A Pilot Study of the Physiological and Behavioural Effects of Snoezelen in Dementia

Recent interest in the use of Snoezelen as an intervention for agitated behaviour in dementia remains supported by limited evidence of efficacy. This pilot study aimed to develop an approach for assessing the effects of Snoezelen on agitated behaviour in patients with dementia and its comparability to an existing reference intervention. Ten subjects with dementia were randomised to receive a four week course of either Snoezelen or reminiscence therapy. Therapeutic effects were assessed using an agitated behavioural mapping instrument (ABMI), the Cohen-Mansfield Agitation Inventory (CMAI) and by heart rate recording. Differences in dementia severity between the two groups hindered direct comparison of outcomes. Both interventions were well tolerated and the majority of both Snoezelen and reminiscence sessions were rated positively. ABMI ratings suggested that Snoezelen might reduce agitated behaviour during and immediately after the session but that this effect is short-lived. CMAI scores indicated reduced agitated behaviour during the intervention period. Heart rate data showed both decreases and increases during the sessions for different subjects. With minor modifications, the measures used will be appropriate for a full-scale comparative trial. Both interventions may have helpful short-term effects and whilst for some subjects the sessions are primarily relaxing, for others, they may have a more stimulating effect. Introduction Snoezelen therapy is increasingly used in the management of patients suffering from dementia especially when there are associated behavioural and psychological problems. It is an intervention commonly used by occupational therapists in dementia and other fields of care. Snoezelen is a concept that originated in the Netherlands in the field of learning disabilities in the 1960‘s and 70‘s (Cleland and Clark 1966, Hulsegge and Verheul 1987). Nowadays it is used in the UK and many other parts of the world, not only in the field of learning disabilities, but also in dementia care, terminal care, child psychiatry and pain clinics. The concepts behind Snoezelen arose out of the observation that organised activities for people with learning disabilities consisted mainly of performance orientated tasks. These activities may place excessive expectations on patients and fail to make good use of their potential to enjoy a variety of stimuli. People with severe and multiple handicaps often experience very limited psychological and sensory stimulation, and have limited opportunities for individual choice and control. Studies of sensory deprivation in the 1960’s suggested that unchanging, monotonous environments are stressful and that thinking and concentration could be negatively affected (Leiderman et al 1958, Zuckerman 1964). This provided a possible theoretical basis for the therapeutic effects of Snoezelen. Snoezelen creates a relaxing, stimulating and failure-free environment. In Snoezelen rooms unpatterned visual, auditory, olfactory and tactile stimuli (stimuli which follow no specific pattern or form, and require no recognition or high level cognitive processing) can be offered (Baker 1998). No special tasks need to be performed and the patient is encouraged to explore the room at their own pace. The therapy being non-directive and the stimuli being unpatterned helps to create a relaxing effect (Baker et al 1997). This explains the word Snoezelen, which freely translated is a amalgamation of the Dutch words explore and relax. The similarities between the care for patients suffering from dementia and learning disabilities was one of the reasons for Snoezelen therapy to expand into dementia care. In particular behavioural and psychological symptoms in dementia could potentially be responsive to multi-sensory treatments. Although these symptoms are of enormous clinical importance (Rabins et al 1982, Knopman et al 1988) definitive interventions for them are not yet available (Auer et al 1996). Research in this area has been relatively sparse and mainly focused on pharmacological interventions. The few randomised controlled trials of antipsychotic drugs for behavioural and psychological symptoms in dementia indicated only moderate efficacy (Schneider 1996, Lanctot et al 1998) whilst side-effects are an important problem. For these reasons research into the effects of non-pharmacological interventions such as Snoezelen is important, although so far there have only been four studies published which include ten or more patients (Moffat et al 1993, Holtkamp et al 1997, Baker et al 1998, Hope 1998). Positive effects included a reduction in levels of disturbed behaviour (Holtkamp et al 1997) and positive changes in the levels of enjoyment, the ability to relate to others, talk spontaneously, recall memories and attentiveness to the environment (Baker et al 1998). Moffat et al (1993) found an increase in ratings of happiness and interest and a reduction in ratings of sadness and fear. This article describes a pilot study in which the effects of Snoezelen were compared with reminiscence therapy in a group of patients suffering from dementia with associated agitation. No other published research has focused specifically on patients with dementia who exhibit significant agitated behaviour and assessed the impact of Snoezelen on that behaviour. Reminiscence therapy was selected as the control intervention because it is an established, generally well tolerated and non task-orientated therapy in dementia (Woods et al 1992; Robertson 1996). It was carried out on a one-to-one basis rather than group setting in order to control for the effect of staff attention. In the unit where this research was carried out reminiscence is an established activity with dementia patients of all abilities. Reminiscence has been shown to be beneficial with people suffering from severe dementia (Finnema et al 2000) and the authors felt that although reminiscence with these patients is perhaps different, to reminiscence with individuals in the earlier stages of dementia, in terms of their ability to communicate verbally, they remain able to appreciate the materials presented to them and benefit from the interaction with others. We wanted to include an objective measure of the level of agitation / relaxation. Monitoring a physiological response such as heart-rate was felt to be a valid approach to this, which has been used successfully in a study of Snoezelen in learning disabilities (Shapiro et al 1997). The main aim of this pilot study was to evaluate the feasibility of using a detailed approach to behavioural and physiological assessments both before during and after Snoezelen sessions for patients suffering from various forms of dementia. Methods Setting and subjects: This randomised controlled pilot study was primarily based at a day hospital for psychiatry for the elderly, though one subject was recruited from an acute organic assessment ward. Subjects were included in the study if they had a clinical diagnosis of dementia and were rated by the staff as exhibiting significant agitated behaviour. Subjects were excluded if they had a significant hearing impairment, visual acuity of less than 3/6, were non-English speaking or consumed more than 21 units of alcohol per week. Any patient who developed evidence of delirium, significant ill health or had any change in their psychotropic medication immediately before or during the trial were withdrawn. As patients were unable to give informed consent, written consent was obtained from their next of kin. The project was approved by the local Research Ethics Committee. Procedure: Patients were randomised (using a sealed-envelope technique) to receive either eight Snoezelen or eight reminiscence therapy sessions, which took place twice weekly and lasted up to 40 minutes. The session was terminated immediately if the patient expressed the desire to leave. The Snoezelen therapy was given in a specially designed multi-sensory room, featuring comfortable seating and equipment designed to create a relaxing but also stimulating atmosphere. The equipment included a projector with special-effects wheels, projecting moving pictures slowly around the room, spotlights and mirror ball, fibre optic spray, music equipment, a bubble tube and an aromatherapy oil diffuser. Each patient was accompanied by one of the therapists (JR, NR, DAS) who had experience with both Snoezelen and reminiscence therapy. The therapist would facilitate rather than direct the patient to explore the environment. Reminiscence therapy also took place in a separate room, with a one to one patient/therapist ratio. At baseline patients’ dementia severity and cognitive impairment was rated using the Clinical Dementia Rating (CDR) scale (Hughes et al 1982, Berg 1988) and the Mini Mental State Examination (MMSE; Folstein et al 1975) respectively. The Cohen Mansfield Agitation Inventory (CMAI; Cohen-Mansfield 1989a), was completed at baseline, after the four weeks of therapy, and again after four weeks without intervention, both with the main carer and with the nurse-keyworker. The Agitation Behaviour Mapping Instrument (ABMI; Cohen-Mansfield et al 1986, 1989b, 1992), was completed by one of the investigators for four three-minute periods each session: once before the session, then immediately after, 15 minutes after and 30 minutes after the session. The Interact Scale (Baker and Dowling 1995, Baker et al 1997) was completed immediately after each session by the therapist, who also made detailed notes about the session. The patients’ heart rate was recorded from 10 minutes before each session, during the session and until 30 minutes after the session. Measurements: The MMSE is an 11 item scale which assesses cognitive function. Summing the points assigned to these items gives a maximum score of 30 (i.e. good cognitive function). A score of 23 or less is frequently used as an indication of cognitive decline sufficient for a diagnosis