SYMPOSIUM
Multisensory environments and
older people with dementia
T he increase in longevity
has led to a higher
percentage of the population
developing dementia and
mental health problems (Jorm
et al, 1987). The cost of
caring is high on the agenda
of health authority and social
services debate. The needs of
older people who are able to
communicate are currently
being met using a range of
therapeutic group and
individual interventions, e.g.
reminiscence therapy, reality
orientation and relaxation.
Unfortunately these
interventions fail to meet the
needs of older people who
lose the ability to
communicate verbally
(Kitwood, 1993). Multisensory
environments and a
multisensory model of care
appear to go some way to
meeting these needs and
improving quality of life for
patients and carers (Hope,
1997).
Mrs Lesley Ann Wareing is
Head Occupational
Therapist at Kings Park
Community Hospital,
Bournemouth BH7 6JE,
Professor Peter G Coleman
is Professor of
Psychogerontology,
Department of Geriatric
Medicine, University of
Southampton,
Southampton and
Professor Roger Baker is
Head of Research and
Support Unit, Bournemouth
University, Bournemouth
Correspondence to:
Mrs LA Wareing
Nursing & Residential Care, July 1999, Vol 1, No 4
Lesley Ann Wareing, Peter G Coleman and
neuropsychological
assessment may assist with
diagnosis. The Mini-Mental
Roger Baker report on a study into the State Examination is
use of multisensory environments with currently used as a guide,
and is shown with the
four men in the later stages of dementia. natural history of
Alzheimer’s disease in Figure
The benefits that resulted following
1 (Feldman and Gracon,
treatment were reduction in apathy and 1996).
Individual progression
socially disturbed behaviour with varies considerably in the
increased interest in the environment. pattern of cognitive
impairment and the rate of
decline. Initially, patients may
Dementia progressively become less present with depression and
The Royal College of physically and mentally able, the patient with intact insight
Physicians of London and more vulnerable to social will present with good social
Committee on Geriatrics isolation, and present a facade (Conroy, 1997).
(1981) describes dementia as: challenge to both service However, word finding
‘The global impairment of providers and clinicians. difficulties, loss of
higher cortical functions, Dementia does not topographical memory and
including memory, the discriminate between sex, spatial perception causing
capacity to solve the social class or occupation disorientation in place and
problems of day-to-day and its prevalence increases time, may be obvious.
living, the performance of exponentially with age,
learned perceptuomotor reaching 20% of people over Mild to moderate stage
skills, the correct use of 85 years of age. Although diagnosis at the
social skills and control of Characteristics vary as the early stage of dementia may
emotional reactions in the disease progresses (Gray and be difficult to distinguish
absence of gross clouding Fenn, 1993). from normal ageing, this
of consciousness.The becomes clearer with loss of
condition is often Early stage cognitive abilities affecting
irreversible and In the early stages of executive functioning,
progressive’. dementia, short-term visuospatial function,
It is described more simply memory loss is often language and memory. As
by the Alzheimer’s Disease accompanied by loss of relentless deterioration
Society (1992): functional autonomy and continues, memory for
‘Dementia is used to social skills. Relatives current events diminishes
describe a group of frequently report personality with loss of memory for
illnesses which cause a change as the first sign, family member names.
progressive decline in the although on testing there is Activities of daily living and
ability to remember, to often cognitive decline as language become
learn, to think and to well. Memory tests alone are progressively more difficult
reason’. not yet specific enough to and supervision is required
Whether dementia is use as diagnosis for for washing, dressing,
described in a clinical, Alzheimer’s disease at the toileting, eating, and for most
psychological or social early stage (Gauthier et al, social activities (Gauthier et
context, older people 1997), and a al, 1997). Neuropsychiatric
211
SYMPOSIUM

symptoms include anxiety
and phobias, hallucinatory
disturbances, paranoid and
delusional symptoms with
subsequent aggressiveness
and marked personality
changes.
Later stages
The deterioration in daily
living skills continues in the
later stages of dementia,
resulting in wandering,
day–night reversal of sleep
pattern, loss of verbal
communication with
disinhibited antisocial
behaviour, aggression and
finally withdrawal. Social
isolation occurs as the result
of increasing inability to
have meaningful attachments
30
25
20
Mini Mental State Score
to people (Miesen and
Jones, 1997) and non-
psychopathological
symptoms, e.g. depression,
aggression and agitation,
contribute to the burden of
caregivers (Haupt, 1996).
The effects of sensory
deprivation is well
documented generally
(Solomon et al, 1961; Bower,
1967; Marieb, 1995) and is
likely to aggravate the
patient’s condition.
The multisensory
environment
Behavioural and
environmental interventions
aimed at increasing
appropriate sensory
stimulation show promise
Symptoms
Diagnosis
(Moffat et al, 1993; Baker et
al, 1997; Hope, 1997; Spaull
and Leach, 1998).
This study focused on
communication in the later
stages of dementia when
traditional interventions
ceased to have meaning and
the patients appeared to be
locked in a world unable to
express their needs and
desires. Rehabilitation is
defined by the World Health
Organization (1946) as:
‘The use of all means
aimed at reducing impact
of disabling conditions
and enabling disabled
people to achieve optimal
social integration’.
The use of the
multisensory environment
attempts to meet this
definition for people with
dementia. Long and Haigh
(1992) conducted an
exploratory study and found
that clients with a learning
disability responded
positively to the new
stimulating multisensory
interest and active looking.
Baker et al (1997) found
patients were less apathetic
by the end of their sessions
and the main long-term
benefit was improvement in
socially disturbed behaviour.
This paper explores the
effect of a multisensory
environment on mood and
behaviour, and aims to
promote good clinically
effective practice. The four
men were in the later stages
of dementia.
Method
The study took place on a
12-bedded continuing care
ward at Kings Park
Community Hospital in
Bournemouth, Dorset.
Bournemouth is a pleasant
seaside resort on the south
coast of England, where
many people retire.
Consequently the number of
people over 65 years of age is
6% higher than the national
average, with a higher
percentage over 85 years of

Loss of functional
environment being offered age. All 4 patients fulfiled the
15 independence to them. Based on some of Dorset Health Authority
the original principles of Continuing Care Criteria and
sensory integration and were being cared for on a
Behavioural sensory environments, single sex ward as their
10 problems
Moffat et al (1993) published behaviour made it
the first evaluation on the inappropriate for them to be
Nursing care use of the Snoezelen* room cared for on a mixed ward.
5 required
for elderly and confused
people. They found that The study design
0 two-thirds of the patients Four single case studies will
Death
became calmer (less be described. There is a long
anxious) in the room and tradition of single case
there was a general increase research in experimental and
1 2 3 4 5 6 7 8 9 in level of interest. Staff clinical psychology (Kazdin,
commented that their 1982) and the progressive
Years
relationship with the patient nature of this disease makes
Early stage Mild-moderate Later stage
stage improved during the it difficult to conduct large
treatment sessions. Spaull scale studies.
and Leach (1998) suggest The men were aged from
Figure 1. Typical progression and stages in Alzheimer‘s disease. The that the behavioural changes 65–92 years of age (mean
curve represents the natural progression of the neurodegenerative that occur are in interaction, age=76 years) and they all
disorder with clinical and pathological features. Individual progression required assistance with
varies considerably in the pattern of cognitive impairment and the rate *Snoezelen is a registered physical activities including
of decline. Adapted from Gauthier et al (1997). trademark of Rompa. washing, dressing, toileting,

212 Nursing & Residential Care, July 1999, Vol 1, No 4


Figure 2. The equipment available for use in the study. A patient is
sitting in a recliner chair with a key worker.
bathing and eating. Three of
the four men were
aggressive, one was
withdrawn at the time of the
study, and all subjects were
agitated and low in mood.
The difficulties in
communication varied: one
man was mute, another
grunted occasionally, one
man muttered incoherently
most of the time and the
other shouted clearly
confused depressive
thoughts, such as ‘he wants
to die, kill me’.
The equipment used
The room used in the study
is shown in Figure 2. The
subjects in the study had not
previously used the room.
The equipment comprised:
■ Bubble tube and mirror
walls
■ Projector with fluid disc
which projected abstract
shapes
■ A mirror ball and projector
■ Galaxy box and two lava
lamps
■ Fibreoptic spray and
curtain (the curtain
provided the screen for
the raters)
■ Aroma diffuser and audio
tapes
Nursing & Residential Care, July 1999, Vol 1, No 4
■ Tactile equipment
■ A reclining chair.
Treatment sessions
The keyworker conducted a
free form ‘enabling session’
offering sensory stimulation
of sight, sound, smell or
items to touch and explore
encouraging relaxation,
choice and interaction,
according to personal
preference. The enabling
approach is defined as being
responsive to the patient, not
directive or demanding. The
sessions finished when the
patient indicated that he
wished the session to end, or
when he became very
relaxed and the keyworker
brought the session to a
close. Observations continued
outside the room when the
session finished early.
Sessions were conducted
by the patient’s keyworker
with two raters (the
researcher and a nurse)
sitting unobtrusively at the
opposite end of the room.
The raters recorded data
using the Interact Rating Scale
(IRS) (Baker and Dowling,
1995) 10 minutes before and
after sessions when the
patient was in the day room
Multisensory environments
Social disturbance
Communication
difficulties
30
Apathy
Physical disability
20
Score
10
0 subjects before
Subjects
Figure 3. Behavioural Rating
Scale scores pre-treatment.
and for 30 minutes during the
sessions. The treatment
sessions took place three
times a week for 3weeks, a
total of 9 sessions each.
Measurements
Baseline measurements:
The Behavioural Rating Scale
(BRS) is part of the Clifton
Mood
Speech
Relating to others
Relating to environment
Need for promoting
Stimulation level
Figure 4. Interact Rating Scale items measured.
Assessment Procedures for
the Elderly (CAPE), and was
developed by Pattie and
Gilleard (1979). The BRS was
used once a week for
12weeks to provide a
baseline measurement. It
measures social disturbance,
communication difficulties,
apathy and physical disability.
A stacked bar chart of the
BRS (Figure 3) shows the
BRS scores of the four
commencement of the study,
indicating the severity of their
condition.
Measurement of treatment
effects using IRS: An
extensive literature search
revealed a need for more
specific rating forms to record
any immediate change in
behaviour during treatment
sessions. The IRS scale was
produced by Baker and
Dowling in 1995, and was
used for before and after
treatment sessions (Figure 4).
1. Tearful/sad
2. Happy/content
3. Fearful/anxious
4. Confused
5. Talked spontaneously
6. Related well to other staff/patients
7. Attentive/responding to/
focused on environment
8. Did things for own initiative
9. Wandering, restless or aggressive
(undesirably active)
10. Enjoying self, active or alert
(desirably active)
11. Bored, inactive or sleeping
inappropriately (undesirably active)
12. Relaxed, content or sleeping
appropriately (desirably inactive)
213
SYMPOSIUM

It consists of 12 questions terms during the treatment 6

addressing mood, behaviour
and interaction, rated across
5 possible scores, from 1–5. A
longer version of IRS with
22 questions (the additional
questions focusing on the
phase in each man, and Subject A
remained low for the 3 weeks
5
following treatment, were in
the domain of apathy and
social disturbance. 4
Before

Scores
relationship to the keyworker IRS scores 3
During
and relationship to the The mood and behaviour
environment) was used scores were recorded before After
2
during treatment sessions. IRS and after treatment sessions.
has user instructions and Two of the four men
defines each behaviour and recorded positive changes on 1
mood item clearly. four of the same mood items,
Interrater reliability of IRS: these were: 0
1 2 3 4 5 6 7 8 9
Observations of behaviour ■ Happiness
require observers to make ■ Relating to the Treatment sessions
judgments about whether a environment
6 Subject B
response occurs in a given ■ Enjoying self
situation. Agreement of raters ■ Relaxed, content.
5
(observers) for the treatment The IRS scores for item
sessions was therefore central seven, ‘relating to the
to accurate recording; environment’ were significantly 4
evaluation and checks or different pre-treatment and
Scores

agreement were carried out post-treatment for three of the

3
throughout the study. four patients. There was a
Pearson’s correlation was slight positive change in
2
used for this purpose, the ‘relating to the environment’
mean reliability correlation score shown by the fourth
coefficient of the two raters patient, however, this was not 1
with the four subjects was r = statistically significant.
0.995 which is very good, The significant difference is
0
indicating agreement between shown graphically in Figure 5 1 2 3 4 5 6 7 8 9
the raters observations and for the nine treatments
Treatment sessions
recordings. before, during and after each
session, for each of the three 6
Subject C
Results men.
BRS scores 5
The mean BRS score reduced Discussion
in all four subjects and is There is increasing evidence
4
shown in Table 1. The scores to suggest that multisensory
that reduced, indicating environments are influential
Scores

improvement in behavioural in the care and treatment of 3

Table 1. 2

MEAN BEHAVIOURAL RATING SCALES SCORES BETWEEN

PHASES
1

Mean before Mean during Mean after

Subject treatment 3 week treatment treatment 0
1 2 3 4 5 6 7 8 9
A 26.6 24 24.3
Treatment sessions
B 19.6 18.3 14
C 24 21 19.6
Figure 5. Relating to the environment. Interact Rating Scale scores for
D 21.16 18.3 20.6 the three men, showing the change in scores, before, during and after
each of the nine treatment sessions.

214 Nursing & Residential Care, July 1999, Vol 1, No 4


people with dementia
(Dowling et al, 1997;
Holtkamp et al, 1997; Hope,
1997; Morrissey and Biela;
1997; Spaull and Leach, 1998).
This small study found that
three out of the four men
increased interest in their
surroundings following
treatment sessions. The
results complement findings
of Spaull and Leach (1998)
who found significant
changes in active looking,
interest and interaction which
confirm a decrease in apathy.
Holtkamp et al (1997)
focused on behavioural
problems and found they
reduced following treatment
sessions in the multisensory
room. Baker et al (1997)
reported an increase in
memory recall, suggesting this
could be as a result of
increase in concentration
ability, which was found by
Ashby et al (1995) with people
with learning disabilities.
Conclusions
Given the opportunity to
experience an appropriate
multisensory environment,
the mood and behaviour of
people with severe dementia
may be altered by an increase
in interest and decrease in
apathy. Qualitative recordings
made by the raters on activity
and behaviour during each
treatment session reveal that
all four men enjoyed tactile
stimulation during some of
the treatment sessions, this
included holding and
exploring the fibreoptic spray,
couche balls, vibrating
cushion or vibrating tube and
items from the tactile box,
e.g. keys and tools.
As evidence increases that
multisensory environments
provide a valuable, humanistic
approach to care (Woodrow,
1998), therapists should take a
lead role in this development
Nursing & Residential Care, July 1999, Vol 1, No 4
and assessment of individual
needs should include the use
of a multisensory
environment. The processes
that occur in the environment,
however, require further in-
depth investigation and
research. Clinicians working
with this patient group should
be diligent in seeking out best
possible practice to meet the
need of the people for whom
they care.
This small study provides
further evidence of the value
of multisensory environments
and sensory stimulation for
this vulnerable and growing
number of people. Never has
there been a more timely
focus as clinical effectiveness
and clinical governance are
high on the agenda of all
health-care managers,
clinicians and carers. NRC
This article is reprinted from the
British Journal of Therapy and
Rehabilitation Vol 5(12), p. 624–9
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KEY POINTS
■ Individual case analyses can provide the catalyst for larger
scale research and evidence-based practice.
■ Current therapeutic interventions are not meeting the needs of
those in the later stages of dementia who have the most
difficulty in communication.
■ There is a need for development and use of validated tests to
assess the effect of therapeutic interventions on behaviour of
patients with dementia.
■ There is increasing evidence that multisensory environments
can provide a therapeutic setting to treat and care for older
people with dementia.
■ The processes occuring in the people with dementia in the
multisensory environment is little understood, and needs
further research.
215