Journal of Gerontological Nursing

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Feature Article 

Use of Multisensory Environments in the Home for People with Dementia

Cheryl K. Riley-Doucet, PhD, RN

Abstract

The purpose of this pilot study was to explore the feasibility and effectiveness of using multisensory environments (MSE) in the home of people with dementia. A qualitative research design was used, which included semi-structured interviews and self-rated caregiver observation checklists. Field notes and audio recorded interviews were transcribed for data analysis. Data were reduced and coded for theme identification. Positive and negative effects of the use of MSE in the home on the behaviors of the person with dementia, caregiver burden, and family interpersonal relationships were revealed. Overall, MSE was discovered to promote a relaxing and calm environment in the home, which helped the person with dementia attend more to their immediate surroundings, and to improve family interactions. Although the majority of caregivers reported they enjoyed the MSE, they acknowledged their disappointment in the MSE as not providing more caregiver respite.

Abstract

The purpose of this pilot study was to explore the feasibility and effectiveness of using multisensory environments (MSE) in the home of people with dementia. A qualitative research design was used, which included semi-structured interviews and self-rated caregiver observation checklists. Field notes and audio recorded interviews were transcribed for data analysis. Data were reduced and coded for theme identification. Positive and negative effects of the use of MSE in the home on the behaviors of the person with dementia, caregiver burden, and family interpersonal relationships were revealed. Overall, MSE was discovered to promote a relaxing and calm environment in the home, which helped the person with dementia attend more to their immediate surroundings, and to improve family interactions. Although the majority of caregivers reported they enjoyed the MSE, they acknowledged their disappointment in the MSE as not providing more caregiver respite.

Dr. Riley-Doucet is Assistant Professor, School of Nursing, Oakland University, Rochester, Michigan.

Address correspondence to Cheryl K. Riley-Doucet, PhD, RN, Assistant Professor, School of Nursing, Oakland University, 452 O’Dowd Hall, Rochester, MI 48309; e-mail: rileydou@oakland.edu.

© iStockphoto.com

© iStockphoto.com

The use of environmental modalities to promote a sense of well-being and reduce anxiety and agitation in people with dementia has been increasingly accepted by administrators in nursing homes across America (Melillo & Houde, 2005; Whall, 2002). The multisensory environment (MSE) has been discussed in the nursing literature as a successful environmental modality used in long-term care facilities to produce a sense of calm in people with dementia and has been shown to be an acceptable alternative therapy in the care and treatment of people with dementia (Chitsey, Haight, & Jones, 2002; Hope, 1998; van Diepen et al., 2002).

MSE consists of visual, auditory, tactile, and olfactory stimulation, usually offered to patients in a specially designed room or environment through a variety of lights, music, aromas, and tactile objects. Although much of the literature supporting the use of MSE in people with dementia remains largely anecdotal (Melillo & Houde, 2005), most reports indicate that MSE promotes relaxation and gentle stimulation in an enabling atmosphere (Baillon et al., 2004; Chitsey et al., 2002; Minner, Hoffstetter, Casey, & Jones, 2004). In addition, MSE has been reported to aid communication in people with dementia, which may improve interpersonal relationships (Hope, 1998; Minner et al., 2004).

Literature Review

To date, there is no research that explores the use of MSE in the home and its effect on interpersonal relationships between family caregivers and people with dementia. It is estimated that nearly 10% of Americans older than age 65 have some kind of dementia and that slightly more than half of those with dementia receive care at home (Geriatric Mental Health Foundation, 2003). Therefore, caregivers of individuals with dementia often look for management strategies that will help maintain the integrity of their family interpersonal relationships, while addressing the anxiety and agitation (Minner et al., 2004; Thompson & Spilsbury, 1998).

Because it is known that interpersonal relationships are often strained between caregivers and people with dementia (Geriatric Mental Health Foundation, 2003), identifying the feasibility and effectiveness of a treatment strategy that can be implemented in the home to improve the interpersonal relationships between people with dementia and their caregivers is warranted. Thus, the purpose of this pilot study was to explore the effectiveness and feasibility of using MSE in the home through a qualitative research design. The intent of this research was to explore: (a) how the use of MSE in the home affects the behaviors of people with dementia, (b) how the use of MSE in the home affects the interpersonal relationships between people with dementia and their family caregivers, and (c) the feasibility of using MSE in the home as a nonpharmacological care modality.

Method

Design

The qualitative method of in-depth semi-structured focused interviews was used to collect data from both those with dementia and their family caregivers. Semi-structured focused interviews were viewed as the most appropriate method of obtaining specific information on participants’ opinions about the usefulness of MSE as a nonpharmacological care modality used in the home. According to Streubert Speziale and Carpenter (2003), semi-structured focus interviews allow respondents the time and scope to talk about their opinions on a particular topic to understand their point of view rather than make generalizations about behavior. In addition to the semi-structured interviews, a demographic questionnaire, designed by the investigator, that included Pfeiffer’s (1975) 10-item Short Portable Mental Status Questionnaire (SPMSQ) and a Caregiver Observation Record adapted from Rozen (n.d.), were also used to collect supplemental descriptive data.

Sample

Study participants consisting of adults older than age 65 with a confirmed medical diagnosis of dementia and their primary family caregivers (age 18 and older) were recruited from caregiver support groups sponsored by the Alzheimer’s Association of greater Michigan, the county older persons commission, and a hospital home care center. Data were collected until saturation (the repetition of salient points and themes) was discovered after 10 family dyads were interviewed. According to Streubert Speziale and Carpenter (2003), data that are repetitive in nature are considered to be a confirmation of previously collected information rather than new information. Therefore, the sample of 10 family dyads was determined to be adequate for obtaining qualitative data that will enhance understanding of how useful MSE is as a nonpharmacological home care modality, as well as how it affects both caregivers and people with dementia living at home (Krueger & Casey, 2000).

Procedure

The principal investigator (C.K.R.-D.), accompanied by a research assistant, made the first home visit. At this time, an informed consent was obtained from the family caregivers and assent from responsible parties of older adults unable to give legal consent according to procedures outlined by guidelines for the protection of human subjects. Caregivers were asked to complete a demographic form for themselves and their family members. This demographic form included two questions that assessed the family caregivers’ knowledge of and/or exposure to MSE using a dichotomous scale (0 = no and 1 = yes). Family caregivers were asked if they had heard of MSE or Snoezelen® rooms before and whether they had ever used any multisensory mediums (either alone or in combination) to help them or the people with dementia relax and reduce agitated behaviors. If they indicated yes to this question, they were asked to select the sensory mediums from a prepared list. If they used any other medium that was not listed, they were asked to write it in.

The 10-item SPMSQ (Pfeiffer, 1975) was then administered to the person with dementia by the principal investigator to asses the level of cognitive impairment. The SPMSQ has been shown to have comparable reliability with other assessment scales for organic disease and is less anxiety provoking for older adults with organic brain deficits than longer screening scales (Erkinjuntti, Sulkava, Wikström, & Autio, 1987; Parker & Philp, 2004).

A 45-minute interview took place with both the caregiver and the person with dementia concerning information about daily interactions between the dyad, focusing specifically on behaviors of anxiety and/or agitation in the person with dementia and how this affected the family interpersonal relationships. The following are examples of the initial interview questions:

  • In the past year, has your family member ever demonstrated behaviors of anxiety or agitation, for example, pacing back and forth, shouting, pushing, wringing hands, verbal repetitiveness, and/or any other examples of behaviors you have observed in the person with dementia?
  • Is there anything that seems to trigger this agitation in your family member?
  • What about this behavior is most disturbing for you? How does this behavior affect the relationship you have with your family member?

Following the initial interview, the principal investigator and research assistant set up the MSE equipment in a room designated by the family as a quiet, undisturbed room with which the person with dementia was familiar. The caregiver and person with dementia were orientated to the MSE equipment and provided with instruction on how to use it. At this time, the person with dementia and the family caregiver were given an opportunity to try out all of the equipment and ask questions.

A portable Snoezelen kit purchased through Flaghouse ( http://www.flaghouse.com), the official supplier of equipment for Snoezelen rooms, provided the sensory equipment for this pilot study. Each kit contained specific sensory equipment that stimulated individual senses and was chosen for its perceived suitability for older adults with cognitive impairment. A list of the sensory equipment, with a description and rationale for each selected piece, is outlined in Table 1.

Multisensory Environment Equipment Description and Rationale

Table 1: Multisensory Environment Equipment Description and Rationale

The investigator emphasized the importance of customizing the sensory stimulation to suit the enjoyment of the person with dementia; therefore, the families were instructed to start sessions with all of the equipment in place and then add, subtract, or replace stimuli according to the preference of the person with dementia. For example, one family replaced the CD stereo with a music box that their family member with dementia loved to listen to.

Caregivers were asked to complete a Caregiver Observation Record adapted from Rozen (n.d.), which included the date, time, and duration of the MSE session for the person with dementia. Caregivers were also asked to rate their loved one’s behavioral response to the MSE (1 = irritable and not cooperative, 2 = partial cooperation, 3 = relaxed and cooperative), as well as their perception of how much the person with dementia enjoyed the MSE session (1 = disliked MSE, 2 = somewhat disliked MSE, 3 = somewhat enjoyed MSE, and 4 = enjoyed MSE).

Before leaving the first home visit, several important points were discussed with the caregiver prior to commencing each MSE session:

  • Orientation to the MSE equipment. The person with dementia should be shown and reminded of each piece of sensory equipment at the beginning of each session. Caregivers were instructed to give their loved one the opportunity to choose which equipment they preferred to experience each session.
  • Timing of sessions. It was recommended that the MSE be used before typical periods in the day when the person with dementia became restless or agitated. Caregivers were asked to record each session on the observation record.
  • Length of session. Although the length of time spent in each session should be dictated by the person with dementia, previous literature (Pinkney & Barker, 1994) suggests the optimum length of time per session is 20 to 30 minutes. Thus, it was recommended that caregivers encourage their family members to stay at least 15 to 20 minutes.

After 1 week of using the MSE, a telephone interview was scheduled with the caregiver to assess the family’s progress. This interview followed another set of semi-structured questions that asked how many times and for how long the person with dementia used the MSE per day, whether the person with dementia was accompanied by the caregiver into the room, and how long the caregiver stayed with the person with dementia. During this interview, caregivers were also reminded to complete the Caregiver Observation Record.

Following the third week of using the MSE, a second home visit was made and a final semi-structured interview was held with the caregiver. Questions focused on summarizing the caregiver’s perceived effect of the MSE on the person with dementia and the family interpersonal relationships. The following are examples of the questions asked in the final interview:

  • What were the most positive and negative aspects of using the MSE in the home?
  • Can you summarize how satisfied you were with using the MSE in the home?
  • How did the MSE influence your relationship with your family member?

All interviews were audio recorded, and notes were also taken during the interview to ensure accuracy. The individuals with dementia and their family caregivers each received a $10 gift certificate to a national pharmacy for their participation in the study. Confidentiality was ensured through patient identification numbers, and data were kept in a locked file.

Data Analysis

Analysis of qualitative data followed Krueger and Casey’s (2000) systematic and sequential method of analysis. Field notes, audio recordings, and transcripts were first compared for content accuracy. Transcripts were read line by line and discussion phrases were categorized under three basic content areas (Graneheim & Lundman, 2004):

  • Satisfaction with and ease in using MSE in the home.
  • Benefits of MSE to the person with dementia and the family caregiver.
  • Interest in future use of MSE in the home.

Reduction and abstraction of data were performed by the principal investigator in collaboration with an expert in the field, and data were coded for further theme identification. N6 software was used to sort the data electronically into specific nodes of coded data that allowed for the isolation of shorter quotations that were nested in longer quotations for more specific theme identification. Descriptive statistics were used to determine patient and caregiver demographics, previous use of sensory stimuli, and caregivers’ rating of their loved one’s reaction to the MSE experience during each session.

Results

Sample Characteristics

Sample characteristics for the 10 family dyads are presented in Table 2. The family caregivers were an average of 59 years old, Caucasian (70%), women (80%), and had achieved post high school education (70%). All family caregivers were kin (spouses, daughters, and daughters-in-law) who lived with the person with dementia. This is consistent with previous reported statistics for family caregivers (Riley-Doucet, 2005).

Description of the Family Caregiver-Person with Dementia Dyads

Table 2: Description of the Family Caregiver-Person with Dementia Dyads

The average age of the people with dementia was 83, and most were widowed women who had achieved at least high school education. The level of intellectual functioning for the majority of those with dementia (60%) fell into the severe range with 8 to 10 errors on the SPMSQ, 30% fell within the moderate intellectual functioning range (5 to 7 errors), and only 1 person with dementia fell into the mild range with 4 errors made on the SPMSQ. None of the families had experience with or knowledge of MSE at the time of the interviews; however, several families had used two to three individual sensory stimulants in the past to promote relaxation in the person with dementia (Table 3).

Sensory Mediums Previously Used by Caregivers to Promote Relaxation in People with Dementia (N = 10)

Table 3: Sensory Mediums Previously Used by Caregivers to Promote Relaxation in People with Dementia (N = 10)

The person with dementia and his or her caregiver attended the MSE sessions together an average of one time per day and spent an average of 27.5 minutes per session (Table 4). The caregivers also observed the person with dementia to be relaxed and cooperative during the MSE session, and the majority of caregivers rated their family member as at least somewhat enjoying the MSE session (Figure).

Average Frequency and Duration of Multisensory Environment Sessions

Table 4: Average Frequency and Duration of Multisensory Environment Sessions

Caregivers’ Ratings of the Average Enjoyment of the Person with Dementia in the Multisensory Environment (MSE).

Figure. Caregivers’ Ratings of the Average Enjoyment of the Person with Dementia in the Multisensory Environment (MSE).

Three themes were revealed from the qualitative data that described the effects of using MSE in the home for both the person with dementia and the caregiver: The Effects of MSE on the Behaviors of the Person with Dementia, the Effects of MSE on Caregiver Burden, and the Effects of MSE on the Family Interpersonal Relationships.

The Effects of MSE on the Behaviors of the Person with Dementia

Positive effects of the MSE were the major focus of this theme. Family caregivers reported that, overall, their loved ones were satisfied with the multisensory stimulation and showed a curiosity about the equipment:

He was very relaxed and touched things. He really liked the music. In fact, one time we were listening to a CD, and I said OK the CD is over and…he wanted to listen to more music so we stayed a little longer. (Caregiver 5)

Caregivers also identified a positive change in the demeanor and state of restlessness of the person with dementia as a result of being exposed to the MSE:

His aide came in yesterday, and he [loved one with dementia] was starting to physically get upset. I said let’s go into the [MSE] room. We put some music on, sat down, [and] he started watching the projector’s picture on the wall. You could see the change in him; he wasn’t paying attention to his anger, he was paying more attention to the other stimulants, and for the rest of the day he was good until about 4:30. (Caregiver 5)

She seemed more relaxed or something; she seemed to be able to stay in one place more. As long as she held that light rope she stayed in this room. (Caregiver 2)

A change in the cognitive state of the people with dementia was another positive effect of MSE identified by caregivers. Caregivers reported improvements in their loved one’s recall of family members and general alertness. Reports by caregivers indicated that their loved one was even more cooperative in following directions:

My daughter noticed definite change in my wife. We had breakfast with her a couple of times, and she said that mom seemed to be speaking more clearly. She even called my son by his first name, which was the first time in about a year…. I noticed that it wasn’t as hard to get her into the bathroom some mornings this week [after MSE]. (Caregiver 3)

She was 10 times more responsive…. I showed this picture…she identified my dad, this was interesting because she normally would not look at that picture…and during a session my back was turned to her…and then, just as clear like normal, [she said] “Cindy, could you get this for me?” She knew me even from the back! (Caregiver 6)

The major negative effect of MSE on the people with dementia was identified as their being distressed with a particular piece of the MSE equipment:

The globe. She reacted very violently to it…. She started shaking it while it was flashing. I just turned it off and didn’t put it on again. (Caregiver 2)

The ball…she just ignored that, never went near it. (Caregiver 1)

The Effects of MSE on Caregiver Burden

The predominant positive effect that emerged from the data was that the presence of MSE in the home precipitated a relaxed atmosphere and promoted a sense of well-being for family members functioning in their roles as caregivers. Family caregivers enjoyed being with their family members in the room and feeling more connected to their family member as they helped their loved one interact with the MSE:

I sat in here with her several times and kind of enjoyed watching her touch the items and pick them up. I even sat in here by myself once in awhile. I don’t know, it just made me feel relaxed…. I’m glad you came here and showed this to us. (Caregiver 3)

Yeah. We talked, we sang, we listened to the music. We liked the music. The lights added festivity and gave it atmosphere. So there was just a little bit more. He was relaxed. It seemed he was in a good mood and so was I. (Caregiver 4)

[It was] a recreation for the two of us and if we got tired of television or staying in,…and I think it would be very, very effective in the wintertime because we’re more confined. (Caregiver 10)

Caregivers also described MSE as a medium for them to feel useful to their family members, which also helped them view their caregiving role as more positive and worthwhile:

You know…[it gave] you something to do when you are with them… when she’s doing this [MSE] it makes her more alert so then she focuses in, and you feel you’re not just talking to the air. (Caregiver 6)

I think that with this here I just tried to relate to her more. Instead of being one more job for me to do, really relate to her and her feelings and this just part of that, you know…. I do think there have been times when she seemed more conversive after having used it. (Caregiver 8)

Observing some of the changes in their family member’s behaviors also promoted a sense of hopefulness in the caregivers:

I was telling my one sister that to me the biggest thing about this is, the hope I have seeing her react to it [MSE]…it’s like that one little thing keeps you going. There’s no reward in all of this…but to do this and get that little response will keep people going and give them that hope. (Caregiver 7)

The major negative aspect of MSE for caregivers that emerged from the data was the inability of MSE to be used as a distraction or provide some respite for caregivers. Data revealed that the MSE did not meet the caregivers’ expectations for being more convenient and providing some relief of their caregiving duties; therefore, they viewed it as an added task to their daily routine:

You know, taking the time to think about it and do it…I’m the one that has to do the grocery shopping and put all the things away, do all the work…. After dinner I’m done in. I don’t feel like going around and putting on all the stuff. (Caregiver 2)

Well, I was kind of disappointed that it [MSE] didn’t do more, like keeping her busy while I did the laundry or took a shower. Every time I left her in the room by herself, she came out looking for me. (Caregiver 9)

She liked it fine, but she didn’t want to be left alone in there. When I asked her if she wanted to stay in while I go do something else, she didn’t want to. (Caregiver 4)

The Effects of MSE on the Family Interpersonal Relationships

The data revealed only positive effects of the MSE on the family interpersonal relationships. Caregivers described themselves as feeling more connected with their loved ones while interacting with them in the MSE. They found that the pleasantness of the MSE promoted a more lighthearted interaction with their loved one:

Well, I tell you that it does relax you. It [MSE] really seemed it was a calming effect to the point where we were relaxed and we were enjoying it. Just taking time out for something different, that was really what it amounted to. I found that we had a little more conversation or were just enjoying the music or singing along with it. Mainly he sings because he remembers all the words, I don’t. It really kind of made it [their relationship] kind of sweeter, you know. He paid attention to me and vise versa, instead of just being. (Caregiver 3)

Well I’m not so uptight when I’m with her in there. She has been calmer and happier but I don’t know if it’s because of it [MSE], or maybe it’s because of that, you know, me being calmer, how do you know? (Caregiver 1)

It was kind of fun having it [MSE] around, both of us got into different things. She really liked that snake light…. I liked the music and smells. It was good doing something together again. (Caregiver 4)

Discussion

The purpose of this qualitative pilot study was to gather information about the feasibility of using MSE in the home as a nonpharmacological care modality and explore its effect on people with dementia and their family caregivers. Three thematic categories emerged from the data that informed about the effect of using MSE in the home. The first thematic category focused on the responses of the people with dementia to the use of MSE in their home. Overall, those with dementia seemed satisfied with the sensory stimulation and showed interest in interacting with the MSE equipment (i.e., looking at or touching it). This finding is similar to previous studies that found that exposure to MSE for residents in long-term care facilities was a positive experience in terms of response to equipment and effect on behavior (Baker et al., 2001; Hope, 1998).

In this study, the majority of people with dementia and family caregivers attended the MSE sessions together approximately one to two times per day, with each session lasting nearly 30 minutes. Overall, the behavioral changes in the person with dementia following exposure to the MSE were described by the family caregivers as the person being more relaxed and responsive to the environment and other family members. This is similar to some findings described in the literature. Baillon et al. (2004) found that long-term care residents demonstrated an increase in relaxation and a reduction in restlessness during sessions, and Baker et al. (2001, 2003) found patients to be more alert and less bored or inactive after sessions; they also related better with others afterward.

A noteworthy positive effect that caregivers described was the cognitive changes in some individuals with dementia, especially those who fell within the range of severe deficits in cognitive functioning. These participants were reported to have recalled names of offspring and family members, a cognitive function they had not achieved for a long period of time. Similar findings have been reported in previous research (Baker et al., 2001; Hope & Waterman, 2004).

In addition, caregivers did not report any behaviors of anxiety or agitation in their family members during the 3-week period of using the MSE at home. Perhaps by using the MSE fairly regularly (approximately one to two times per day), the need for diversion and stimulation was met, especially for those with greater cognitive impairment. This, in turn, may have prevented some of the typical behavioral problems that have been reported in previous research as a result of inactivity and/or sensory deprivation in people with dementia (Loew & Silverstone, 1971). Previous research on the use of MSE in long-term care facilities has found that MSE is a useful mode of stimulation for individuals with cognitive impairment because, as cognitive abilities deteriorate, it is more difficult for patients to participate in activities that involve some kind of cognitive processing, such as reminiscence, board games, and quizzes (Baker et al., 2003; Cox, Burns, & Savage, 2004; Wheeler & Houston, 2005). The majority of people with dementia in this study fell within the range of severe cognitive impairment on the SPMSQ; thus, MSE sessions would be an appropriate mode of nonpharmacological therapy that could be used in the home to enhance their quality of life.

Few negative effects of MSE on those with dementia were reported. There were no reports of the person with dementia refusing to participate in the MSE. In fact, caregiver ratings of the behavior of the person with dementia while in the MSE all fell within the cooperative range (Figure). Interestingly, it was discovered that findings indicating low satisfaction with MSE were associated with caregivers who did not stay in the MSE with their family members during the sessions. However, these findings differ somewhat from those of previous studies where some in-patient residents were reported to show resistance in attending the MSE (Hope, 1998). Perhaps in this study, there was more acceptance of the MSE when it was placed in a familiar location within the person’s home.

The second theme focused on the positive and negative effects of MSE on caregiver burden. The caregivers reported that the MSE was beneficial in helping them view their caregiver role as more rewarding and valued. They described feeling more useful to their loved ones as they helped them engage in the MSE. The changes they saw while observing their family member interact with the MSE equipment sparked in them a sense of hope. These results are congruent with the literature on caregiver burden, as much has been written about how psychologically beneficial it is for family caregivers to feel like they are doing something to help relieve the suffering of their loved ones. (Riley-Doucet, 2005). Even small changes in behaviors have been found to be positive for family caregivers and may improve the quality of life for both the people with dementia and their family caregivers (Baker et al., 2003; Kempenaar, McNamara, & Creaney, 2001).

The caregivers also felt a sense of relaxation and lightheartedness while in the MSE, which created a positive atmosphere in which the caring relationship took place. They also benefited from the relaxed atmosphere the MSE promoted and believed they could spend more time with their loved ones and be more attentive to their needs. These results are similar to study findings that have investigated caregiver burden among professional caregivers who work with patients with Alzheimer’s disease. Caregivers reported greater motivation and concern for their patients when they were given adequate time to complete their care in a relaxed atmosphere (Hope, 1998). The positive reactions by caregivers to MSE have also been documented in the literature; the ability to spend time with their clients and softly talk with or massage them allows a greater connectedness from which both caregivers and patients have benefited (Zinn, 2000).

Despite the many positive effects of MSE the caregivers described, one major frustration was that the MSE did not appear useful in providing a “distraction” for their loved one, so he or she could be left alone. The caregivers clearly stated that this was a disappointment for them, as they had expected to receive some respite by bringing the MSE into the home. Recent studies have shown a significant relationship between caregiver respite and caregiver well-being (Feinberg & Newman, 2004). Although caregiver respite has not been found to significantly improve caregiver burden, it is welcomed by caregivers and has been found to improve caregiver mental health and quality of life (Lawton, Brody, & Saperstein, 1989). This is an important finding because it is essential that family caregivers understand that while MSE provides some benefits in inducing relaxation and promoting person-centered care, it should not be viewed as a “distraction” or an independent care modality.

The final thematic category focused on the effect of MSE in the home on the family interpersonal relationships. The family caregivers found the MSE extremely beneficial in acting as a medium for improving and enhancing the family relationships. Previous research suggests that family relationships between the caregiver and person with dementia are frequently strained because of behavioral and personality changes in the person with dementia that prevent familiar interactions to continue (Thompson & Spilsbury, 1998). While in the MSE, both the person with dementia and the family caregiver were able to experience joint pleasure and relaxation, which renewed some familiar interactions between the two.

The caregivers also found that using the MSE in the home encouraged one-on-one interactions with their loved one in a nonthreatening atmosphere. Evidence suggests that caregivers often withdraw emotionally from their family members with dementia as a way of coping with the emotional burden that comes with confronting the person’s cognitive decline (Perel, 1998). In this study, caregivers were able to reconnect with their loved one in a relaxed, unstructured environment that did not require special skills or specific roles. Therefore, the MSE acted as an acceptable home-based intervention for enhancing interpersonal communication with the person with dementia.

Limitations

The principal investigator realized that a potential for obtaining false data could exist because the MSE was left in the home without direct observation and supervision by the investigator regarding its use in the home. Certain research methods were used to compensate for this, such as providing caregivers with step-by-step instructions on how to use each piece of MSE sensory equipment and how to use the observation checklist, as well as the telephone interview with caregivers midway through the study to assess if they were having any difficulty using the MSE and to remind them to complete the observation checklist.

Recommendations for Future Research

Although the findings of this pilot study suggest that this nonpharmacological intervention has some therapeutic value for both people with dementia and their family caregivers, future research is needed to fully investigate the impact of MSE on caregiver burden and patient cognitive outcomes. Future studies should include measures of caregiver stress, as well as cognitive and biomedical measures of physical functioning, as outcome measures. Along with the observation measures used in this pilot study, other methods of observation can be used to assess the effectiveness of this intervention, for example, videotaping the behaviors of the people with dementia during and after MSE sessions. Future studies should also be conducted to investigate the impact of MSE on individuals with dementia and their caregivers during situations of direct caregiving, such as toileting and bathing.

Conclusion

This study demonstrated the feasibility of using MSE in the home. MSE for cognitively impaired older adults is an emerging concept that will require further research to determine its full potential as a nonpharmacological nursing care intervention and its effectiveness in improving quality of life for caregivers and people with dementia being cared for at home. Nevertheless, the underpinning philosophy of MSE is in stark contrast to the typical medical model, which dictates that treatment should involve only the damaged part, not the whole person, and certainly not the caregiver as well.

MSE provides both caregivers and people with dementia an alternative method of managing undesirable behaviors and creating a therapeutic experience for all who experience it in the home environment. Despite its many benefits, MSE should not be viewed as a “distraction” or independent care modality. van Diepen et al. (2002) pointed out that the therapeutic value of MSE comes when people with dementia are gently guided by their caregivers to participate in the sensory experience. Therefore, MSE is most useful as a medium for improving and enhancing family interpersonal relationships. Further empirical research is needed to develop caregiver education on ways MSE can be implemented as part of everyday care practices in the home and in formal patient care facilities.

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Multisensory Environment Equipment Description and Rationale

EquipmentDescriptionRationale
Bubble tubeStreams of bubbles rise inside an illuminated column of water. The plastic tube gently vibrates and hums for added stimulation.The bubbles slowly change color as they float to the top, providing a great visual effect. It was also chosen for visual tracking.
Evening breezeA small fan that must be turned on manually by hitting a large, surface-mounted switch.This is meant to provide tactile stimulation by producing a gentle sensation that is often pleasurable for those who find the wind outdoors too strong and overwhelming.
Chase light stringA yellow rope light that is attached to a chaser unit, which can be manually adjusted to chase lights slower or faster to give a glimmering effect.The rope cable is smooth to the touch and can be explored safely with the hands. The chasing lights produce gentle visual stimulation.
Plasma ballA clear ball that when turned on projects the electricity flowing through the ball. When the ball is touched with a hand, the lightning effect jumps toward the hand.This ball is used to provide visual distraction and tactile stimulation. It is made of a clear plastic that is safe to touch and not easily broken.
Solar efects projectorThis projector rotates a special-effect wheel, which creates patterns and pictures that move slowly around the room.The images are great for visual stimulation and tracking. Simply changing the effect wheel can change the atmosphere from vibrant to tranquil.
Stereo and speakers (music)A small portable stereo box that contains two speakers and a CD player.The inclusion of stimulating yet comforting music can greatly enhance the relaxation experience. Selections range from serene ocean sounds, classical compositions by the masters, to lullabies.
Vibrating tubeThis is a soft, pliable tube that vibrates in two different intensity settings. It is battery powered and can be adjusted to rest on shoulders or passed over the arms and legs.This sensory equipment is meant to produce gentle tactile stimulation and produce relaxation for users who enjoy vibration.
Aroma air spraySpurts of aroma fragrance that can be adjusted to the desired concentration are sprayed out from this apparatus at timed intervals.This is meant to provide olfactory stimulation. Precautions were taken to avoid allergic reactions to the different fragrances. It also is used to stimulate implicit memory recall.

Description of the Family Caregiver-Person with Dementia Dyads

People with DementiaFamily Caregivers
VariablenRangeMeannRangeMean
Age1074 to 94831035 to 8759.5
Gender
  Women78
  Men32
Race
  Caucasian77
  African American23
  Mixed race10
Highest level of education
  Grade school10
  High school53
  Post high school47
Relationship to the person with dementia
  Spouse3
  Daughter5
  Daughter-in-law2
Intellectual functioning of the person with dementia
  Mild impairment (3 to 4 errors on the SPMSQ)1
  Moderate impairment (5 to 7 errors on the SPMSQ)3
  Severe impairment (8 to 10 errors on the SPMSQ)6
Knowledge of and exposure to multisensory environments
  Yes00
  No1010

Sensory Mediums Previously Used by Caregivers to Promote Relaxation in People with Dementia (N = 10)

Sensory MediumPercentage
Music90
Food40
Heat30
Aromatherapy20
Exercise20
Massage20
Bath10
Cold10
Light therapy0

Average Frequency and Duration of Multisensory Environment Sessions

VariableMean (SD)Range
Duration of session27.5 minutes (8.897)15 to 45 minutes
Frequency of session
  Daily1.3 times (0.443)2 to 3
  Weekly2.2 times (0.421)

Multisensory Environments for Dementia

Riley-Doucet, C.K. (2009). Use of Multisensory Environments in the Home for People with Dementia. Journal of Gerontological Nursing, 35(5), 42–52.

  1. Multisensory environments (MSE) consist of visual, auditory, tactile, and olfactory stimulation, usually offered to patients in a specially designed room or environment through a variety of lights, music, aromas, and tactile objects.

  2. MSE is a nonpharmacological care modality that may positively affect both caregivers and people with dementia living at home.

  3. Environmental modalities can promote a sense of well-being and reduce anxiety and agitation in people with dementia.

  4. Caregivers described themselves as feeling more connected with their loved ones while interacting with them in the MSE, thus family interpersonal relationships were improved.

Authors

Dr. Riley-Doucet is Assistant Professor, School of Nursing, Oakland University, Rochester, Michigan.

Address correspondence to Cheryl K. Riley-Doucet, PhD, RN, Assistant Professor, School of Nursing, Oakland University, 452 O’Dowd Hall, Rochester, MI 48309; e-mail: .rileydou@oakland.edu

10.3928/00989134-20090331-01

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