Journal of Gerontological Nursing

Snoezelen®: A Multisensory Environmental Intervention

Amanda M Chitsey, MSN, RN; Barbara K Haight, DrPH, RNC, FAAN; Melaina M Jones, RN, MSN

Abstract

ABSTRACT

Snoezelen® is a multisensory intervention delivered in a specially designed room with high-tech instruments. It is especially useful for end-stage patients with Alzheimer's disease. Snoezelen provides an enabling atmosphere in a failure-free environment. It has been a popular intervention in Great Britain and is just beginning to appear in the United States.

Abstract

ABSTRACT

Snoezelen® is a multisensory intervention delivered in a specially designed room with high-tech instruments. It is especially useful for end-stage patients with Alzheimer's disease. Snoezelen provides an enabling atmosphere in a failure-free environment. It has been a popular intervention in Great Britain and is just beginning to appear in the United States.

Snoezelen® is a term used t describe an environmental intervention designed to stimulate the primary senses of touch, hearing, sight, smell, and taste. Multisensory stimulation is achieved in the Snoezelen environment, or room, by combining soft music, aromatherapy, textured objects, colored lighting effects, and favorite foods. The first patients to use these multisensory rooms for leisure and relaxation were children with mental disabilities (Hong, 1996). More recently, Snoezelen has been targeted at elderly patients with dementia to provide a stress free, entertaining environment both to stimulate and to relax.

The term "Snoezelen" is based on two Dutch words meaning "to sniff" and "to doze." The expression Snoezelen attempts to capture a lazy, relaxed feeling. Within this setting, a philosophy of Snoezelen is created, embracing the concept of "enabling" within a failure-free environment (Hutchinson, 1991). The terms Snoezelen and "multisensory stimulation" are used interchangeably in the United Kingdom (Haggar & Hutchinson, 1991; O'Grady, 1992). Snoezelen was recently adopted as the registered trademark of Rompa® Inc. (Chesterfield, England).

Currently, there are more than 2,000 Snoezelen rooms in Europe. Flaghouse, a private company in New Jersey marketing Snoezelen products in the United States, estimates that there are 100 Snoezeien rooms in America, the bulk of which are designed for children with learning disabilities (Flaghouse, 2000).

BACKGROUND

Most British literature states that Snoezelen rooms were initiated in the Netherlands in the early to mid 1980s. The Dutch did not publish widely in the English language. Therefore, there was little dissemination of their innovative practices until adopted by the English. Although not as high tech or well recognized, a similar, but more basic form of multisensory stimulation for elderiy patients with dementia dates back to 1966 in America (Weil, 1966). American multisensory activities used favorite foods, soft cloths, and recorded music to stimulate interest. Numerous observational reports showed that elderly individuals enjoyed the multisensory environment and that the environment had positive effects on their behavior and attitude (Bower, 1967; Bumside, 1969; Loew & Silverstone, 1971; Weil, 1966).

Currently, Snoezelen is a more technologically advanced form of multisensory stimulation using modern equipment, such as strobe lights, vibratory objects, and scented oils. Although American and British therapists used different stimulation devices in two separate age groups, both shared the purpose of providing a meaningful activity to a special population. The use of multisensory stimulation in America after 1971 is minimal, but Snoezelen rooms, once initiated in The Netherlands, spread rather rapidly across Europe (Schofield, 1996a). To date, the majority of the literature, both research and reports of the use of multisensory stimulation, comes from Europe, more specifically Holland and the United Kingdom.

The use of Snoezelen flourished in Europe in the 1980s and 1990s even though there were only a few empirical research studies to support its use. In 1988, what is believed to be the first large-scale multisensory center for Snoezelen was opened in the United Kingdom (Schofield, 1996a). The purpose of this large center was to provide a leisure, rather than therapeutic activity, with equipment specifically designed for enjoyment by children with learning disabilities (Schofield, 1996b). Researchers describe the therapeutic benefits of multisensory Snoezelen environments as relaxation, behavior modification, improved cognitive function, improved quality of life, and improved pain control (Arno & Frank, 1994; Holtkamp, Kragt, van Dongen, van Rossum, & Salentijn, 1997; Pinkney, 1997; Schofield, 1996a. 1996b).

PURPOSE AND DATA COLLECTION

The purpose of this article is to review the published literature pertaining to the use of multisensory stimulation with older adults and to provide recommendations for future practice and research. To begin this review, the literature was searched using the following key words: sensory stimulation, Snoezelen, multisensory environment, multisensory stimulation, and sensory integration. The search was limited to material published in the English language from 1966 to the present. Literature was also limited to a specific focus on elderly participants and involved the stimulation of more than two senses. The search included all printed material available through the electronic databases, such as Internet and textbased Mediine, Medical University of South Carolina's "Mini Mediine," Internet-based "Pub Med," America Online's "AOL Net Find," and a hand search of all references in the articles retrieved.

REVIEW OF THE LITERATURE

In its most basic form, multisensory stimulation activities and therapy for older adults began in the early 1950s, with most of the studies being published in the mid 1960s. Weil (1966) developed a multisensory program for institutionalized, "senile" older adults after finding that they could not compete mentally and physically with other patients. Weil noted that their inability to communicate with social peers intensified their feelings of rejection and further accelerated their mental deterioration. Additionally, patients who were confused, and often mentally unstable, disrupted group activity sessions, frustrated staff, and threatened to jeopardize the psychological well being of the more lucid patients.

In response to these problems and to provide suitable activities for this population, Weil designed simple, nontaxing activities such as finger painting, sorting colored buttons, listening to music, and winding a ball of yarn. He found that patients who were apathetic "came alive" during these activities and patients who were disturbed became quiet and serene. Weil was one of the first health care providers to recognize the need for activities thai could be enjoyed by individuals who are cognitively impaired.

MULTISENSORY STIMULATION STUDIES

Bower (1967) published a similar article describing the use of multisensory stimulation in older adults. Bower investigated the behavioral changes of 25 elderly participants with senile dementia after 6 months of stimulation therapy sessions. Bower did not have the modern technologic equipment available currently for sensory stimulation. Instead, he used basic activities such as listening to music, dancing, watching color slides, and drinking hot tea. He reported that stimulation therapy slowed the progression of senile dementia, an observation not based on empirical data and probably not possible.

He also reported that the participants experienced an improvement in communication, emotions, and intellectual functioning. Overt problem behaviors decreased, while motivation and social skills increased. Though it is currently known that it is almost impossible to slow the progression of dementia, except through medications such as donepezil HCl (Aricept), the behaviors Bower reported were probably present. It is more likely that increased socialization and communication were a result of the activities and these increased behaviors seemed like increased intellectual functioning to Bower. Unlike similar research studies published prior to 1967, Bower's study included the stimulation of all five senses, which probably accounted for his excellent outcomes.

Largely based on Bower's work, Burnside (1969) wrote about group work in an institutional setting that involved the stimulation of au five senses. However, Burnside's participants were different because they were older adults with multiple disabilities, but they did not suffer from dementia. The stimulation activities Burnside chose to implement were different from the more traditional activities provided for older adults who were institutionalized, such as games, watching television, and arts and crafts.

Burnside stated that older adults with multiple disabilities could not enjoy traditional activities. Many blind patients could not watch a film or participate in crafts, some patients were unable to sign their name on a Christmas card, and still others did not have the attention span or mental capacity to play chess or checkers. Realizing the special needs of older adults who were disabled, Burnside creatively designed a stimulation program that her patients could enjoy, even with a disability. She used activities that involved all five senses. They included afternoon coffees, tasting favorite foods, listening to music, smelling flowers, and receiving visits from teenagers.

Burnside (1969) found that older adults who attended her session became more talkative and sociable. Attention spans and general level of interest increased and unpleasant or belligerent attitudes improved. Burnside also noted staff interest and enthusiasm for the project.

More than likely, the participants in both Bowers and Burnside's groups were bored and suffering from sensory deprivation, causing them to draw more into themselves. Once stimulated and involved, their boredom behaviors and attitudes changed and improved, as reported in the outcomes. The aforementioned studies were not experimental with controlled groups and outcome measures. They were more observational of the effects brought about by changes in practice, but still important in their own right.

In 1971, Loew and Silverstone published the first experimental controlled study investigating the use of multisensory stimulation in a group of elderly patients in an institutional setting. Their study focused on the very old, those 80 and older, with senile dementia. The researchers initiated the study after observing the sensory deprivation experienced by older adults who were placed in institutions characterized by "depersonalization, monotonous routines, and blandness in the physical surroundings" (p. 341). The experimental group of 14 older men was exposed to sessions of intense multisensory stimulation, including tactile, auditory, visual, and gustatory sensations, for 6 months. A control group of 14 similar older men continued routine activities.

The activities Loew and Silverstone (1971) conducted included listening to recorded music, playing the piano, touching or tasting dough, smelling flowers, and drinking wine. They also used family photos, brightly colored walls, curtains, and mobiles to invigorate the atmosphere. The results of the study indicated no significant differences in the cognitive functions of the experimental and control group, but results did suggest that the experimental group improved their memory, attention, ability to retain information, and orientation to time.

The experimental group also had a higher energy and motivational level and became more sociable than the control group. Of interest, Loew and Silverstone said the staff reported that the experimental group initially became more vociferous, often complaining and arguing about scheduled activities. In contrast to the control group, the experimental patients began to show greater interest in the outside world, requesting newspapers and asking for visits from family. Experimental participants also improved their personal habits, smiled more frequently, and were more continent. As the sessions progressed, these patients continued to become more assertive.

A second randomized, controlled study investigated the short-term effectiveness of sensory stimulation in older adults with a psychiatric disorder. Like Bower and Burnside, Paire and Karney (1984) stimulated all five senses to include kinesthetic and vestibular stimulation activities. They used perfumes and aromatherapy; colors, shapes, and pictures; rhythmical sounds and music; warm water; beanbags; sponge balls; and hot chocolate. The experimental group showed improved hygiene skills, demonstrated an increased interest in activities, and were more involved in group participation. They continued to show improvements after stimulation therapy was discontinued.

The research continued at a slow pace, but over time became more rigorous. In a study by Corcoran and Barren (1987), nursing staff identified 11 female patients as the "most regressed" and conducted a randomized, controlled double-blinded experiment When exposed to multisensory stimulation therapy for 16 weeks, these patients showed improvement in physical endurance, posture, motor activity, verbalization, quality of verbal responses, attention span, problem-solving skills, orientation, and affect Patients were noted to smile and laugh more frequently, as well.

Maloney and Daily (1986) and Norberg, Melin, and Asplund (1986) published studies similar to the work of Paire and Karney (1984). Maloney and Daily (1986) conducted a longitudinal observational study during a 3-year period that used similar stimulation techniques, including the use of flowers, scented lotion and oil, soft; fabrics, massage, balloons, beanbags, cookies, and music. Maloney and Daily found that stimulation therapy helped older adults with dementia to relax and achieve a more peaceful state, while becoming more sociable and talkative. They claimed that stimulation therapy maintained or improved the cognitive and social function in more than half of their patients. Norberg, Melin, and Asplund (1986) studied two patients with Alzheimer's disease and found that these patients became more verbal and appeared more peaceful and relaxed during therapy, but no longterm changes were evident.

HIGH-TECH MULTISENSORY STIMULATION

In Holland in the early to mid 1980s, a similar, but more technologically advanced form of multisensory stimulation was being developed independent of the work published in America. Hulsegge and Verheul (1987) conducted an experiment in Holland successfully using multisensory stimulation environments as a leisure activity for children and adults with profound disabilities. Similar to previous researchers, they sought to provide activities that could be enjoyed regardless of cognitive or physical ability.

Unlike previous sensory stimulation studies, Hulsegge and Verheul used modern technological equipment such as bubbles tubes, image projectors, and fiber optic strands, as well as the more traditional activities of touching and listening to music. They coined the term Snoezelen, and in 1987, established a foundation for Snoezelen. Snoezelen is as an extension of the original concepts of multisensory stimulation using more technological equipment (Barker & Pinkney, 1994). It is a therapy consisting of sensory experiences delivered to stimulate the primary senses with few demands placed on cognitive ability (Hong, 1996).

With this new description, came the concept of setting aside a special room equipped with devices to enhance a sensory stimulation session. This equipped room became known as the Snoezelen room and it is here that the multisensory stimulation sessions occur. Typically, a Snoezelen room consists of a wide variety of modern technologic equipment designed to provide passive sensory stimulation. The equipment may include fiber optics, image projectors, lava lamps, mirror balls, as well as relaxing devices such as rocking chairs and soothing sounds and smells.

Although not the focus of this literature review, the bulk of the literature involving multisensory stimulation after the work of Hulsegge and Verheul (1987) was devoted almost exclusively to adults and children with profound learning, mental, or physical disabilities. Most studies originated in the United Kingdom and consisted of interventions in typical Snoezelen rooms. Numerous studies investigating the use of multisensory stimulation with the learning disabled found that the rooms provided a pleasant, relaxing environment and often instigated a noticeable positive change in behavior (Ashby, Lindsay, Pitcaithly, Broxholme, & Geelen, 1995; Deakin, 1995; Haggar & Hutchinson, 1991; Long & Haig, 1992; Mount & Cavet, 1995).

In addition to the work with children, several randomized, controlled studies were published investigating the use of multisensory stimulation in older adults with dementia. In 1994, Robichaud, Hebert, and Desrosiers published the first of these studies. They provided activity sessions for 40 elderly participants from three different institutions in Canada. Stimulation activities included playing with balls and sandbags; listening to music; and enjoying food, cards, and calendars. Though not high tech, the sessions provided activity. The patients were exposed to three 45-minute sessions a week for 10 weeks. Statistical analyses revealed that the multisensory stimulation had no significant effect on improving and stimulating the behavior of older adults with dementia. However, the researchers did observe a significant decrease in the frequency of disruptive behaviors and a reciprocal decrease in caregivers* negative reactions to these behaviors.

The second study was conducted by Bryant (1991), with a convenience sample of older adults who were institutionalized. Bryant divided participating older adults into groups according to their behaviors, but there were no controls. For example, Group A included sensory stimulation designed for older adults who were labeled as wanderers. There were four groups and each contained a specific subset of the institutional population. Older adults participated in weekly 45-minute sessions of stimulation, including typical activities, such as music, gardening, textured objects, balloons, snacks, and throwing balls. All groups experienced an increase in enthusiasm, improvement in mood and behavior, and a decrease in wandering and anxiety. Staff and patient relationships became calmer and less hostile.

Baker, Dowling, Wareing, Dawson, and Assey (1997) compared the effects of eight Snoezelen sessions to a control group exposed to eight traditional activity sessions. The 31 older adults were not institutionalized, but lived at home and attended a day hospital at least 2 days a week. The sessions were delivered in the day hospital.

Results indicated that the control group's deviant behaviors and social and speech skills worsened during the course of the study, whereas the experimental group remained the same on those measures. The social skills in the patients exposed to multisensory stimulation improved after the sessions. The experimental group appeared more active, with a decrease in boredom and inappropriate napping. However, the measured shortterm outcomes of Snoezelen did not differ significantly from the shortterm outcomes of the control group. The outcomes of both groups included an increase in enjoyment, contentment, happiness, attentiveness, and verbal communication.

Older adults with confusion in both institutions and day hospitals were the participants of an observational study in 1994. Participants were exposed to the multisensory environments for 3 hours a day for 4 weeks. The majority of patients and staff enjoyed the sessions. Forty percent of the staff stated that the stimulation made a difference in the patients' anxiety and behavior. Objective outcome measurements indicated a significant increase in happiness and level of interest when compared to baseline measurements, as well as a reduction in sadness and fear. The behavior change of patients while attending a multisensory session was statistically insignificant, but showed trends toward decreased agitation and more involvement (Barker & Pinkney, 1994).

Similar to other researchers, Arno and Frank (1994) found that patients with dementia were unable to participate in the recreational activities provided at their institution because of cognitive deficits or behavioral problems. Their purpose in creating the stimulation sessions was to improve the quality of life of these patients. Patients were exposed to more traditional, basic activities such as listening to music, smelling perfume, passing balls, walking outside, and using pet therapy. Patients had one 90-minute session a week for 9 weeks. Results showed that patients were better able to follow directions, more communicative, and more sociable. Patients also displayed less anxiety during the sessions. The researchers concluded that stimulation therapy enhanced the quality of life for these individuals.

A similar randomized, controlled trial at a nursing home in Amsterdam was conducted by Holtkamp et al. (1997) to investigate the effect of multisensory stimulation on the well being of 16 older adults who were demented and institutionalized. Similar to Barker and Pinkney (1994), the study compared multisensory stimulation to standard activities. Those enjoying the multisensory stimulation displayed a relatively low level of behavioral problems during the time of the intervention. These authors concluded that multisensory stimulation improved the well being of elderly patients with dementia.

In 1997, Pinkney published her second project involving the use of multisensory stimulation focusing on elderly women with Alzheimer's disease. She compared multisensory stimulation sessions to basic music relaxation classes. Participants attended three stimulation or music relaxation sessions a week for 9 weeks. Stimulation activities included mirror balls, spot lights, fiber optic spray, music, and aroma oils. The music relaxation sessions involved placing the participants in a dark room seated in comfortable chairs listening to classical music. Based on observations of body gestures made by older adults during each session, Pinkney concluded that unnecessary body movement was reduced. Participants sang during the sessions and became less interactive. Pinkney stated that multisensory stimulation could be used in the treatment and management of severe dementia by manipulating mood and affect in a positive way.

Witucki and Twibell (1997) focused on 15 institutionalized patients with advanced Alzheimer's disease. The participants attended multisensory stimulation classes for 15 minutes during an unidentified period of time. Activities included music, massage, and smelling oils such as orange and cinnamon. Witucki and Twibell used the Discomfort Scale for Dementia's of the Alzheimer's Type to measure their outcomes (Hurley, Volicer, Hanrahan, Houde, & Volicer, 1992). Their findings suggested that multisensory stimulation activities lowered the psychological discomfort of patients. They also found that the stimulation resulted in an immediate increase in psychological well being.

A different approach was taken by Hope (1997) who identified factors that influenced or deterred staff from using a multisensory room already established within the faculty. The multisensory room was located on the first floor of a three-story building and contained equipment such as bubble tubes, fiber optic spray, cassette players, and textured objects. Hope's findings identified numerous problems that deterred staff from using the multisensory room.

Patients, although initially willing to go to the multisensory room, became anxious during the long transfer to the room on the first floor. Once a patient was agitated, the multisensory room was of little assistance, perhaps influenced again by the travel to the room. Staffing was also a problem. The floors could not "spare" a staff member to take a patient down to the multisensory room, and a staff member would have to then stay with the patient during the session. Although Hope's recommendations are useful to anyone planning to open a multisensory room, the geographical and staffing constraints in this study should be taken into consideration before planning a Snoezelen room.

Figure 1. Publication trends by decade.

Figure 1. Publication trends by decade.

DESCRIPTIVE STUDIES

More than half of the articles in the 1990s were not research-based, but described multisensory stimulation in older adults. Schofield (1996a, 1996b) and Schofield and Davis (1998) published three articles reviewing the use of multisensory stimulation with people with chronic pain. Schofield (19%b) stated that, to date, the results seemed promising because some patients had experienced a decrease in pain and improvement in their overall sense of well being and sleeping habits as a result of multisensory stimulation.

McKenzie (1995) described the opening of a multisensory stimulation room in a nursing home. Her stimulation activities included aromatherapy, music, tactile stimulation, image projectors, and bubbles. McKenzie reported that elderly patients and staff responded positively to the room. Morrissey (1997) and Hong (1996) reviewed the literature and summarized the benefits of the use of multisensory stimulation with elderly patients. Morrissey (1997) described the major benefits as providing an environment that encouraged meaningful relationships among staff and patients, promoting relaxation, and reducing psychological stress and staff burnout. Hong said the benefits were relaxed patients, increased sense of happiness and interest, and reduced sadness and fear.

However, Savage (1996) cautioned nurses against using activities such as multisensory stimulation because of the lack of empirical research to support their use. Savage believed the search for alternative treatments for dementia was analogous to the search for a cure for carcinoma. Interestingly, Savage (1996) offered no negative findings on the use of multisensory stimulation, but rather a skeptical view. However, caution may be warranted because many of the studies described lacked scientific rigor.

RESULTS

Twenty-six pieces of literature from various journals were included in this review. It was difficult to study the topic of an environmental intervention with multisensory stimulation because the term itself has many different labels ranging from "eclectic therapy" to "Snoezelen." Furthermore, most of the literature available is not published in America, and a large portion of the empirical research on the participant is published in Dutch.

Multisensory stimulation, or Snoezelen, is very popular as evidenced by the number of manuscripts originating in Great Britain. British authors published more than 50% of the literature on this topic. Figure 1 shows the number of reports pertaining to the use of multisensory stimulation in older adults published per decade from 1960 to 1990. This figure highlights the increased interest in the intervention in the 1990s. Nearly 70% of the literature retrieved was published in the past decade.

Both nurses and occupational therapists have contributed significantly to the knowledge base of multisensory stimulation in older adults. As in many other instances, nurses have given many of their original tasks to other disciplines as their own work requirements changed. Using interventions to enhance quality of life has most recently become the purview of occupational therapists rather than nurses (Figure 2). In fact, when examining combined authorship, more than half of the research reviewed in this search was conducted by these combined disciplines.

Seventy percent of the literature retrieved in this search was research based (Figure 3). Half of these were experimental research studies, five of which were randomized and controlled. Nearly 90% of the empirical research found that multisensory stimulation made a significant improvement in the behavior, affect, social, and verbal skills of elderly patients (Baker et al., 1997; Corcoran & Barren, 1987; Holtkamp et al., 1997; Paire, 1984).

There was only one empirically based study that found sensory stimulation had no statistically significant effect on elderly patients with dementia (Robichaud, Herbert, Desrosiers, 1994). Robichaud et al. (1994) did find a significant decrease in the frequency of disruptive behaviors of elderly participants exposed to multisensory stimulation, a decrease in their caregiver's reactions to these disruptive behaviors, and an improvement in the level of assistance required for activities of daily living. However, the differences were not statistically significant. They also reported problems implementing and evaluating the program, and that may have affected the outcomes.

The remainder of the articles reviewed were informal, uncontrolled studies with small numbers and convenience samples of mostly institutionalized elderly patients with dementia. Despite the lack of rigor in the research, the descriptions in these studies contributed significantly to the knowledge base of multisensory stimulation. They may have provided the basis for the presently increasing interest in Snoezelen because they reported positive outcomes and supported the use of multisensory stimulation with an aging population.

The descriptive studies found that muhisensory stimulation programs benefited older adults in numerous ways. The most common benefits included an increase in sociability and level of interest and a decrease in disruptive behaviors and levels of anxiety (Arno & Frank, 1991; Bower, 1967; Loew & Silverstone, 1971; Maloney & Daily, 1986; Norberg et al., 1986; Pinkney, 1997). Other studies found that multisensory stimulation improved patients' affect and communication skills (Bower, 1967; Bryant, 1991; Moffat, Barker, Pinkney, Garside, & Freeman, 1993; Barker & Pinkney, 1994; Weil, 1966).

Still others noted an improvement in staff morale and patient and staff relationships (Barker & Pinkney, 1994; Bryant, 1991; Robichaud et al., 1994). Although a few patients did not like the multisensory stimulation, and therefore did not continue with the intervention, no one reported using multisensory stimulation with older adults had any significant negative effects. Importantly, the studies reviewed failed to describe dose-response effects and length of time for the intervention, making replication and validation of findings difficult.

DISCUSSION AND IMPLICATIONS FOR NURSING

The health care community began to experiment with multisensory stimulation in older adults in the 1960s in response to the sensory deprivation experienced by many older adults who were institutionalized - a situation not different from the problems facing nursing homes currently. In 1967, Bower justified the need for multisensory stimulation by describing older adults who were institutionalized as rows and rows of pathetic figures in wheelchairs who either leaned against the walls or shuffled about seemingly without purpose. He accused health care professionals of neglecting a large segment of the patient population by focusing on rehabilitating patients with functional disease only. Themes describing apathetic older adults were repeatedly echoed in most of the earlier research and drew attention to the need for activities and programs that provide a pleasurable leisure activity for elderly patients suffering from cognitive and physical impairments.

Although empirical research investigating multisensory stimulation in older adults is minimal, currently 90% of empirical research supports its use as both therapeutic and effective. These findings are reinforced by the nonscientific reports supporting the use of multisensory stimulation with older adults. These interventions are ripe for re-adoption by both nursing researchers and clinicians in collaboration with occupational therapists.

It is evident from this review of the literature that multisensory stimulation is enjoying a resurgence under the label of Snoezelen. Many health care facilities in Europe are currently providing multisensory rooms for elderly patients. However, in this new century, the multisensory rooms are high tech and high touch. As "the graying of America" continues and health care providers become more cognizant of the sensory deprivation and isolation experienced by older adults who are institutionalized, the use of these multisensory rooms will continue to grow. Nurses should be poised to work collaboratively with occupational therapists to become clinically proficient in this current vogue of high tech multisensory stimulation interventions.

CONCLUSION

The concept of multisensory stimulation has many different names and titles and cannot be easily retrieved though computer databases indexed by keywords. In the 1960s, the intervention was referred to as "sensory stimulation" and "special programs for the senile aged." As more research evolved, more names such as "eclectic therapy" and "creative group work for elderly people" began to surface. Currently, it is called everything from "sensory integration therapy" to "Snoezelen." Because the concept of multisensory stimulation encompasses the major components of all of the aforementioned names used to describe this concept, researchers should entitle their program as such, or at least publish an article with "multisensory stimulation" as a key phrase. The difference in terms makes it difficult to replicate or compare the research.

A standardized measurement tool used across studies to better document the effectiveness of multisensory stimulation would provide more useable information. One of the more effective tools found in this literature review was the Discomfort Scale for Dementias of the Alzheimer Type (Hurley et al., 1992). It would also be helpful to see a publication on how to set up a Snoezelen room, because interested health care providers will be looking for information on starting such a program. Only two articles discussed the development and costs of opening such a program (Hope, 1997; McKenzie, 1995).

Not a part of this review, but a new source of helpful information, are four books translated or published in Great Britain. With the new millennium, multisensory intervention has taken hold in Great Britain especially. Rompa, the company that trademarked the term Snoezelen, not only supplies most of the equipment, but they have also published two books to help people get started with the intervention (Hulsegge Oc Verheul, 1987; Hutchinson & Kewin, 1994). Also helpful are two research reports funded by the NHS Trust in Dorset and Derbyshire (Hutchinson, 1991; Moffatetal.,1993).

These latest additions, found after the review was written, should be helpful to nurses and other health care providers who wish to begin Snoezelen with their patients. Though occupational therapists have adopted this intervention, nurses are with patients for longer periods of time than other providers. Nurses are best prepared to interpret patient needs and work collaboratively with occupational therapists to establish and test Snoezelen rooms in the United States. The Snoezelen intervention may be one effective intervention with a positive view and an intent to provide pleasure. As nurses, we should use it.

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