Sensory stimulation and Snoezelen in the management of people with cognitive impairment

Dr Lesley CollierSenior Lecturer

What do we mean by sensory stimulation and Snoezelen

Snoezelen Sensory stimulation

Development of sensory stimulation and Snoezelen

Key areas of practice

• Learning disabilities (Autism, Downs syndrome)

• Older persons mental health (Dementia, depression)

• Acute mental health settings (Stress management, Schizophrenia)

• Palliative care (pain management, end of life care)

• Maternity care (pain management, stress management)

• Neurology (acquired brain injury, sensory retraining)

Problems identified

• Poor concentration

• Restlessness / wandering

• Shouting

• Aggressive behaviour

• Severe disorientation

• Unable to engage in purposeful activity

• General mood disturbance

• Anxiety

• Inability to follow simple instructions

• Severe memory loss

• Loss of social skills

• Physical faility

Sensory challenges

Person

Sensory processing

Just right challenge

Environmental demand

Environmental demandAdapted from the model of sensoristasis

Sensoryimbalance

Corticalsequelae

Behaviouralsequelae

Low-stimulus SensoryImbalance deprivation

Psychicdiscomfort

AgitationDecline in activities of daily livingDecline insocialfunctioning

High-stimulus StressImbalance exceeded threshold

Antecedent

Neu

ro-p

hysio

logical

psych

olo

gicaldeclin

eEn

viron

men

talfactors

Hu

man

interven

tion

Tenets of the model

• An imbalance may occur as a result of neurophysiological or environmental factors

• Too much high-stimulus activity can result in stress threshold being exceeded

• This will occur at a lower level if activity is unpleasant or processing is too fast.

• Too lower stimulus activity may lead to sensory deprivation.

Looking at skill levels

Sensory level

Perception Skill acquisition

(Normal development)

(Cognitive impairment / decline)

Sensory integration is critical for human development and function

Sensory intake

Sensory integration

Planning and

organisation of behaviour

Adaptive behaviour

and learning

Feedback

Attention

Arousal

Sensory modalities

Motivation and drive

Five basic assumptions

Potential for neuroplasticity

Interaction between higher order (cortical) and lower order (subcortical ) areas to modulate sensory input

Neurophysiological development of sensory integration follows a sequential pattern

Adaptive response – ability to adjust performance according to environmental demand

Presence of inner drive to meet and master a challenge

FlowCsikszentmihalyi, 1975

High cognitivedemand

LowCognitivedemand

Ch

allenge

Low Skills High

Anxiety

Flow

ApathyBoredom

The model of sensory processingDunn, 2002

Sensory processing patterns are based on how the nervous system reacts to input and how the person responds to that input.

Nervous system thresholds – thresholds for responding along a continuum based on sensory preference

Self regulation strategies - active management of sensory input

Patterns of sensory processing assessed by the Sensory Profile

Responding strategies

Threshold / reactivity Passive Active

High threshold with low reactivity

Low registration (Bystander)

Does not notice sensory events or is slow to respond

Sensory seeking (Seeker)

Looks for sensory experiences

Low threshold with high reactivity

Sensory sensitivity (Sensor)

Readily notices sensory stimuli, may be distracted by them

Sensory avoider (Avoider)

Deliberately acts to reduce or prevent exposure to sensory stimuli

The sensory tool box

• Sight - visual

• Sound - Auditory

• Touch - Somatosensory / vibration

• Taste - Gustatory and texture

• Smell - Olfactory

• Movement - Vestibular / proprioception

The use of multisensory approaches to improve function performance of people with moderate to severe dementia.

Dr Lesley Collier

Research questions

• To what extent do MSEs influence functional performance compared with a control activity (gardening)?

• To what extent are mood and behaviour affected by MSEs compared with the control activity group?

• To what extent is the sensory profile of the individual associated with the response to the MSE?

Randomised, single blind, repeated measures design

Baseline Intervention (sessions 1 to 12) Follow up

Pilot and Recruitment

Baseline assessment

SMMSE

GBS

Sensory profile

PAL

Randomised to:

MSE or

Gardening

Pre-session assessment

AMPS motor

AMPS process

NRS

Post-session assessment

AMPS motor

AMPS process

NRS

1/12 after Session 12

AMPS motor

AMPS process

NRS

Assessment of Motor and Process Skills (AMPS) Fisher 2003

• Standardised observational assessment of functional performance

• Motor and Process skills in ADL performance

• Uses Rasch analysis to adjust for skill complexity, rater severity and task difficulty

• Sensitive to change

• Significant change ≥0.5 logits

Baseline data: Recruitment sites

Recruitment sites MSE Gardening

NHS ward Assessment ward

NHS ward Continuing care

Day Hospital

Private Nursing Home

5 (29%)

6 (35%)

4 (23%)

2 (12%)

4 (31%)

4 (31%)

4 (31%)

1 (8%)

χ2(3, N = 30) = 0.6, p = 1.0

Baseline to last treatment session

• Both Motor and Process scores improved by the interventions

• No group differences

• Scores equally improved for MSE and gardening

Baseline Last tmt session

Baseline Last tmt session

MSE

Gardening-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

1

1.2

Motor Process

MSE

Gardening

Mean delta AMPS motor scores

-1

-0.5

0

0.5

1

1.5

2

2.5

3

3.5

4

1 2 3 4 5 6 7 8 9 10 11 12

Sessions

AM

PS

delt

a s

co

ress

MSE group

Gardening group

Mean delta AMPS process scores

-1

-0.5

0

0.5

1

1.5

2

1 2 3 4 5 6 7 8 9 10 11 12

Sessions

AM

PS

delt

a s

co

res

MSE group

Gardening group

Percentage improvers

6 7 %

4 5 % 4 7 %

3 0 %

0

10

20

30

40

50

60

70

80

Motor Process

Perc

en

tag

eMSE

Gardening

Motor scores t(30) = 2.28, p = .030Process scores, ns differences

p < .05

Baseline to last treatment session

• NRS scores improved (reduced) by the interventions

• No group differences

• Scores equally improved for MSE and gardening

Before

After

MSE

Gardening

0

5

10

15

20

25

30

35

40

NR

S M

ea

n

sc

ore

MSE

Gardening

Sensory stimulation and Snoezelen in the management of people with dementia

Dr Lesley CollierSenior Lecturer

What do we mean by sensory stimulation and Snoezelen

Snoezelen Sensory stimulation

Sensory challenges experienced by people with dementia

Person with

dementia

Sensory processing

Just right challenge

Environmental demand

Assessment tools to assess sensory needs

• Adult sensory profile (Brown & Dunn)

• Sensory profiling tool (Rompa)

• The Pool Activity Levels occupational Profiling Tool

(Pool, 2012)

Adult sensory profile

The model of sensory processingDunn, 2002

Sensory processing patterns are based on how the nervous system reacts to input and how the person responds to that input.

Nervous system thresholds – thresholds for responding along a continuum based on sensory preference

Self regulation strategies - active management of sensory input

Patterns of sensory processing assessed by the Sensory Profile

Responding strategies

Threshold / reactivity Passive Active

High threshold with low reactivity

Low registration (Bystander)

Does not notice sensory events or is slow to respond

Sensory seeking (Seeker)

Looks for sensory experiences

Low threshold with high reactivity

Sensory sensitivity (Sensor)

Readily notices sensory stimuli, may be distracted by them

Sensory avoider (Avoider)

Deliberately acts to reduce or prevent exposure to sensory stimuli

The sensory profiling tool

Implementing the Pool Activity Level Occupational Profiling Tool

• Life History Profile

• A Checklist of how the person carries out everyday tasks

• Activity Profile which assists the translation of understanding into practice

• Individual Action Plans for personal ADL

• Outcome Sheet for recording results

The Pal

Planned

• Complete activity• Search for objects• Follow simple instruction• Can use memory prompts

Exploratory

• Complete familiar task• Concerned about the effect of doing the task• May not have an end result in mind• Need activity broken down into steps

Sensory

• No thoughts regarding the purpose of the task• Concerned with sensation• One step at a time• Verbal and non-verbal direction

Planned

• No aware of the environment• Movement is in response to stimulus• Can only process one sensation at a time• Communication is predominately non-verbal

The sensory tool box

• Sight - visual

• Sound - Auditory

• Touch - Somatosensory / vibration

• Taste - Gustatory and texture

• Smell - Olfactory

• Movement - Vestibular / proprioception

Analysing the Snoezelen environment

• Intensity

• Amount

• Consistency

• Any competing stimuli

• Familiarity

• Level of arousal

• Environmental cues

Organising a session

• Identifying focus for the session based on assessment outcomes

• Techniques for specific needs

• Timing and the therapeutic intervention

• Measuring outcome

• Reflection on the session

Using the PAL to guide the session

Positioning of objects – eye line, direct contact, one sense at a time

Verbal directions – Allow time to settle and explore, guide movements, reinforce response with verbal and non-verbal cues

Directions – Breakdown to one step at a time, session length approximately 10 minutes, one to one sessions, end session by gradually increasing light

Activity characteristics – To arouse conscious awareness of self and immediate environment

Achieving sensory modulation within session

Balance of excitation & inhibition

Excitation – over-response eg. release phenomena in brain injury & stroke.

Inhibition – under-response, fail to notice stimulation eg. Neglect

Role of feedback system to regulate balance

Arousal & alerting systemsSensory system Arousal / alerting

descriptorsDiscriminating/ mapping descriptors

For all systems Unpredictable –unfamiliar, cannot anticipate the sensory experience

Predictable – familiar, can anticipate what will happen next

Somatosensory Light touchPain – sharp, pinchTemperature Small surface contact

Pressure touchLong duration stimuliLarge body surface contact

Vestibular Head position changeSpeed changeDirection changeRotary head movement

Linear head movement –rocking, bouncingRepetitive

Arousal & alerting systems

Sensory system

Arousal / alerting descriptors

Discriminating/ mapping descriptors

Proprioception Quick stretch – brisk tapping Sustained tension –constant action on muscles, heavy objects

Visual High intensity – bright visual stimulusHigh contrast – difference between stimulus & environmentVariable – changing characteristics

Pressure touchLong duration stimuliLarge body surface contact

Auditory Variable – changing characteristicsHigh intensity – loudCompetitive – conflicting sound

Linear head movement –rocking, bouncingRepetitive

Olfactory / gustatory

Strong intensity Mild intensity

Incorporating sensory qualities into integrated therapy programmes

Visual

Arousal

• High intensity – to increase arousal & attention

• High contrast – to enhance location & attention

• Variability – Maintain alertness & attention

Discrimination

• Low intensity – generate searching behaviours

• Low contrast –discrimination

• Competitive – increase tolerance and inhibitory response

Auditory

Arousal

• Variable – maintain arousal or interest in the task

• High intensity – Alerting, location

Discrimination

• Rhythmic – predictable / organising / orientation

• Constant – Environmental orientation

• Competitive – Orientation & tolerance

Olfactory / Gustatory

Arousal

• Strong intensity - arousal

Discriminatory

• Noncompetitive – focus attention

• Low intensity – generate searching behaviour

• Mild intensity –recognition & memory

Sensory magic

Reduce agitation / education / increase arousal...Sensory Magic offers the individual a safe sensory environment which is structured and predictable. The sensory room can be set according to each individual’s needs and preferences, so that each and every time the experience is identical, providing continuity and stability. In this way, anxiety levels are kept to a minimum. The MSE can be subtly and slowly altered over time to introduce new colours, images and sounds at the individual’s own pace.

• www.rompa.com/sensorymagic

Simon

• 67 year old man with Alzheimer’s disease and attempted insulin overdose

• Sensory seeker using the Sensory Profile

• Sensory level using the PAL

• Graded introduction

• Sensory package for use at home

Claire

• 80 year old woman with vascular dementia and R CVA

• Sensory sensitive using the Sensory Profile

• Exploratory using the PAL

• Graded exposure and relaxation techniques

• Sensory soothing kit

Research• Burns, I., Cox, H., & Plant, H. (2000). Leisure or therapeutics? Snoezelen and the care of older persons

with dementia. Int.J.Nurs.Pract., 6, 118-126.

• Baker, R., Bell, S., Baker, E., et al. (2001). Randomised controlled trial of the effects of multi-sensory stimulation (MSS) for people with dementia. BJClinPysch 40, 81-96.

• Chung, J. C., Lai, C. K., Chung, P. M., & French, H. P. (2002). Snoezelen for dementia. Cochrane.Database.Syst.Rev., CD003152.

• Schofield, P. (2002). Evaluating Snoezelen for relaxation within chronic pain management. Br.J.Nurs., 11, 812-821.

• Staal, J., Pinkney, L., & Roane, D. (2003). Assessment of Stimulus Preferences in Multi-sensory Environment Therapy for Older People with Dementia. British Journal of Occupational Therapy, 66,542-550.

• Heyn, P. (2003). The effect of a multisensory exercise program on engagement, behavior, and selected physiological indexes in persons with dementia. Americal Journal of Alzheimer's disease and Other Dementias, 18, 247-251.

• Baillon, S., Van Diepen, E., Prettyman, R., et al. (2004). A comparison of the effects of Snoezelen and reminiscence therapy on the agitated behaviour of patients with dementia. Int.J.Geriatr.Psychiatry, 19, 1047-1052

• Ball, J. & Haight, B. K. (2005). Creating a multisensory environment for dementia: the goals of a Snoezelen room. J.Gerontol.Nurs., 31, 4-10.

Research cont.• Baillon, S., Van Diepen, E., Prettyman, R., et al. (2004). A comparison of the effects of Snoezelen and

reminiscence therapy on the agitated behaviour of patients with dementia. Int.J.Geriatr.Psychiatry, 19, 1047-1052

• van Weert, J. C., van Dulmen, A. M., Spreeuwenberg, P. M., Bensing, J. M., & Ribbe, M. W. (2005). The effects of the implementation of snoezelen on the quality of working life in psychogeriatric care. Int.Psychogeriatr., 17, 407-427.

• Ball, J. & Haight, B. K. (2005). Creating a multisensory environment for dementia: the goals of a Snoezelen room. J.Gerontol.Nurs., 31, 4-10.

• Staal, J. (2007). The Effects of Snoezelen (Multi-sensory Behavior Therapy) and Psychiatric Care on Agitation, Apathy, and Activities of Daily Living in Dementia Patients on a Short Term Geriatric Psychiatric Inpatient Unit. Journal of Psychiatry in Medicine, 37, 357-370.

• Collier, L., McPherson, K., Ellis-Hill, C., Staal, J., & Bucks, R. (2010). Multisensory Stimulation to Improve Functional Performance in Moderate to Severe Dementia-Interim Results. American Journal of Alzheimers Disease and Other Dementias, 25, 698-703.

• Klages, K., Zecevic, A., Orange, J. B., & Hobson, S. (2011). Potential of Snoezelen room multisensory stimulation to improve balance in individuals with dementia: a feasibility randomized controlled trial.

Clin.Rehabil., 25, 607-616.52

Thank you for listening

Dr Lesley Collier

Centre for Innovation and Leadership

Faculty of Health Sciences

University of Southampton

SO17 1BJ

ljp@soton.ac.uk