelines with studies to support recommendations No 5 Qualitative research that did not meet the criteria of Level 3b Yes 6 Recommendations from manufacturers or consultants who may have a financial interest or bias No Level Description of quality Included 1 Systematic reviews of multiple randomized controlled trials or nonrandomized studies; meta-analysis of multiple experimental or quasi-experimental studies; meta-synthesis of multiple qualitative studies leading to an integrative interpretation No 2 Well-designed experimental (randomized) or quasi-experimental (nonrandomized) studies with a low attrition rate, intention to treat analysis, blinding, masked randomization, and consistent results compared with other similar studies Yes 3a Observational studies with a cohort design; experimental or quasi-experimental studies that did not fulfill the criteria of Level 2 Yes 3b Cross-sectional studies or case–control studies; qualitative research that, based on a literature review, on a theoretical framework, reports a clear method and considers a diversity of views Yes 4 Professional standards or guidelines with studies to support recommendations No 5 Qualitative research that did not meet the criteria of Level 3b Yes 6 Recommendations from manufacturers or consultants who may have a financial interest or bias No View Large Table 1. Levels of Evidence for Health Care Design (Marquardt, Bueter, & Motzek, 2014) adapted from Stichler (2010) Level Description of quality Included 1 Systematic reviews of multiple randomized controlled trials or nonrandomized studies; meta-analysis of multiple experimental or quasi-experimental studies; meta-synthesis of multiple qualitative studies leading to an integrative interpretation No 2 Well-designed experimental (randomized) or quasi-experimental (nonrandomized) studies with a low attrition rate, intention to treat analysis, blinding, masked randomization, and consistent results compared with other similar studies Yes 3a Observational studies with a cohort design; experimental or quasi-experimental studies that did not fulfill the criteria of Level 2 Yes 3b Cross-sectional studies or case–control studies; qualitative research that, based on a literature review, on a theoretical framework, reports a clear method and considers a diversity of views Yes 4 Professional standards or guidelines with studies to support recommendations No 5 Qualitative research that did not meet the criteria of Level 3b Yes 6 Recommendations from manufacturers or consultants who may have a financial interest or bias No Level Description of quality Included 1 Systematic reviews of multiple randomized controlled trials or nonrandomized studies; meta-analysis of multiple experimental or quasi-experimental studies; meta-synthesis of multiple qualitative studies leading to an integrative interpretation No 2 Well-designed experimental (randomized) or quasi-experimental (nonrandomized) studies with a low attrition rate, intention to treat analysis, blinding, masked randomization, and consistent results compared with other similar studies Yes 3a Observational studies with a cohort design; experimental or quasi-experimental studies that did not fulfill the criteria of Level 2 Yes 3b Cross-sectional studies or case–control studies; qualitative research that, based on a literature review, on a theoretical framework, reports a clear method and considers a diversity of views Yes 4 Professional standards or guidelines with studies to support recommendations No 5 Qualitative research that did not meet the criteria of Level 3b Yes 6 Recommendations from manufacturers or consultants who may have a financial interest or bias No View Large Results Participants Participants in the reviewed studies were predominantly 65 years and older, and all had a medical diagnosis of moderate-to-severe dementia. Sample sizes range from 4 to 136, and the gender of participants was predominantly female. To quantify participants’ level of dementia, five studies used the Mini-Mental State Examination (MMSE) (Baillon et al., 2005; Baker et al., 2001; 2003; Cornell, 2004; Staal et al., 2007), two used the Global Deterioration Scale (GDS) (Maseda et al., 2014a), two used the Short Portable Mental Status Questionnaire (SPMSQ) (Riley-Doucet, 2009; Riley-Doucet & Dunn, 2013), one used the Diagnostic Statistical Manual of Mental Disorders 4th Edition (DSM IV) (Milev et al., 2008), one used the Clinical Dementia Rating Scale (CDR) (Baillon et al., 2005), one used the Behavior Rating Scale (BRS), Cognitive Assessment Scale (CAS), and Clifton Assessment Procedures for the Elderly (CAPE) in conjunction with the MMSE (Cornell, 2004), and two used a medical diagnosis of dementia without an additional assessment (Minner, Hoffstetter, Casey, & Jones, 2004; Ward-Smith et al., 2009). Settings The reviewed studies were conducted in Europe, Canada, and the United States (Figure 3). One out of 12 of the studies was conducted within a residential setting (Riley-Doucet, 2009), whereas the majority were conducted within institutional health care facilities. The type of institutional health care facilities varied, including adult day care centers, also known as day hospitals in the United Kingdom (Baker et al., 2001; Cornell, 2004; Riley-Doucet & Dunn, 2013; Ward-Smith et al., 2009), and skilled nursing facilities (Baillon et al., 2005; Maseda et al., 2014a; 2014b; Milev et al., 2008; Minner et al., 2004; Staal et al., 2007). One study included in the review used data from a mixed setting sample, that is, some participants were from an adult day center and some were from skilled nursing facilities (Baker et al., 2003). Figure 3. View largeDownload slide Global settings of included studies. Figure 3. View largeDownload slide Global settings of included studies. Approaches to MSE Therapy In order to understand the effect of MSE therapy for elders, it is important to clarify the defining factors that differentiate it from other therapies. Baker and colleagues (2001) define MSE therapy as a (i) purposefully designed environment offering visual, auditory, tactile, and olfactory stimulation, (ii) where staff follows the lead of the participants during therapy sessions in a nondirective approach where patients are encouraged to interact with sensory stimuli of their choice, and (iii) sensory stimuli are nonsequential and therefore place very low cognitive demands on participants. Of these three factors, the nondirective approach is critical. This differs from one-on-one activity sessions that do not involve MSEs where a staff member may actively participate in a card game or puzzle solving activity with the participant, because in the case of MSE therapy, the staff member takes on a passive role allowing the participant to independently engage with sensory stimuli. All studies identified within this review followed the three guidelines outlined, however, the approaches were varied in terms of approach. Some studies followed the protocol outlined by Baker and colleagues (1998) for a randomized, controlled trial that compared the effects of eight MSE sessions with control sessions (Baillon et al., 2005; Baker et al., 2001; 2003; Maseda et al., 2014a; 2014b). Some studies offered sessions at regular intervals during the week, commencing at the same time of day and for the same duration each week (Cornell, 2004; Milev et al., 2008; Staal et al., 2007), whereas others administered the therapy intermittently (Ward-Smith et al., 2009). Some studies administered the MSE therapy specifically when the BPSD occurred (Minner et al., 2004; Riley-Doucet & Dunn, 2013). Overall, the approach to data collection varied widely between 2 weeks to 1 year, and MSE intervention sessions lasted between 8 and 40 minutes. None of the studies evaluated demonstrated whether the MSE therapy specifically addressed either under- or over-stimulation. Study Design Of the 12 studies included, seven were randomized controlled studies (Baillon et al., 2005; Baker et al., 2001; 2003; Maseda et al., 2014a; 2014b; Milev et al., 2008; Ward-Smith et al., 2009), one within-subjects repeated-measures design (Riley-Doucet & Dunn, 2013), one mixed-design, between-groups study (Staal et al., 2007), one outcome-based quality improvement study (Minner et al., 2004), one single-case design study (Cornell, 2004), and one qualitative study (Riley-Doucet, 2009). Of the randomized controlled trial studies, a variety of designs and comparators were reported in the included studies. Baillon and colleagues (2005) used a crossover design with reminiscence therapy as the control group for two different groups undergoing two intervention sessions, each lasting 2 weeks. Ward-Smith and colleagues (2009) conducted a retrospective medical chart review of patients with documented BPSD receiving routine antipsychotic medication and either MSE therapy or not. Comparators reported in the between-group studies included care as usual (Milev et al., 2008) with activities including card playing, quizzes, or viewing photographs (Baker et al., 2001; 2003; Maseda et al., 2014a; 2014b). Some reviewed studies followed a pre-post design (Riley-Doucet & Dunn, 2013; Staal et al., 2007). Although the studies included in this review were innovative in approach, some weaknesses were identified. Overall, sample sizes were very low. Although this is not a concern in Cornell’s (2004) single-case design study, where each participant was assessed at a large number of intervals throughout the course of the study and became their own control (Kazdin, 2011), it is a concern for the randomized, pre-post and between-group studies. In these designs, a smaller sample size does not provide an adequately generalizable result to the larger population. Baker and colleagues’ study (2001) occurred over a two-and-a-half-year period, and consistent management of the intervention and procedures could be questioned. Baker and colleagues’ study (2003) included data from three adult day centers in the United Kingdom, the Netherlands, and Sweden between 1996 and 2001. The variance in settings, staff, application of the MSE therapy, and follow-up assessments could have confounded findings. Additional details for each of the 12 studies reviewed are shown in Table 2. Table 2. Characteristics of Included Studies First author (year) Level Methods Participants Intervention Outcomes Setting Assessments Results Baillon et al (2005) 2 RCT n = 20, Dementia diagnosis with significant levels of agitation and consistent levels of antipsychotic medication intake MSSE: Snoezelen Room, bubble tubes, projected lights, music, aromatherapy, and tactile objects selected based on individual sensory preferences, RT: Conversational activity, reflect on past experiences using cues relevant to participants’ individual interests Mood, behavior, heart rate SCU & ALF (Geri-psych), UK Dementia: MMSE (mod-severe) & CDR Both interventions: +Mood effect +Behavior effect ↔ Diff(s) BG ↓Heart rate Crossover randomized trial, 3 sessions of Snoezelen or RT for 2 weeks, 1 week off, then 3 sessions with either therapy for 2 weeks, 1-to-1 sessions up to 40 min Agitation: ABMI & CMAI Heart rate: heart rate monitor Mood & behavior: Interact Short Scale Baker et al (2003) 2 RCT n = 136, Dementia diagnosis without other major psychiatric issues MSSE: Room with bubble tubes, fiber optic sprays, gel and image projections, music, tactile stimulation, and aromatherapy Mood, behavior, cognition Day hospital (UK); Geri-psych ward (Netherlands, Sweden) Short Term: Behavior/ mood: Interact, Interact Short (UK/ Netherlands), GIP (Sweden) Long term: Cognition: MMSE Behavior: BRS, CAPE, BMD, REHAB All 3 sites, both groups: +Mood, +Behavior, ↔ Diff(s) BG; MSS Groups: UK & Netherlands ↓Bored/ inactive ↑Interpersonal ↑Memory recall Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks Activity: playing cards, quizzes, looking at photographs All activity groups: ↑ADL over MSS ↔ LT Effect BG Baker et al (2001) 2 RCT Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks, nondirective, enabling approach, generalization of effects over time n = 50, Dementia diagnosis, attending a day hospital 2+ times per week, no other major psychiatric issues, previous MSSE exposure within 3 months MSSE: Purposefully designed auditory, tactile, and olfactory stimulation with varied lighting, music, aromas, and textural objects, nonsequential stimuli, Activity: individually selected (e.g., puzzles) Mood, behavior, cognition Day hospital, UK Short-term assess: Behavior/mood: Interact (during sessions), Interact Short (10 min before and after) Long-term assess: Cognition: MMSE, Behavior: BRS, CAPE, BMD, REHAB, CAS Both groups: ↑Speech ↑Interpersonal ↑Env Engagement ↑Initiative, alert ↓Bored/inactive;MSS group: ↑Attentive to Env +Mood effect AH +Behavior effect AH No lasting LT effect Cornell (2004) 3a Single-case design, Snoezelen sessions, 2× per week for 4 weeks, 30-min sessions, Behavior/mood assessed 30 min before and after each session n = 4, Women with dementia diagnosis, attending day hospital MSSE: Snoezelen room, bubble tubes, mirrors, color-changing fiber optic sprays, music, image and gel projector for walls, mirror ball to project colored patterns, fiber optic carpet, and tactile objects Mood, behavior, response to equipment Day hospital, UK Dementia: Medical diagnosis with BRS, CAS, CAPE, & MMSE less than 10 (moderate stage) ↑Mood, ↑Behavior; Positive mood/behavior lasted at least 30 min, some reported effects lasted 24 h Individual characteristics: medical records Mood/behavior: Interact and Interact Short Response to equipment: PI generated tool Maseda et al (2014a) 2 RCT n = 30, 3 groups: MSSE, Activity, control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, i.e., cards, quiz, photos, Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Biomedical: Heart Rate and SpO2 Specialized residential elderly center, Spain Dementia: GDS Biomedical: Finger pulse oximeters Mood & Behavior: Interact Scale & Interact Short Scale ↑Mood, ↑Positive behavior, ↓Heart rate ↑SpO2 ↔ Diff(s) BG Controlled longitudinal, between-group study, 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, Design followed protocol suggested by Baker et al. (1998) Maseda et al (2014b) 2 RCT n = 30, 3 groups: MSSE, Activity, Control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, tactile board Activity: 1-to-1 individually selected (e.g., cards, quiz, photos) Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Emotional, Cognitive and Functional levels on ADLs, Agitation Specialized residential elderly center, Spain Dementia: GDS Agitation: CMAI MSSE/Activity: ↑Mood ↔Cog Level, ↑Pos Beh Diff(s) BG: MSSE Group ↑F(x) ADL, ↓CMAI Non Ag, Activity/Control ↔F(x) ADL Controlled longitudinal, between-group study; 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, protocol by Baker et al. (1998) Behavior: NPI-NH Mood: CSDD Cognitive Status: MMSEFunctional status with ADLs: Barthel Index Milev et al (2008) 2 RCT n = 21, 7 in each group: control, 1 session per week MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, (e.g., cards) Behavior LTC, CAN Dementia: Medical diagnosis (DSM IV) Behavior: DOS, CGI-I MSE groups: ↓DOS, ↑Pos Beh, Results increased with session intensity, results maintained over 12 weeks Pilot study, 24-week single-blind study, 30-min sessions, 1-3× per week for 12 weeks, no MSE for 12 additional weeks Minner et al (2004) 3a Outcome-based quality improvement study, Single facilitator model, duration varied, Behavior assessed before, during, and after for 1 year period n = 19, Residents with frequent behavior problems MSSE: Snoezelen Room, bubble tubes, rocker, bean bag chair, lightning ball, hanging plastic beads, vibrating pillow, lava lamp, aromatherapy diffuser, music, colored lights, and mirror Problem behaviors: Noisy breathing, Negative vocalization, Sad/frightened expression, Tense body language, and Fidgeting Residential nursing facility, USA CDS/DS-DAT ↓Neg behavior, ↑Pos behavior Riley-Doucet (2009) 4 Pilot study, qualitative research Design, number, and length of sessions varied, Avg 2× per week for 28 min over a total of 3 weeks n = 10, Participants: Aged 65+, dementia diagnosis; n = 10, Caregivers: aged 18+ MSE: Quiet room in home and portable Snoezelen kit: Bubble tube, evening breeze fan, chase light string, plasma ball, solar effects projector, music, vibrating tube, and aroma diffuser Participant and caregiver perceptions of MSE, Level of cognitive impairment, Participant use of MSE, Participant’s behavioral response/ apparent enjoyment Private homes, USA Dementia: Confirmed medical diagnosis & SPMSQ (mod-severe) Caregiver & participant MSE perceptions: semi- structured interviews Demographics: self- report questionnaire Themes: +PT satisfaction w/ MSE, ↑positive affective state, ↑PT cog, ↓CG burden, +CG satisfaction, +Interpersonal PT & CG relationships Use of MSE: COR Riley-Doucet (2013) 3a Pilot study, within- subjects, repeated- measures design, 4 weeks, Number and length of intervention sessions varied, Avg 5× per week for 15 min per session for 4 weeks, total 42 collective sessions, Intervention occurred when PT exhibited BPSD n = 8, Participants: Aged 65+, dementia diagnosis, BPSD history at DCC, attend DCC at least 2× week; n = 4, Caregivers: Aged 18+ MSE: Corner of large activity room enclosed with room dividers, Comfortable chair placed in area, portable Snoezelen kit: aroma diffuser, chase light string, evening breeze fan, fiber optic string light, plasma ball, solar effects projector, music, and vibrating tube Participant: Agitation, Reaction to MSE Caregivers: Satisfaction with MSE to manage BPSD Adult day care center, USA Dementia: Confirmed medical diagnosis & SPMSQ (mostly severe) Demographics: DCC records and questionnaire Length of time in and enjoyment of MSE & engagement time: Obs record Agitation: ABS Caregiver satisfaction: Caregiver exit survey ↓Agitation, +Reaction to MSE, +CG satisfaction; Hierarchy of preferred stimuli: Vibrating tube, music, fiber optic string light, chase light string, solar effects projector, aroma diffuser, plasma ball, and evening breeze Staal et al (2007) 2 RCT Between-group comparison, 2–3 sessions to assess sensory preferences, 6 sessions of MSBT at FT intervals of FT15, FT20-25, FT30 n = 24, MSBT group Avg age 80, Control group Avg age 72 MSBT: Individualized, 1-to-1 administered sensory stimulation (visual, auditory, olfactory, and tactile) Agitation, Apathy, ADL Acute care Geri-psych unit Dementia: Medical diagnosis with BPSD (mod-severe) Cognitive F(x): MMSE MSBT Group: ↓Agitation ↓Apathy ↑ADL Agitation: PAS Physical health: MAI ↔RADL, BDP Behavior: SANS-AD ADL: KI-ADL & RADL & BDP Ward-Smith et al (2009) 2 Between-group comparison study, controlled, not randomized, Intervention between 1 and 4 pm after antipsychotic meds, 84 s essions over 3 months n = 14, 7 in each group, 12/14 female, Avg PT age 81 MSSE: MSE Room, reclining bench, dimmable lights, bubble tubes, light wheel, vibrating pillows, fiber optic lights, aromatherapy, DVDs, comfortable seating, and wind chimes Incidences of problematic behavior SCU within a LTC, USA Dementia: Medical diagnosis MSE Group: ↓PsyB incidence ↔PsyB range; Control group: ↑PsyB incidence Behavior: PBAR and medical records First author (year) Level Methods Participants Intervention Outcomes Setting Assessments Results Baillon et al (2005) 2 RCT n = 20, Dementia diagnosis with significant levels of agitation and consistent levels of antipsychotic medication intake MSSE: Snoezelen Room, bubble tubes, projected lights, music, aromatherapy, and tactile objects selected based on individual sensory preferences, RT: Conversational activity, reflect on past experiences using cues relevant to participants’ individual interests Mood, behavior, heart rate SCU & ALF (Geri-psych), UK Dementia: MMSE (mod-severe) & CDR Both interventions: +Mood effect +Behavior effect ↔ Diff(s) BG ↓Heart rate Crossover randomized trial, 3 sessions of Snoezelen or RT for 2 weeks, 1 week off, then 3 sessions with either therapy for 2 weeks, 1-to-1 sessions up to 40 min Agitation: ABMI & CMAI Heart rate: heart rate monitor Mood & behavior: Interact Short Scale Baker et al (2003) 2 RCT n = 136, Dementia diagnosis without other major psychiatric issues MSSE: Room with bubble tubes, fiber optic sprays, gel and image projections, music, tactile stimulation, and aromatherapy Mood, behavior, cognition Day hospital (UK); Geri-psych ward (Netherlands, Sweden) Short Term: Behavior/ mood: Interact, Interact Short (UK/ Netherlands), GIP (Sweden) Long term: Cognition: MMSE Behavior: BRS, CAPE, BMD, REHAB All 3 sites, both groups: +Mood, +Behavior, ↔ Diff(s) BG; MSS Groups: UK & Netherlands ↓Bored/ inactive ↑Interpersonal ↑Memory recall Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks Activity: playing cards, quizzes, looking at photographs All activity groups: ↑ADL over MSS ↔ LT Effect BG Baker et al (2001) 2 RCT Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks, nondirective, enabling approach, generalization of effects over time n = 50, Dementia diagnosis, attending a day hospital 2+ times per week, no other major psychiatric issues, previous MSSE exposure within 3 months MSSE: Purposefully designed auditory, tactile, and olfactory stimulation with varied lighting, music, aromas, and textural objects, nonsequential stimuli, Activity: individually selected (e.g., puzzles) Mood, behavior, cognition Day hospital, UK Short-term assess: Behavior/mood: Interact (during sessions), Interact Short (10 min before and after) Long-term assess: Cognition: MMSE, Behavior: BRS, CAPE, BMD, REHAB, CAS Both groups: ↑Speech ↑Interpersonal ↑Env Engagement ↑Initiative, alert ↓Bored/inactive;MSS group: ↑Attentive to Env +Mood effect AH +Behavior effect AH No lasting LT effect Cornell (2004) 3a Single-case design, Snoezelen sessions, 2× per week for 4 weeks, 30-min sessions, Behavior/mood assessed 30 min before and after each session n = 4, Women with dementia diagnosis, attending day hospital MSSE: Snoezelen room, bubble tubes, mirrors, color-changing fiber optic sprays, music, image and gel projector for walls, mirror ball to project colored patterns, fiber optic carpet, and tactile objects Mood, behavior, response to equipment Day hospital, UK Dementia: Medical diagnosis with BRS, CAS, CAPE, & MMSE less than 10 (moderate stage) ↑Mood, ↑Behavior; Positive mood/behavior lasted at least 30 min, some reported effects lasted 24 h Individual characteristics: medical records Mood/behavior: Interact and Interact Short Response to equipment: PI generated tool Maseda et al (2014a) 2 RCT n = 30, 3 groups: MSSE, Activity, control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, i.e., cards, quiz, photos, Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Biomedical: Heart Rate and SpO2 Specialized residential elderly center, Spain Dementia: GDS Biomedical: Finger pulse oximeters Mood & Behavior: Interact Scale & Interact Short Scale ↑Mood, ↑Positive behavior, ↓Heart rate ↑SpO2 ↔ Diff(s) BG Controlled longitudinal, between-group study, 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, Design followed protocol suggested by Baker et al. (1998) Maseda et al (2014b) 2 RCT n = 30, 3 groups: MSSE, Activity, Control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, tactile board Activity: 1-to-1 individually selected (e.g., cards, quiz, photos) Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Emotional, Cognitive and Functional levels on ADLs, Agitation Specialized residential elderly center, Spain Dementia: GDS Agitation: CMAI MSSE/Activity: ↑Mood ↔Cog Level, ↑Pos Beh Diff(s) BG: MSSE Group ↑F(x) ADL, ↓CMAI Non Ag, Activity/Control ↔F(x) ADL Controlled longitudinal, between-group study; 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, protocol by Baker et al. (1998) Behavior: NPI-NH Mood: CSDD Cognitive Status: MMSEFunctional status with ADLs: Barthel Index Milev et al (2008) 2 RCT n = 21, 7 in each group: control, 1 session per week MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, (e.g., cards) Behavior LTC, CAN Dementia: Medical diagnosis (DSM IV) Behavior: DOS, CGI-I MSE groups: ↓DOS, ↑Pos Beh, Results increased with session intensity, results maintained over 12 weeks Pilot study, 24-week single-blind study, 30-min sessions, 1-3× per week for 12 weeks, no MSE for 12 additional weeks Minner et al (2004) 3a Outcome-based quality improvement study, Single facilitator model, duration varied, Behavior assessed before, during, and after for 1 year period n = 19, Residents with frequent behavior problems MSSE: Snoezelen Room, bubble tubes, rocker, bean bag chair, lightning ball, hanging plastic beads, vibrating pillow, lava lamp, aromatherapy diffuser, music, colored lights, and mirror Problem behaviors: Noisy breathing, Negative vocalization, Sad/frightened expression, Tense body language, and Fidgeting Residential nursing facility, USA CDS/DS-DAT ↓Neg behavior, ↑Pos behavior Riley-Doucet (2009) 4 Pilot study, qualitative research Design, number, and length of sessions varied, Avg 2× per week for 28 min over a total of 3 weeks n = 10, Participants: Aged 65+, dementia diagnosis; n = 10, Caregivers: aged 18+ MSE: Quiet room in home and portable Snoezelen kit: Bubble tube, evening breeze fan, chase light string, plasma ball, solar effects projector, music, vibrating tube, and aroma diffuser Participant and caregiver perceptions of MSE, Level of cognitive impairment, Participant use of MSE, Participant’s behavioral response/ apparent enjoyment Private homes, USA Dementia: Confirmed medical diagnosis & SPMSQ (mod-severe) Caregiver & participant MSE perceptions: semi- structured interviews Demographics: self- report questionnaire Themes: +PT satisfaction w/ MSE, ↑positive affective state, ↑PT cog, ↓CG burden, +CG satisfaction, +Interpersonal PT & CG relationships Use of MSE: COR Riley-Doucet (2013) 3a Pilot study, within- subjects, repeated- measures design, 4 weeks, Number and length of intervention sessions varied, Avg 5× per week for 15 min per session for 4 weeks, total 42 collective sessions, Intervention occurred when PT exhibited BPSD n = 8, Participants: Aged 65+, dementia diagnosis, BPSD history at DCC, attend DCC at least 2× week; n = 4, Caregivers: Aged 18+ MSE: Corner of large activity room enclosed with room dividers, Comfortable chair placed in area, portable Snoezelen kit: aroma diffuser, chase light string, evening breeze fan, fiber optic string light, plasma ball, solar effects projector, music, and vibrating tube Participant: Agitation, Reaction to MSE Caregivers: Satisfaction with MSE to manage BPSD Adult day care center, USA Dementia: Confirmed medical diagnosis & SPMSQ (mostly severe) Demographics: DCC records and questionnaire Length of time in and enjoyment of MSE & engagement time: Obs record Agitation: ABS Caregiver satisfaction: Caregiver exit survey ↓Agitation, +Reaction to MSE, +CG satisfaction; Hierarchy of preferred stimuli: Vibrating tube, music, fiber optic string light, chase light string, solar effects projector, aroma diffuser, plasma ball, and evening breeze Staal et al (2007) 2 RCT Between-group comparison, 2–3 sessions to assess sensory preferences, 6 sessions of MSBT at FT intervals of FT15, FT20-25, FT30 n = 24, MSBT group Avg age 80, Control group Avg age 72 MSBT: Individualized, 1-to-1 administered sensory stimulation (visual, auditory, olfactory, and tactile) Agitation, Apathy, ADL Acute care Geri-psych unit Dementia: Medical diagnosis with BPSD (mod-severe) Cognitive F(x): MMSE MSBT Group: ↓Agitation ↓Apathy ↑ADL Agitation: PAS Physical health: MAI ↔RADL, BDP Behavior: SANS-AD ADL: KI-ADL & RADL & BDP Ward-Smith et al (2009) 2 Between-group comparison study, controlled, not randomized, Intervention between 1 and 4 pm after antipsychotic meds, 84 s essions over 3 months n = 14, 7 in each group, 12/14 female, Avg PT age 81 MSSE: MSE Room, reclining bench, dimmable lights, bubble tubes, light wheel, vibrating pillows, fiber optic lights, aromatherapy, DVDs, comfortable seating, and wind chimes Incidences of problematic behavior SCU within a LTC, USA Dementia: Medical diagnosis MSE Group: ↓PsyB incidence ↔PsyB range; Control group: ↑PsyB incidence Behavior: PBAR and medical records Note: ↑ = increase, ↓ = decrease, ↔ = no change, + = positive effect. ADL = activities of daily living; AH = at home; ABMI = Agitation Behavior Mapping Instrument; ABS = Agitated Behavior Scale; Ag = aggressive; ALF = assisted living facility; Assess = assessment(s); Avg = average; BDP = Beck Dressing Performance Scale; Beh = behavior; BPSD = behavioral and psychological symptoms of dementia; BG = between group; BMD = Behavior and Mood Disturbance Scale; BRS = Behavior Rating Scale; CAN = Canada; CAPE = Clifton Assessment Procedures for the Elderly; CAS = Cognitive Assessment Scale; CDR = Clinical Dementia Rating; CDS = Comfort/Discomfort Scale; CG = caregiver; CGI-I = Clinical Global Impression-Improvement; CMAI = Cohen-Mansfield Agitation Inventory; Cog = cognition; COR = Caregiver Observation Record; CSDD = Cornell Scale for Depression in Dementia; DCC = Day Care Center; Diff(s) = differences; DOS = Daily Observation Scale; DS-DAT = Discomfort Scale-Dementia of the Alzheimer’s Type; DSM IV = Diagnostic Statistical Manual of Mental Disorders 4th Edition; Env = environment; F(x) = functioning; FT = fixed time; Geri-psych = geriatric psychiatry; GDS = Global Deterioration Scale; GIP = Swedish Behavior Observation Scale for Intramural Psycho-geriatrics; KI-ADL = Katz Index of Activities of Daily Living; LT = long term; LTC = long-term care facility; MAI = Multi-level Assessment Instrument; MMSE = Mini-Mental State Examination; Mod-severe = moderate to severe; MSBT = multisensory behavioral therapy; MSE = multisensory environment; MSS = multisensory stimulation; MSSE = multisensory stimulation environment; Neg behavior = negative behavior; Non Ag = nonaggressive behavior; NPI-NH = Neuropsychiatric Inventory-Nursing Home; Obs = observation; PAS = Pittsburg Agitation Scale; PBAR = Psychotic Behavior Assessment Record; PI = principle investigator; Pos behavior = positive behavior; PsyB = psychotic behavior; PT = participant; RADL = Refined Activities of Daily Living Assessment Scale; RCT = randomized controlled trial; REHAB = Rehabilitation Evaluation Hall and Baker Tool; RT = reminiscence therapy; SANS-AD = Scale for the Assessment of Negative Symptoms in Alzheimer’s Disease; SCU = specialty care unit; SPMSQ = Short Portable Mental Status Questionnaire; SpO2 = arterial oxygen saturation; SR = self-report. View Large Table 2. Characteristics of Included Studies First author (year) Level Methods Participants Intervention Outcomes Setting Assessments Results Baillon et al (2005) 2 RCT n = 20, Dementia diagnosis with significant levels of agitation and consistent levels of antipsychotic medication intake MSSE: Snoezelen Room, bubble tubes, projected lights, music, aromatherapy, and tactile objects selected based on individual sensory preferences, RT: Conversational activity, reflect on past experiences using cues relevant to participants’ individual interests Mood, behavior, heart rate SCU & ALF (Geri-psych), UK Dementia: MMSE (mod-severe) & CDR Both interventions: +Mood effect +Behavior effect ↔ Diff(s) BG ↓Heart rate Crossover randomized trial, 3 sessions of Snoezelen or RT for 2 weeks, 1 week off, then 3 sessions with either therapy for 2 weeks, 1-to-1 sessions up to 40 min Agitation: ABMI & CMAI Heart rate: heart rate monitor Mood & behavior: Interact Short Scale Baker et al (2003) 2 RCT n = 136, Dementia diagnosis without other major psychiatric issues MSSE: Room with bubble tubes, fiber optic sprays, gel and image projections, music, tactile stimulation, and aromatherapy Mood, behavior, cognition Day hospital (UK); Geri-psych ward (Netherlands, Sweden) Short Term: Behavior/ mood: Interact, Interact Short (UK/ Netherlands), GIP (Sweden) Long term: Cognition: MMSE Behavior: BRS, CAPE, BMD, REHAB All 3 sites, both groups: +Mood, +Behavior, ↔ Diff(s) BG; MSS Groups: UK & Netherlands ↓Bored/ inactive ↑Interpersonal ↑Memory recall Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks Activity: playing cards, quizzes, looking at photographs All activity groups: ↑ADL over MSS ↔ LT Effect BG Baker et al (2001) 2 RCT Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks, nondirective, enabling approach, generalization of effects over time n = 50, Dementia diagnosis, attending a day hospital 2+ times per week, no other major psychiatric issues, previous MSSE exposure within 3 months MSSE: Purposefully designed auditory, tactile, and olfactory stimulation with varied lighting, music, aromas, and textural objects, nonsequential stimuli, Activity: individually selected (e.g., puzzles) Mood, behavior, cognition Day hospital, UK Short-term assess: Behavior/mood: Interact (during sessions), Interact Short (10 min before and after) Long-term assess: Cognition: MMSE, Behavior: BRS, CAPE, BMD, REHAB, CAS Both groups: ↑Speech ↑Interpersonal ↑Env Engagement ↑Initiative, alert ↓Bored/inactive;MSS group: ↑Attentive to Env +Mood effect AH +Behavior effect AH No lasting LT effect Cornell (2004) 3a Single-case design, Snoezelen sessions, 2× per week for 4 weeks, 30-min sessions, Behavior/mood assessed 30 min before and after each session n = 4, Women with dementia diagnosis, attending day hospital MSSE: Snoezelen room, bubble tubes, mirrors, color-changing fiber optic sprays, music, image and gel projector for walls, mirror ball to project colored patterns, fiber optic carpet, and tactile objects Mood, behavior, response to equipment Day hospital, UK Dementia: Medical diagnosis with BRS, CAS, CAPE, & MMSE less than 10 (moderate stage) ↑Mood, ↑Behavior; Positive mood/behavior lasted at least 30 min, some reported effects lasted 24 h Individual characteristics: medical records Mood/behavior: Interact and Interact Short Response to equipment: PI generated tool Maseda et al (2014a) 2 RCT n = 30, 3 groups: MSSE, Activity, control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, i.e., cards, quiz, photos, Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Biomedical: Heart Rate and SpO2 Specialized residential elderly center, Spain Dementia: GDS Biomedical: Finger pulse oximeters Mood & Behavior: Interact Scale & Interact Short Scale ↑Mood, ↑Positive behavior, ↓Heart rate ↑SpO2 ↔ Diff(s) BG Controlled longitudinal, between-group study, 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, Design followed protocol suggested by Baker et al. (1998) Maseda et al (2014b) 2 RCT n = 30, 3 groups: MSSE, Activity, Control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, tactile board Activity: 1-to-1 individually selected (e.g., cards, quiz, photos) Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Emotional, Cognitive and Functional levels on ADLs, Agitation Specialized residential elderly center, Spain Dementia: GDS Agitation: CMAI MSSE/Activity: ↑Mood ↔Cog Level, ↑Pos Beh Diff(s) BG: MSSE Group ↑F(x) ADL, ↓CMAI Non Ag, Activity/Control ↔F(x) ADL Controlled longitudinal, between-group study; 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, protocol by Baker et al. (1998) Behavior: NPI-NH Mood: CSDD Cognitive Status: MMSEFunctional status with ADLs: Barthel Index Milev et al (2008) 2 RCT n = 21, 7 in each group: control, 1 session per week MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, (e.g., cards) Behavior LTC, CAN Dementia: Medical diagnosis (DSM IV) Behavior: DOS, CGI-I MSE groups: ↓DOS, ↑Pos Beh, Results increased with session intensity, results maintained over 12 weeks Pilot study, 24-week single-blind study, 30-min sessions, 1-3× per week for 12 weeks, no MSE for 12 additional weeks Minner et al (2004) 3a Outcome-based quality improvement study, Single facilitator model, duration varied, Behavior assessed before, during, and after for 1 year period n = 19, Residents with frequent behavior problems MSSE: Snoezelen Room, bubble tubes, rocker, bean bag chair, lightning ball, hanging plastic beads, vibrating pillow, lava lamp, aromatherapy diffuser, music, colored lights, and mirror Problem behaviors: Noisy breathing, Negative vocalization, Sad/frightened expression, Tense body language, and Fidgeting Residential nursing facility, USA CDS/DS-DAT ↓Neg behavior, ↑Pos behavior Riley-Doucet (2009) 4 Pilot study, qualitative research Design, number, and length of sessions varied, Avg 2× per week for 28 min over a total of 3 weeks n = 10, Participants: Aged 65+, dementia diagnosis; n = 10, Caregivers: aged 18+ MSE: Quiet room in home and portable Snoezelen kit: Bubble tube, evening breeze fan, chase light string, plasma ball, solar effects projector, music, vibrating tube, and aroma diffuser Participant and caregiver perceptions of MSE, Level of cognitive impairment, Participant use of MSE, Participant’s behavioral response/ apparent enjoyment Private homes, USA Dementia: Confirmed medical diagnosis & SPMSQ (mod-severe) Caregiver & participant MSE perceptions: semi- structured interviews Demographics: self- report questionnaire Themes: +PT satisfaction w/ MSE, ↑positive affective state, ↑PT cog, ↓CG burden, +CG satisfaction, +Interpersonal PT & CG relationships Use of MSE: COR Riley-Doucet (2013) 3a Pilot study, within- subjects, repeated- measures design, 4 weeks, Number and length of intervention sessions varied, Avg 5× per week for 15 min per session for 4 weeks, total 42 collective sessions, Intervention occurred when PT exhibited BPSD n = 8, Participants: Aged 65+, dementia diagnosis, BPSD history at DCC, attend DCC at least 2× week; n = 4, Caregivers: Aged 18+ MSE: Corner of large activity room enclosed with room dividers, Comfortable chair placed in area, portable Snoezelen kit: aroma diffuser, chase light string, evening breeze fan, fiber optic string light, plasma ball, solar effects projector, music, and vibrating tube Participant: Agitation, Reaction to MSE Caregivers: Satisfaction with MSE to manage BPSD Adult day care center, USA Dementia: Confirmed medical diagnosis & SPMSQ (mostly severe) Demographics: DCC records and questionnaire Length of time in and enjoyment of MSE & engagement time: Obs record Agitation: ABS Caregiver satisfaction: Caregiver exit survey ↓Agitation, +Reaction to MSE, +CG satisfaction; Hierarchy of preferred stimuli: Vibrating tube, music, fiber optic string light, chase light string, solar effects projector, aroma diffuser, plasma ball, and evening breeze Staal et al (2007) 2 RCT Between-group comparison, 2–3 sessions to assess sensory preferences, 6 sessions of MSBT at FT intervals of FT15, FT20-25, FT30 n = 24, MSBT group Avg age 80, Control group Avg age 72 MSBT: Individualized, 1-to-1 administered sensory stimulation (visual, auditory, olfactory, and tactile) Agitation, Apathy, ADL Acute care Geri-psych unit Dementia: Medical diagnosis with BPSD (mod-severe) Cognitive F(x): MMSE MSBT Group: ↓Agitation ↓Apathy ↑ADL Agitation: PAS Physical health: MAI ↔RADL, BDP Behavior: SANS-AD ADL: KI-ADL & RADL & BDP Ward-Smith et al (2009) 2 Between-group comparison study, controlled, not randomized, Intervention between 1 and 4 pm after antipsychotic meds, 84 s essions over 3 months n = 14, 7 in each group, 12/14 female, Avg PT age 81 MSSE: MSE Room, reclining bench, dimmable lights, bubble tubes, light wheel, vibrating pillows, fiber optic lights, aromatherapy, DVDs, comfortable seating, and wind chimes Incidences of problematic behavior SCU within a LTC, USA Dementia: Medical diagnosis MSE Group: ↓PsyB incidence ↔PsyB range; Control group: ↑PsyB incidence Behavior: PBAR and medical records First author (year) Level Methods Participants Intervention Outcomes Setting Assessments Results Baillon et al (2005) 2 RCT n = 20, Dementia diagnosis with significant levels of agitation and consistent levels of antipsychotic medication intake MSSE: Snoezelen Room, bubble tubes, projected lights, music, aromatherapy, and tactile objects selected based on individual sensory preferences, RT: Conversational activity, reflect on past experiences using cues relevant to participants’ individual interests Mood, behavior, heart rate SCU & ALF (Geri-psych), UK Dementia: MMSE (mod-severe) & CDR Both interventions: +Mood effect +Behavior effect ↔ Diff(s) BG ↓Heart rate Crossover randomized trial, 3 sessions of Snoezelen or RT for 2 weeks, 1 week off, then 3 sessions with either therapy for 2 weeks, 1-to-1 sessions up to 40 min Agitation: ABMI & CMAI Heart rate: heart rate monitor Mood & behavior: Interact Short Scale Baker et al (2003) 2 RCT n = 136, Dementia diagnosis without other major psychiatric issues MSSE: Room with bubble tubes, fiber optic sprays, gel and image projections, music, tactile stimulation, and aromatherapy Mood, behavior, cognition Day hospital (UK); Geri-psych ward (Netherlands, Sweden) Short Term: Behavior/ mood: Interact, Interact Short (UK/ Netherlands), GIP (Sweden) Long term: Cognition: MMSE Behavior: BRS, CAPE, BMD, REHAB All 3 sites, both groups: +Mood, +Behavior, ↔ Diff(s) BG; MSS Groups: UK & Netherlands ↓Bored/ inactive ↑Interpersonal ↑Memory recall Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks Activity: playing cards, quizzes, looking at photographs All activity groups: ↑ADL over MSS ↔ LT Effect BG Baker et al (2001) 2 RCT Between-group study, MSSE or activity groups, 8–30 min sessions for 4 weeks, nondirective, enabling approach, generalization of effects over time n = 50, Dementia diagnosis, attending a day hospital 2+ times per week, no other major psychiatric issues, previous MSSE exposure within 3 months MSSE: Purposefully designed auditory, tactile, and olfactory stimulation with varied lighting, music, aromas, and textural objects, nonsequential stimuli, Activity: individually selected (e.g., puzzles) Mood, behavior, cognition Day hospital, UK Short-term assess: Behavior/mood: Interact (during sessions), Interact Short (10 min before and after) Long-term assess: Cognition: MMSE, Behavior: BRS, CAPE, BMD, REHAB, CAS Both groups: ↑Speech ↑Interpersonal ↑Env Engagement ↑Initiative, alert ↓Bored/inactive;MSS group: ↑Attentive to Env +Mood effect AH +Behavior effect AH No lasting LT effect Cornell (2004) 3a Single-case design, Snoezelen sessions, 2× per week for 4 weeks, 30-min sessions, Behavior/mood assessed 30 min before and after each session n = 4, Women with dementia diagnosis, attending day hospital MSSE: Snoezelen room, bubble tubes, mirrors, color-changing fiber optic sprays, music, image and gel projector for walls, mirror ball to project colored patterns, fiber optic carpet, and tactile objects Mood, behavior, response to equipment Day hospital, UK Dementia: Medical diagnosis with BRS, CAS, CAPE, & MMSE less than 10 (moderate stage) ↑Mood, ↑Behavior; Positive mood/behavior lasted at least 30 min, some reported effects lasted 24 h Individual characteristics: medical records Mood/behavior: Interact and Interact Short Response to equipment: PI generated tool Maseda et al (2014a) 2 RCT n = 30, 3 groups: MSSE, Activity, control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, i.e., cards, quiz, photos, Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Biomedical: Heart Rate and SpO2 Specialized residential elderly center, Spain Dementia: GDS Biomedical: Finger pulse oximeters Mood & Behavior: Interact Scale & Interact Short Scale ↑Mood, ↑Positive behavior, ↓Heart rate ↑SpO2 ↔ Diff(s) BG Controlled longitudinal, between-group study, 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, Design followed protocol suggested by Baker et al. (1998) Maseda et al (2014b) 2 RCT n = 30, 3 groups: MSSE, Activity, Control, Dementia level mild-severe MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, tactile board Activity: 1-to-1 individually selected (e.g., cards, quiz, photos) Control: Typical daily routine, no MSSE or individualized activity Mood, Behavior, Emotional, Cognitive and Functional levels on ADLs, Agitation Specialized residential elderly center, Spain Dementia: GDS Agitation: CMAI MSSE/Activity: ↑Mood ↔Cog Level, ↑Pos Beh Diff(s) BG: MSSE Group ↑F(x) ADL, ↓CMAI Non Ag, Activity/Control ↔F(x) ADL Controlled longitudinal, between-group study; 2× weekly sessions for 30 min for 16 weeks, 8-week follow-up, protocol by Baker et al. (1998) Behavior: NPI-NH Mood: CSDD Cognitive Status: MMSEFunctional status with ADLs: Barthel Index Milev et al (2008) 2 RCT n = 21, 7 in each group: control, 1 session per week MSSE: Snoezelen Room, bubble tubes, fiber optic cables, vibroacoustic seating, mirror ball, interactive projection system, music, aroma therapy, and tactile board, Baker protocol, Activity: 1-to-1 individually selected, (e.g., cards) Behavior LTC, CAN Dementia: Medical diagnosis (DSM IV) Behavior: DOS, CGI-I MSE groups: ↓DOS, ↑Pos Beh, Results increased with session intensity, results maintained over 12 weeks Pilot study, 24-week single-blind study, 30-min sessions, 1-3× per week for 12 weeks, no MSE for 12 additional weeks Minner et al (2004) 3a Outcome-based quality improvement study, Single facilitator model, duration varied, Behavior assessed before, during, and after for 1 year period n = 19, Residents with frequent behavior problems MSSE: Snoezelen Room, bubble tubes, rocker, bean bag chair, lightning ball, hanging plastic beads, vibrating pillow, lava lamp, aromatherapy diffuser, music, colored lights, and mirror Problem behaviors: Noisy breathing, Negative vocalization, Sad/frightened expression, Tense body language, and Fidgeting Residential nursing facility, USA CDS/DS-DAT ↓Neg behavior, ↑Pos behavior Riley-Doucet (2009) 4 Pilot study, qualitative research Design, number, and length of sessions varied, Avg 2× per week for 28 min over a total of 3 weeks n = 10, Participants: Aged 65+, dementia diagnosis; n = 10, Caregivers: aged 18+ MSE: Quiet room in home and portable Snoezelen kit: Bubble tube, evening breeze fan, chase light string, plasma ball, solar effects projector, music, vibrating tube, and aroma diffuser Participant and caregiver perceptions of MSE, Level of cognitive impairment, Participant use of MSE, Participant’s behavioral response/ apparent enjoyment Private homes, USA Dementia: Confirmed medical diagnosis & SPMSQ (mod-severe) Caregiver & participant MSE perceptions: semi- structured interviews Demographics: self- report questionnaire Themes: +PT satisfaction w/ MSE, ↑positive affective state, ↑PT cog, ↓CG burden, +CG satisfaction, +Interpersonal PT & CG relationships Use of MSE: COR Riley-Doucet (2013) 3a Pilot study, within- subjects, repeated- measures design, 4 weeks, Number and length of intervention sessions varied, Avg 5× per week for 15 min per session for 4 weeks, total 42 collective sessions, Intervention occurred when PT exhibited BPSD n = 8, Participants: Aged 65+, dementia diagnosis, BPSD history at DCC, attend DCC at least 2× week; n = 4, Caregivers: Aged 18+ MSE: Corner of large activity room enclosed with room dividers, Comfortable chair placed in area, portable Snoezelen kit: aroma diffuser, chase light string, evening breeze fan, fiber optic string light, plasma ball, solar effects projector, music, and vibrating tube Participant: Agitation, Reaction to MSE Caregivers: Satisfaction with MSE to manage BPSD Adult day care center, USA Dementia: Confirmed medical diagnosis & SPMSQ (mostly severe) Demographics: DCC records and questionnaire Length of time in and enjoyment of MSE & engagement time: Obs record Agitation: ABS Caregiver satisfaction: Caregiver exit survey ↓Agitation, +Reaction to MSE, +CG satisfaction; Hierarchy of preferred stimuli: Vibrating tube, music, fiber optic string light, chase light string, solar effects projector, aroma diffuser, plasma ball, and evening breeze Staal et al (2007) 2 RCT Between-group comparison, 2–3 sessions to assess sensory preferences, 6 sessions of MSBT at FT intervals of FT15, FT20-25, FT30 n = 24, MSBT group Avg age 80, Control group Avg age 72 MSBT: Individualized, 1-to-1 administered sensory stimulation (visual, auditory, olfactory, and tactile) Agitation, Apathy, ADL Acute care Geri-psych unit Dementia: Medical diagnosis with BPSD (mod-severe) Cognitive F(x): MMSE MSBT Group: ↓Agitation ↓Apathy ↑ADL Agitation: PAS Physical health: MAI ↔RADL, BDP Behavior: SANS-AD ADL: KI-ADL & RADL & BDP Ward-Smith et al (2009) 2 Between-group comparison study, controlled, not randomized, Intervention between 1 and 4 pm after antipsychotic meds, 84 s essions over 3 months n = 14, 7 in each group, 12/14 female, Avg PT age 81 MSSE: MSE Room, reclining bench, dimmable lights, bubble tubes, light wheel, vibrating pillows, fiber optic lights, aromatherapy, DVDs, comfortable seating, and wind chimes Incidences of problematic behavior SCU within a LTC, USA Dementia: Medical diagnosis MSE Group: ↓PsyB incidence ↔PsyB range; Control group: ↑PsyB incidence Behavior: PBAR and medical records Note: ↑ = increase, ↓ = decrease, ↔ = no change, + = positive effect. ADL = activities of daily living; AH = at home; ABMI = Agitation Behavior Mapping Instrument; ABS = Agitated Behavior Scale; Ag = aggressive; ALF = assisted living facility; Assess = assessment(s); Avg = average; BDP = Beck Dressing Performance Scale; Beh = behavior; BPSD = behavioral and psychological symptoms of dementia; BG = between group; BMD = Behavior and Mood Disturbance Scale; BRS = Behavior Rating Scale; CAN = Canada; CAPE = Clifton Assessment Procedures for the Elderly; CAS = Cognitive Assessment Scale; CDR = Clinical Dementia Rating; CDS = Comfort/Discomfort Scale; CG = caregiver; CGI-I = Clinical Global Impression-Improvement; CMAI = Cohen-Mansfield Agitation Inventory; Cog = cognition; COR = Caregiver Observation Record; CSDD = Cornell Scale for Depression in Dementia; DCC = Day Care Center; Diff(s) = differences; DOS = Daily Observation Scale; DS-DAT = Discomfort Scale-Dementia of the Alzheimer’s Type; DSM IV = Diagnostic Statistical Manual of Mental Disorders 4th Edition; Env = environment; F(x) = functioning; FT = fixed time; Geri-psych = geriatric psychiatry; GDS = Global Deterioration Scale; GIP = Swedish Behavior Observation Scale for Intramural Psycho-geriatrics; KI-ADL = Katz Index of Activities of Daily Living; LT = long term; LTC = long-term care facility; MAI = Multi-level Assessment Instrument; MMSE = Mini-Mental State Examination; Mod-severe = moderate to severe; MSBT = multisensory behavioral therapy; MSE = multisensory environment; MSS = multisensory stimulation; MSSE = multisensory stimulation environment; Neg behavior = negative behavior; Non Ag = nonaggressive behavior; NPI-NH = Neuropsychiatric Inventory-Nursing Home; Obs = observation; PAS = Pittsburg Agitation Scale; PBAR = Psychotic Behavior Assessment Record; PI = principle investigator; Pos behavior = positive behavior; PsyB = psychotic behavior; PT = participant; RADL = Refined Activities of Daily Living Assessment Scale; RCT = randomized controlled trial; REHAB = Rehabilitation Evaluation Hall and Baker Tool; RT = reminiscence therapy; SANS-AD = Scale for the Assessment of Negative Symptoms in Alzheimer’s Disease; SCU = specialty care unit; SPMSQ = Short Portable Mental Status Questionnaire; SpO2 = arterial oxygen saturation; SR = self-report. View Large Effects of MSE Therapy Generally, the studies reported positive results regarding the impact of MSE therapy on BPSD. Specific results included a decrease in the number of BPSD incidences (Maseda et al., 2014a; Minner et al., 2004; Riley-Doucet & Dunn, 2013; Staal et al., 2007; Ward-Smith et al., 2009), positive changes in mood/behavior (Baillon et al., 2005; Baker et al., 2001; 2003; Cornell, 2004; Maseda et al., 2014b), and positive changes in engagement (Milev et al., 2008). Significant differences were not found in the between-group studies when MSEs were compared with other one-to-one interventions (Maseda et al., 2014a; Staal et al., 2007; Ward-Smith et al., 2009). Results on long-term effects were mixed, as some found that observed positive effects did not last significantly beyond the treatment sessions (Baker et al., 2001; 2003; Cornell, 2004). Although one study demonstrated long-term benefits of MSE therapy at 12 weeks after treatment (Milev et al., 2008), no other studies found long-term effects. Three studies examined how participants responded to the MSE equipment: one in a qualitative self-reporting format (Riley-Doucet, 2009) and two with an observational tool developed by the principal investigators (Cornell, 2004; Riley-Doucet & Dunn, 2013). Behavior and Mood Behavior and/or mood were the most commonly assessed outcome variables across the 12 studies included within this review. Several investigators used the Interact and Interact Short (Maseda et al., 2014a) to evaluate behavior and/or mood. The Interact is an observational assessment tool designed to measure the impact of the intervention on people with dementia using a mood/behavior rating scale. Other tools used to assess behaviors and mood included the Cohen-Mansfield Agitation Index (CMAI) (Baillon et al., 2005; Sánchez et al., 2013), Neuropsychiatric Inventory-Nursing Home (NPI-NH), Cornell Scale for Depression in Dementia (CSDD) (Maseda et al., 2014b), Psychotic Behavior Assessment Record (PBAR) (Ward-Smith et al., 2009), Daily Observation Scale (DOS) (Milev et al., 2008), and Clinical Global Impression-Improvement (CGI-I) (Milev et al., 2008). Activities of daily living, such as feeding or dressing one’s self, were assessed using the Barthel Index (Maseda et al., 2014b), Katz Index of Activities of Daily Living (KI-ADL), Refined Activities of Daily Living Assessment Scale (RADL), and Beck Dressing Performance Scale (BDP) (Staal et al., 2007). Trained staff and researchers completed the standardized assessments, whereas participants and family members completed preference assessments. Six of the included studies examined MSE impact on both behavior and mood (Baillon et al., 2005; Baker et al., 2001; 2003; Cornell, 2004; Maseda et al., 2014a; Sánchez et al., 2013). Two evaluated MSE impact on agitation (Riley-Doucet & Dunn, 2013; Staal et al., 2007), two studied incidences of problematic behavior alone (Milev et al., 2008; Ward-Smith et al., 2009), and two incorporated caregiver perceptions of the MSE intervention among family caregivers (Riley-Doucet, 2009) and dementia-care staff members (Riley-Doucet & Dunn, 2013). Overall, the studies showed consistent improvement in mood, an increase in positive behaviors, and/or a reduction of BPSD (Baillon et al., 2005; Baker et al., 2001; 2003; Cornell, 2004; Maseda et al., 2014a; 2014b; Milev et al., 2008; Minner et al., 2004), either during or following MSE therapy. Although all of the included studies demonstrated a positive impact of MSE therapy on BPSD, several showed no difference in impact compared with a one-on-one control activity, thus reporting that the study and control interventions were equally effective. Alternative therapies shown to be equally effective were reminiscence therapy (Baillon et al., 2005) and directive activities requiring intellectual/physical demands (i.e., playing cards, quizzes, and looking at photographs) (Baker et al., 2001; 2003; Maseda et al., 2014a; 2014b). One study reported that the impact of MSE therapy increased with more sessions per week (over 8 weeks) and a longer duration of therapy over time (Milev et al., 2008). Biomedical Response As an adjunct to behavior, several studies investigated biomedical parameters including heart rate (Baillon et al., 2005; Maseda et al., 2014a) and cognition (Baker et al., 2001; 2003; Maseda et al., 2014a). Baillon and colleagues (2005) demonstrated that both the MSE and reminiscence therapy showed a decrease in the mean heart rate by the end of each session, with more post-session carryover effect after MSE therapy. Other researchers (Baker et al., 2001; 2003) found that differences in cognition between MSE group versus activity groups without MSE were not significant in either study. Quality of the Evidence Eight out of 12 studies were rated Level 2 evidence, three were Level 3a, and one was Level 4 evidence, indicating that the majority of articles were of relatively high levels of quality, as seen in Figure 4. Figure 4. View largeDownload slide Levels of evidence of reviewed studies. Figure 4. View largeDownload slide Levels of evidence of reviewed studies. Discussion Summary of Efficacy and Gaps in the Literature Overall, published studies support efficacy of MSEs in reducing BPSD, potentially improving QoL for participants and caregivers. However, the studies do not offer conclusions on the timing of MSE therapy (i.e., when to use it), the frequency with which it should be used, or how to identify candidates who would likely benefit from MSE therapy. Furthermore, reviewed studies do not show that the intervention was more effective than other potentially less expensive therapies, such as reading to and talking with an individual. Results were mixed regarding whether the MSE interventions provided lasting effects for participants. This systematic review of MSE interventions revealed several gaps in the literature. The topic has been researched widely since 1990, as evidenced by the 1,226 articles found after the original database search. However, only 12 of the 1,226 articles identified shared a comparable level of intervention design and analogous empirical quality. A weakness in the studies using activities as comparators is the level of cognition required to complete the tasks. For example, activity-based sessions require higher levels of cognitive functioning in order for the participant to understand instructions and complete tasks, such as playing cards or completing puzzles. This is a major weakness in studies comparing MSE therapy with activity sessions and should be abandoned in further research. Recommendations for the Design of Future Studies An examination of the study designs reveals inconsistencies and provides directions for future research. For instance, the physical locations of the settings, duration of therapy sessions, and duration of the data collection period varied widely, ranging from temporary MSEs made by placing room dividers in the back corner of a therapy room, to rooms in people’s homes, to specifically designated rooms within a medical facility. Not all studies reported whether MSE interventions were provided consistently on the same day of each week, at the same time of day, and for the same duration each day, which should be made clear in future studies. There is a need for more research that follows a controlled, longitudinal investigation of the impact of MSE environments on behavior in a methodologically transparent, rigorous, and organized way that can be replicated. Furthermore, future studies should meet the criteria for higher levels of evidence quality. Important questions that have not yet been studied include the identification of the specific equipment that is most impactful, the role of participants’ sensory preference on the effectiveness of MSE therapy, and the use of study methods that are specifically designed to evaluate small sample sizes. Another important question to address is whether there are specific rooms where problem behaviors typically occur for people living with dementia (i.e., the bathroom) where interventions might be implemented to achieve more significant results. Investigations pursuing these questions can potentially help establish the value of MSE therapy in the future. Another important question is whether taking people to an MSE to achieve sensoristasis, then placing them back in the environment that may have contributed to their sensory disequilibrium, is an appropriate therapeutic approach. It is conceivable that, instead, more effort should be directed toward finding design solutions that allow individuals to have greater control at all times over the sensory conditions of their immediate surroundings, assuming that they could understand how their actions might alter their environment in a manner that is beneficial for them. Evidence About Other Environmental Interventions There is additional evidence regarding the impact of purposefully built environments as behavioral interventions for people with dementia. Clark, Lipe, and Bilbrey (1998) investigated the impact of music as a nonpharmacological behavioral intervention for people with dementia. The music condition demonstrated significant decrease in a majority of aggressive behaviors, and hitting. It was observed that the participants’ moods were significantly better during the music condition and they were overall more cooperative during assisted bathing. Whall and colleagues (1997) and Cohen-Mansfield and Parpura-Gill (2007) investigated the impact of natural elements within the bathing room on acts of agitated, aggressive behavior by patients with dementia. The natural elements used as positive distractions included sounds of birds, babbling brooks, corresponding images, and food. The study revealed decreased agitation during the natural element intervention. Environmental cues such as signs, labels, and color coding can be used as effective environmental interventions to support wayfinding and decrease wandering (Kincaid & Peacock, 2003; Marquardt, 2011; Passini, Pigot, Rainville, & Tétreault, 2000). These studies support the role of the environment as a behavioral intervention leading to reduced BPSD for people with dementia which can lead to improved care outcomes (Marquardt et al., 2014). It should be noted that environmental interventions should be implemented with careful consideration to the individual preferences and sensitivities of participants so as not to induce BPSD through unintended overstimulation. Feasibility of Implementation in Practice Settings Although MSE was not shown to have a greater effect on BPSD than other types of one-on-one activities, e-searchers and care providers must consider whether regular and consistent one-on-one interaction is feasible in adult day care facilities, special care units, and assisted living facilities, as this is not congruent with typical staff-to-patient ratios that impede the regular one-to-one interaction within an assisted living situation. But, it is important to remember that there are other ways to provide one-on-one therapy interactions that do not involve staff, such as those that are between different patients, between patients and volunteers, and between patients and family members. One-on-one activities with persons other than clinical staff may provide similar results in a relatively low-cost, purposeful manner. These activities might be as simple as peeling and eating a tangerine together to engage multiple senses (tactile, visual, olfactory, taste, and sound). When regularly occurring one-on-one multisensory activities are not feasible, other sensorial activities, such as group music interventions, may help reduce BPSD. Group activities may be led by staff, volunteers, or other residents. Although the innovative nature of multisensory environments piques the interest of caregivers, an often cited barrier to implementing MSE is cost. Specific MSE equipment can range in price from $995.00 to $6,495.00 for a mobile sensory cart, and a built MSE room that is approximately 120 square feet can cost an estimated $28,000.00 to $30,000.00 for equipment, shipping, and installation. Because of the cost of the equipment, it would be beneficial to discern if there are specific pieces of equipment that are preferred more than others to help decision makers selecting MSE equipment make the most efficient use of available resources. For instance, if research shows that the most impactful types of MSE equipment are the bubble tube, projector, and fiber optic cables, each can be purchased a-la-cart and used purposefully within a smaller interior space. Limitations Some limitations to this study are acknowledged. First, only empirical quantitative or qualitative studies from 1990 to 2015 written in English were included. Empirical research within this review was considered to be studies that were based on either experimentation or observation to address a question or evaluate a hypothesis. Although some qualitative studies did emerge within this criteria, the overwhelming results were skewed toward quantitative research. Second, the authors sought articles for review that incorporated at least three sensory-based items including ergonomic virbroacoustic furniture, bubble tubes, color-changing lights, music, and fiber optics. The intention for this specific requirement was to compile a list of studies that were as homogenous as possible for in-depth comparison of assessments and outcomes. However, this may have excluded multisensory stimulation studies that used informal yet relevant modes of sensory stimulation. Despite these limitations, all effort was made by the authors to conduct a thorough investigation of the available literature in a way that allowed for in-depth comparison of intervention, assessment, and outcome measures to aid the development of future research of MSE therapy. Conclusion According to this literature review, there is evidence that MSE interventions have a positive impact on mood and behavior (e.g., independence in ADLs), reduce BPSD, and therefore likely improve QoL for patients and caregivers. However, much of the focus of the studies has been on one-to-one interaction with people with moderate-to-severe dementia using a wide variety of study designs and assessment tools. Furthermore, the use of pre-post studies using impersonalized MSE therapy solutions with activity comparators should be abandoned in future research. Single-case design study methods, well validated in the field of applied behavioral research, should be investigated in future studies because they align well with the person-centered approach at the core of MSE interventions and are controlled. Also, direct participant preference should be systematically evaluated before the intervention begins and comparators that do not require any more cognitive ability than MSE therapy should be used. None of the studies included in this review focused on the impact of MSE therapy during assisted bathing which is an area of critical need in dementia care. Sensorial deprivation or overload can result in behavior problems including agitation and aggression and tend to occur during times of personal care assistance (Cipriani, Vedovello, Nuti, & Di Fiorino, 2011; Sloane et al., 2004; Teri, Larson, & Reifler, 1988). In fact, it is believed that 86% of nursing home residents with dementia display problem behaviors during times of bathing and toileting assistance (Baker, Hanley, & Mathews, 2006; Sloane et al., 2004). Purposefully designed, person-centered MSE bathing environments have the potential to reduce aggression for people with dementia in a specific area of critical need, where a majority of BPSD occur. These future studies will greatly benefit the QoL of the rising number of people with dementia and their caregivers through a methodologically sound research design and systematic preference assessment. Results from these studies will not only benefit people living with dementia, but potentially a broader population of people with cognitive impairments ranging from developmental to trauma-related disabilities. Supplementary Material Please visit the article online at http://gerontologist.oxfordjournals.org/ to view supplementary material. References References marked with an asterisk (*) were included in the review. * Baillon S. van Diepen E. Prettyman R. Rooke N. Redman J. & Campbell R . ( 2005 ). Variability in response of older people with dementia to both Snoezelen and Reminiscence . 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The GerontologistOxford University Press

Published: Feb 13, 2017

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