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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.
Jason A. Staal, Psy.D.
Amanda Sacks, Ph.D.
Robert Matheis, Ph.D.
Tina Calia, M.A.
Henry Hanif, OTR/L.
Lesley Collier, MSC., Dip COT SROT.
Eugene S. Kofman B.A.
Previous presentation: A poster of this paper was presented at the Alzheimer’s Association International Conference on Prevention of Dementia: Early diagnosis and intervention. July 18-21, 2005, Washington, D.C. Location of work and address for reprints: Jason A. Staal, Psy.D. Assistant Professor of Psychiatry, University Hospital for the Albert Einstein College of Medicine, Department of Psychiatry Division of psychology. Beth Israel Medical Center First Avenue at 16th Street, New York, New York 10003, Office location: 6K, e-mail: [email protected]. ABSTRACT
A randomized, controlled, single-blinded, between group study of 24 participants with moderate to severe dementia was conducted on a geriatric psychiatric unit. All participants received pharmacological therapy, occupational therapy, structured hospital environment, and were randomized to receive multi sensory behavior therapy (MSBT) or a structured activity session. Greater independence in activities of daily living (ADLs) was observed for the group treated with MSBT and standard psychiatric inpatient care on the Katz Index of Activities of Daily Living (KI-ADL; P=0.05) than standard psychiatric inpatient care alone. The combination treatment of MSBT and standard psychiatric care also reduced agitation and apathy greater than standard psychiatric inpatient care alone as measured with the Pittsburgh Agitation Scale and the Scale for the Assessment of Negative Symptoms in Alzheimer’s Disease (P=0.05). Multiple regression analysis predicted that within the multi-sensory group, activities of daily living (KI- ADL) increase as apathy and agitation reduced (R2 = 0.42; p = 0.03). These data suggest that utilizing MSBT with standard psychiatric inpatient care may reduce apathy and agitation and additionally improve activities of daily living in hospitalized people with moderate to severe Keywords: Snoezelen, multi-sensory therapy, agitation therapy, dementia, behavior therapy, INTRODUCTION
The present study is the first to assess whether a combined treatment comprised of standard psychiatric inpatient care and a non-pharmacological intervention, multi-sensory behavior therapy (MSBT), reduces agitation and apathy and improves ADLs in people with dementia on an acute care psychiatric hospital unit compared to standard psychiatric inpatient Psychiatric inpatient care for the behavioral, psychological symptoms of disease (BPSD) consists of atypical antipsychotics for the reduction of agitation and psychosis, mood-stabilizers, antidepressants, a structured hospital environment, and occupational therapy [4]. Older people are often sensitive to adverse effects such as sedation, orthostatic hypotension, and extrapyamidal effects that can limit the use of medication and compromise efficacy [5]. Sensory stimulation was first introduced in America the 1960’s as an intervention to improve well-being in institutionalized people with dementia [6]. Sensory stimulation developed in The Netherlands under the term Snoezelen. Three previous studies suggest Snoezelen reduces BPSD [7-9]. To differentiate the study from its a-theoretical predecessors (Multi Sensory Environmental Therapy (MSET) and Dutch Snoezelen), a new term labeled multi-sensory behavior therapy (MSBT) was developed to describe the integration of behaviorism and Dutch Snoezelen [10]. The theoretical framework of MSBT is based on the operant paradigm of automatic reinforcement [11-12] and the physiological model of the relaxation response [13]. Staal has developed a method of sensory assessment to match the preferences of the dementia patient with stimuli that target the visual, auditory, olfactory, and tactile systems and in turn individualizes the intervention to the We predicted that participants randomized to combined psychiatric care and MSBT would have a greater reduction in agitation and apathy and improvement in ADLs compared to those who received standard psychiatric care and attention controlled structured activity group. Furthermore, we hypothesized that the use of a combination treatment to treat BPSD would be associated with greater improvement in ADLs. Baseline and post-baseline assessment outcomes included measurement of level of agitation, apathy, and ADLs. Recruitment of Participants
The present study recruited 24 geriatric inpatients with the admitting diagnosis dementia with behavioral disturbances on an acute care geriatric psychiatry unit. Prior to the administration of baseline assessment measures, all study participants were randomly assigned to either the MSBT experimental group (n =12) or a standard inpatient psychiatric care control group (n =12). Informed written consent and a HIPAA form (Health Insurance Portability and Accountability Act of 1996) was obtained from all participants and legal guardians and the study was approved by the Institutional Review Board. The study sample was comprised of 8 males and 16 females (X2 = 1.67, p = 0.44). There were statistically significant differences in mean age between the treatment and control groups: The MSBT group (M = 80.33, SD =1.59) was significantly older than the control group (M = 72.00, SD = 0.84). There were no differences in Global Deterioration Scale (GDS) between the MSBT and control groups. Moderate differences in Mini Mental Status scores were observed where the MSBT group scored slightly higher (M= 19.17, SD = 1.47) than the control group (M = 11.83, SD = 2.77; p = 0.08); both groups, however, were within the critical range. Cognitive change was not an endpoint of this study and this cognitive screening instrument was a mere gate keeper measurement to insure that participants had a minimum cognitive status to understand directions and benefit from the intervention. Differences in group overall health scores, as measured by the Multi-level Assessment Instrument (MAI), were statistically significant between groups, with the MSBT group scoring a mean of 4.17 and the control group scoring a mean of 2.83. A mixed design evaluated the effectiveness of MSBT on activities of daily living. The between groups variable was the type of intervention (MSBT vs. structured activity) and the repeated within group variable was measures of improvement in ADLs over time. Medication dosage was individually adjusted by psychiatrists blind to the participant’s group. Procedure
Baseline levels of agitation and apathy were measured. Participants were randomized to the comparison control group one to one attention using therapeutic recreation activities such as play dough or to the experimental group, one to one individualized sensory stimulation. A six session protocol, 25 to 30 minutes per session, was conducted post MSBT assessment. Dressing was measured by research assistants post both groups using a sweater. Nurses were blind to the study’s aims rated overall patient ADL post experimental and control groups on the inpatient unit. Research assistants measured apathy and agitation post sessions for both groups. [Insert Table 1 here]
Outcome Measures
The Global Deterioration Scale (GDS) determined stage of illness. The interrater concordance for the GDS is .95 for a zero or one point difference and a concordance of .70 for The Pittsburgh Agitation Scale (PAS) assessed agitation. Inter-rater reliability for all four domains assessed with kappa exceed .80 [27]. From the Multi-level Assessment Instrument, one subscale (Physical Health) as a covariate in this study. The test-retest reliability of the physical health domain was 0.95 and the The Scale for the Assessment of Negative Symptoms in Alzheimer’s Disease (SANS- AD) measured negative symptoms in patients with dementia. Inter-rater reliability ranged from 0.70 for affective flattening to 0.88 for avolition-apathy [33]. The Katz Index of Activities of Daily Living (KI-ADL) assessed bathing, dressing, toileting, transfer, continence, and feeding. Inter-rater reliability assessed with a kappa The Refined Activities of Daily Living Assessment Scale (RADL) assess ADLs. Agreement on nurses’ ratings using Cronbach’s alpha ranged from 0.89 to 0.98 and correlations with existing established ADL scales were 0.60 with the Physical Self-Maintenance Scale and 0.64 with the Performance Test of Activities of Daily Living suggesting moderate validity [29]. The Beck Dressing Performance Scale BDP measures dressing ability. The content validity and inter-rater reliability for this instrument calculated by kappa coefficients was established to be The Mini Mental Status Exam (MMSE) is an instrument for screening gross cognitive functioning, with interrater reliability at 0.88 and test-retest reliability of 0.89 [31]. Statistical Analyses
In order to determine the effects of MSBT, a 2 (group) x 6 (time) repeated measures analysis of covariance (ANCOVA) examined the efficacy of MSBT on apathy and agitation and ADLs while covarying out physical health and age. A hierarchical multiple regression was used to determine if measures on agitation and apathy were predictive of improvement in ADLs. The MSBT group improved significantly in levels of agitation as compared to the control group (F (6, 120) = 3.56, p = 0.003). The MSBT group significantly improved in level of apathy as compared to the control group (F (1, 20) = 4.47, p = 0.04). Repeated measure analysis revealed a significant interaction; only participants in the MSBT treatment group experienced improvement in apathy from baseline to session six (F (6, 120) = 3.15, p = 0.01). One-way univariate analyses of variance (ANOVA) were conducted to ensure group equivalence at baseline on all ADL measures. The results indicated no significant group differences in KI-ADL scores (F (1, 23) = 1.00, p = 0.33), RADL scores (F (1, 23) = 2.53, p = 0.13), or BDP scores (F (1, 23) = 1.17, p = 0.29). A 2 (group) x 7 (time) repeated measures factorial ANCOVA was employed with time and group as primary factors along with age and general health status as covariates. The results revealed the MSBT treatment group to have significantly improved levels of independence in ADLs on the KI-ADL than members of the control group (F (1, 20) = 4.72, p = 0.04). Contrary to our hypothesis, neither group demonstrated significant change in ADL status as measured by the RADL, or on the BDP when dressing was assessed post group [Insert table 2 here]
[Insert Table 3 here]
The results of the multiple regression analysis revealed that KI-ADL performance was predicted significantly from the proposed model which included apathy and agitation scores as well as health status and age as covariates (R = 0.65, R2 = 0.42; F (4, 19) = 3.40, p = 0.03). The RADL was predicted significantly only by agitation scores (R = 0.68, R2 = 0.46; F (4, 19) = 4.00, p = 0.02), and the model did not predict BDP scores beyond chance expectations (R = 0.56, R 2= 0.31; F (4, 19) = 2.16, p = 0.11). Within the experimental group (MSBT), nine of the twelve participants were on atypical antipsychotic medications. A one-way, post hoc, between groups ANOVA was run for each measure to compare those participants on antipsychotic medications that received MSBT and those not on antipsychotic medications that received MSBT. The findings were not significant for any of the measures; however, the trend for agitation was in the hypothesized direction (F (1, 12) = 2.80, p = .133). The nine participants who received MSBT and atypical antipsychotic medications did have better results than the three subjects who received MSBT and were not on atypical antipsychotic medications. [Insert table 4 here]
DISCUSSION
The results indicated that over the course of 6 sessions of intervention, both the MSBT group and control group had reduced agitation. However, the MSBT group demonstrated higher decreases in agitation than the control comparison group. Improvement by both groups may reflect the efficacy of psychiatric inpatient care. However, it appears that the combination of pharmacological treatment and MSBT may have efficacy in reducing levels of agitation more The results for apathy indicated that the MSBT group improved above and beyond the comparison control group. Different from agitation, however, the comparison control group did not show improved levels of apathy. MSBT may have a beneficial effect on apathy when combined with psychiatric inpatient care by evoking interest/focusing on the environment. The MSBT group had improved levels of general independence in ADLs compared to members of the comparison control group as measured by the KI-ADL. In contrast, no difference between groups was observed when using discrete ADL assessment (RADL) and when assessing sweater dressing behavior (BDP). A possible explanation is the KI-ADL’s sensitivity to identifying levels of functional independence. Theoretically, the operant paradigm is used to explain the efficacy of MSBT in improving agitation and apathy and the global functioning in ADL. First, the use of modified operant procedures were used to match the preferences of the person to the sensory stimuli [14]. Secondly, non-contingent, automatic sensory reinforcement is theorized to be the active factor in Controlling for health status and age, both apathy and agitation scores emerged as significant predictors of KI-ADL performance. RADL performance was predicted significantly by the proposed model, however, only agitation scores specifically predicted performance on that scale. Agitation and apathy were not found to be predictive of BDP performance. The finding that the proposed model containing agitation, apathy scores, and the covariates of physical health and age predict performance (as measured by the KI-ADL and RADL scales) is consistent with previous research indicating that these factors negatively impact ADLs [15]. Demonstrating this relationship infers a theoretical basis to demonstrate how MSBT may improve independence in ADL functioning, by reducing agitation and apathy. The current study improved upon previous studies of MSEs. It is hypothesized that by matching a stimulus (sensory reward) to the person’s preference and using graded intervals of time to allow people to become accustomed to the MSE environment resulted in no early termination from the MSBT group. A prior MSE study resulted in four dropouts due to negative In this study, a non-contingent schedule of reinforcement was utilized [17]. The presentation of sensory reward was not based on a desired response from the participant or performance of a behavior at a set time. The use of a non-contingent schedule of reinforcement combined with orienting/prompting the person with dementia to each type of stimulation differs from the enabling approach used previous MSE studies [18]. One class of reward, edible reinforces (food) was excluded from this study even though it has been a part of the multi-sensory package of stimuli used in MSEs. The positive outcomes found in this study support the use of sensory reinforcement (visual, auditory, olfactory and tactile) as classes of rewards in the people with dementia. As individuals experience actions that lead to reward though engagement in MSBT, meaning may occur, which may lead to subjective states of well being and behavioral momentum for action which may continue across contextual MSBT combined with standard psychiatric care reduced levels of agitation and apathy; central components of BPSD, on an acute care inpatient geriatric psychiatric unit, expands previous MSE studies, which demonstrated reductions in apathy and agitation in therapeutic settings such as day treatment programs and nursing homes [7-9]. Previous MSE studies did not account for standard psychiatric care that may have been received by participants and therefore did not validate MSE as a complementary treatment to standard pharmacological care [7-9, 16-17]. The current study assessed for stage of dementia utilizing the GDS, which allowed for a greater specificity of research sample. Controlling for the stage of illness infers that MSBT combined with standard psychiatric care may be beneficial for moderate to severe stages of The current study controlled for physical health and age, both of which can negatively impact on individuals’ ability to engage in ADL despite level of BPSD or dementia. Including these factors as covariates in the statistical analysis allowed for a more accurate examination of study variables and demonstrated that the combined treatment is useful despite such differences. The positive effects of MSBT treatment combined with standard inpatient psychiatric care appear to transfer from the MSE room to the unit. This finding is consistent with the Baker’s study [18] which concluded generalization of the effects whereby improvements in behavior and mood from a day treatment center were maintained at home. Other MSE studies failed to detect a transfer of effect from the Snoezelen room to the care environment [16-17]. There are several limitations of the present study. The first methodological limitation of the study involves instrument selection. Baseline measures of dressing revealed that some study participants had the capacity to dress themselves. Since these participants were not excluded from the study, the improvement that was made by these higher functioning participants may have been too small to be detected due to the lack of measurement sensitivity of the measures used (RADL, BPD). Behavioral, not cognitive, change is a more important variable in relation to BPSD instruments at that staging of illness. A BPSD may be more important than gatekeeper measures such as the MMSE, which may reveal very little about functional change for this A second limitation, observer bias may have occurred by the use of observational measures to assess agitation and apathy. The nature of working on a small psychiatric unit may have revealed the group (experimental or control) of a given participant. However, the group identity of the participant was less likely to be known by the nurses performing the global ADL measure due to blinding of raters and the delay between intervention and assessment. Measuring independence in ADLs on an inpatient unit presented methodological challenges. No control was exercised in relation to meal time and staff activity during mealtime. Assessment of toileting was hindered by respect for patient privacy and nurse discomfort There are limitations in the design of this analysis, particularly sample size yet due to the pilot nature of the investigation and the rigors of inpatient research. Replication by independent Future MSBT studies should examine schedules of reinforcement to assess maintenance of MSBT treatment benefits over time, assessing session frequency and temporal spacing. Training staff in MSBT methods and procedures and integrating multi-sensory interventions into care plans may play a role in the efficacy of MSBT treatment to continue post therapy sessions Behavioral interventions, Strategies for Promoting Independence of ADLs (SPID) has relative success increasing independence of ADLs in people with dementia [21]. MSBT used in conjunction with SPID may provide a comprehensive behavioral treatment for increasing ADL 1. Lyketsos, C. Steinberg, M. Norton, M. et al: Mental and behavioral disturbances in dementia: findings from the cache county study on memory and aging. Am J of Psychiatry 2000; 157: 2. McShane, R: What are the syndromes of behavioral and psychological symptoms of dementia? Int Psychogeriatr 2000; 12: Suppl./1, 147 153. 3. Torres, H. Hilleras, P. Winblad, B: Disability in activities of daily living among the elderly. 4. Cummings, J: Drug therapy: Alzheimer’s Disease. N Engl J of Med 2004; 351: (1), 56 67. 5. Mansdorf, I. Calapai, P. Caselli, L. et al: Reducing psychotropic medication usage in nursing home residents: the effects of behaviorally oriented psychotherapy. The Behavior Therapist 6. Bower, H: Sensory stimulation and the treatment of senile dementia. Med J Aust 1967; 1: 7. Holtkamp, C. Kragt, K. VanDongen, M. et al: Effect of Snoezelen on the behavior of the demented elderly. Tijdscher Gerontological Geriatrics 1997; 28: 124-128. 8. Baker, R. Bell, S. Gibson, S. et al: A randomized controlled trial of the effects of multi- sensory stimulation for people with dementia. Br J Clin Psychol 2001; 40: 81 96. 9. Weert, J: Multi-sensory stimulation in 24-hour dementia care. Netherlands Institute for Health Services Research (NIVEL) The Netherlands, 2005. 10. Staal, J: An integration of Snoezelen with behavioral theory and practice to promote effective therapeutic outcomes. Paper presented at the third Snoezelen World Congress, Toronto, 11. Skinner, B: Science and Human Behavior. New York: The Free Press 1953 12. Vaughan, M. Michael, J: Automatic reinforcement: an important but ignored concept. 13. Benson, H. Klipper, M: The Relaxation Response. New York: Avon Books, 1975 14. Staal, J. Pinkney, L. Roane, D: Assessment of stimulus preferences in multisensory environment therapy for older people with dementia. British Journal of Occupational 15. Reichman, W. Negron, A: Negative symptoms in the elderly patient with dementia. Int Journal Geriatr Psychiatry 2001; 16: 11 16. 16. Baker, R. Dowling, Z. Wareing, L: (1997). Snoezelen: its long-term and short-term effects on older people with dementia. British Journal of Occupational Therapy 1997; 60: 213 218. 17. Vollmer, T: The concept of automatic reinforcement: implications for behavioral research in developmental disabilities. Res Dev Disabil 1994; 15: (3), 187 207. 18. Hope, K: The effects of multi-sensory environements on older people with dementia. J Psychiatr Ment Health Nurs 1998; 5: 377 385. 19. Kitwood, T: A dialectical framework for dementia. Edited by Woods R. Handbook of the clinical psychology of aging. Chichester: John Wiley and Sons Ltd, 1996 20. Moffat, N. Pinkey, L. Barker, P: Snoezelen: An experience for people with dementia. 21. Spaull, D. Leach, C: An evaluation of the effects of multi-sensory stimulation with people who have dementia. Behavioral and Cognitive Psychotherapy 1998; 26: 77 86. 22. Robichaud, L. Herbert, R. Desrosiers, J: Efficacy of a sensory integration program on the behaviors of inpatients with dementia. Am J Occup the 1994 48: (4), 355 360. 23. DeGrandpre, R: A science of meaning: can behaviorism bring meaning to psychological science. Am Psychol 2000; 55: (7), 721-739. 24. Hammell, K: Dimensions of meaning in the occupations of daily life. Can J Occup Ther 25. Beck, C. Vogelpohl, T. Rasin, J: Effects of behavioral interventions on disruptive behavior and affect in demented nursing home residents. Nurs Res 2002; 51: 219227. 26. Gottlieb, G. Gur, R. & Gur, R: Reliability of psychiatric scales in patients with dementia of Alzheimer type. Am J Psychiatry 1988; 145:7, 857-860 27. Rosen, J. Burgio, L. Kollar, M. Cain, M. Allison, M. Fogleman, M. Micheal, M. Zubenko, G: The Pittsburgh Agitation Scale: A user friendly instrument for rating agitation in dementia patients. The Am J Geriatr Psychiatry 1994; 2, 52-59 28. Greshman, G. Philips, T. Labin, M: ADL status in stroke: relative merits of three standard indexes. Arch Phys Med Rehabil 1988; 61, (8) 355-8 29. Tappen, R: The effect of skill training on functional abilities of nursing home residents with dementia. Res Nurs Health 1994; 17, 159-165 30. Beck, C. Hencock, P. Mercer, S. Walls, R. Rapp, C. Vogelpohl, T: Improving dressing behavior in cognitively impaired nursing home residents. Nurs Res 1997; 46, 126-131 31. Ferris, S. Crook, T. Flicker, C: Assessing cognitive impairment and evaluating treatment effects. 1986; In L.W. Poon (Ed) Handbook for clinical memory assessment in older 32. Lawton, P: A research and service oriented multi-level assessment instrument. Journal of 33. Reichman, W. Coyne, A. Amireni, B. Molino, J. Egan, S: Negative symptoms in Alzheimer’s disease. Am J Psychiatry 1996; 153, 424- 426 Intervention Sequence
Participants Assessed for eligibility (n=24) Participants
Allocation
Expand duration of each session using fixed time intervals (FT) intervals in minutes: FT 15, FT Procedure
Mean ADL Post test Scores Across Study Note. *Increasing scores denote less independence. **Decreasing scores denote less
independence All scales were not administered at every session; empty cells denote a scale was not administered. Note. *Increasing scores denote worse performance. Donepezil HCI (5mg), Risperidone, (.25mg) Olanzapine (5mg), Donepezil HCI (5mg/qd) Olanzapine (5mg/pogd), Donepezil HCI (10mg/pogd), Quetiapine fumarate (25 mg po/daily) Subject #3 Quetiapine fumarate (50mg/qam & 75 mg/qd, Donepezil HCI (10mg/qd), Quetiapine fumarate Quetiapine fumarate (100 mg), Citalopram Quetiapine fumarate, Donepezil HCI, Ginko: Quetiapine fumarate (dose unknown), Cognitive Citalopram Hydrobromide (4mg), Ativan (.5mg) enhancer – type and dose unknown Subject #6 Neurortin (400mg TID), Donepezil HCI (5mg, Risperidone, Donepezil HCL, Memantine HCL Risperidone, Divalproex Sodium (doses unknown) Olanzapine (10mg/QHS), Divalproex Sodium (250mg/BP), Reminyl (4,g/POBD), Haldol (1mg/POQpm) Olanzapine (5mg/QHS), Zoloft (75mg/POQD), Klonopin, Quetiapine Fumarate (doses unknown) Trazadone (150mg), Abilify (15mg), Remenyl Subject #12 Unable to retrieve medical chart due to Subject #12 Unable to retrieve medical chart due to missing chart number

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