Sensory stimulation and Snoezelen in the management of people with cognitive impairment. Dr Lesley Collier Senior Lecturer

Transcription

1 Sensory stimulation and Snoezelen in the management of people with cognitive impairment Dr Lesley Collier Senior Lecturer

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4 What do we mean by sensory stimulation and Snoezelen Snoezelen Sensory stimulation

5 Development of sensory stimulation and Snoezelen Key areas of practice Learning disabilities (Autism, Downs syndrome) Older persons mental health (Dementia, depression) Acute mental health settings (Stress management, Schizophrenia) Palliative care (pain management, end of life care) Maternity care (pain management, stress management) Neurology (acquired brain injury, sensory retraining)

6 Problems identified Poor concentration Restlessness / wandering Shouting Aggressive behaviour Severe disorientation Unable to engage in purposeful activity General mood disturbance Anxiety Inability to follow simple instructions Severe memory loss Loss of social skills Physical faility

7 Sensory challenges Sensory processing Person Environmental demand Just right challenge

8 Environmental demand Adapted from the model of sensoristasis Antecedent Neuro-physiological psychological decline Environmental factors Human intervention Sensory imbalance High-stimulus Imbalance exceeded Stress threshold Low-stimulus Sensory Imbalance deprivation Cortical sequelae Psychic discomfort Behavioural sequelae Agitation Decline in activities of daily living Decline social functioning in

9 Tenets of the model An imbalance may occur as a result of neurophysiological or environmental factors Too much high-stimulus activity can result in stress threshold being exceeded This will occur at a lower level if activity is unpleasant or processing is too fast. Too lower stimulus activity may lead to sensory deprivation.

10 Looking at skill levels Sensory level Perception Skill acquisition (Normal development) (Cognitive impairment / decline)

11 Sensory integration is critical for human development and function Attention Sensory intake Sensory modalities Feedback Sensory integration Arousal Adaptive behaviour and learning Planning and organisation of behaviour Motivatio n and drive

12 Five basic assumptions Potential for neuroplasticity Interaction between higher order (cortical) and lower order (subcortical ) areas to modulate sensory input Neurophysiological development of sensory integration follows a sequential pattern Adaptive response ability to adjust performance according to environmental demand Presence of inner drive to meet and master a challenge

13 Flow Csikszentmihalyi, 1975 High cognitive demand Anxiety Flow Low Cognitive demand Challenge Apathy Boredom Low Skills High

14 The model of sensory processing Dunn, 2002 Sensory processing patterns are based on how the nervous system reacts to input and how the person responds to that input. Nervous system thresholds thresholds for responding along a continuum based on sensory preference Self regulation strategies - active management of sensory input

15 Patterns of sensory processing assessed by the Sensory Profile Responding strategies Threshold / reactivity Passive Active High threshold with low reactivity Low registration (Bystander) Does not notice sensory events or is slow to respond Sensory seeking (Seeker) Looks for sensory experiences Low threshold with high reactivity Sensory sensitivity (Sensor) Readily notices sensory stimuli, may be distracted by them Sensory avoider (Avoider) Deliberately acts to reduce or prevent exposure to sensory stimuli

16 The sensory tool box Sight - visual Sound - Auditory Touch - Somatosensory / vibration Taste - Gustatory and texture Smell - Olfactory Movement - Vestibular / proprioception

17 The use of multisensory approaches to improve function performance of people with moderate to severe dementia. Dr Lesley Collier

18 Research questions To what extent do MSEs influence functional performance compared with a control activity (gardening)? To what extent are mood and behaviour affected by MSEs compared with the control activity group? To what extent is the sensory profile of the individual associated with the response to the MSE?

19 Randomised, single blind, repeated measures design Baseline Intervention (sessions 1 to 12) Follow up Pilot and Recruitment Baseline assessment Randomised to: Pre-session assessment Post-session assessment 1/12 after Session 12 SMMSE GBS Sensory profile PAL MSE or Gardening AMPS motor AMPS process NRS AMPS motor AMPS process NRS AMPS motor AMPS process NRS

20 Assessment of Motor and Process Skills (AMPS) Fisher 2003 Standardised observational assessment of functional performance Motor and Process skills in ADL performance Uses Rasch analysis to adjust for skill complexity, rater severity and task difficulty Sensitive to change Significant change 0.5 logits

21 Baseline data: Recruitment sites Recruitment sites MSE Gardening NHS ward Assessment ward 5 (29%) 4 (31%) NHS ward Continuing care Day Hospital Private Nursing Home 6 (35%) 4 (23%) 2 (12%) 4 (31%) 4 (31%) 1 (8%) χ2(3, N = 30) = 0.6, p = 1.0

22 Baseline to last treatment session MSE Gardening Both Motor and Process scores improved by the interventions No group differences Baseline Motor Last tmt session Baseline Last tmt session Process MSE Gardening Scores equally improved for MSE and gardening

23 Mean delta AMPS motor scores AMPS delta scoress Sessions MSE group Gardening group

24 Mean delta AMPS process scores AMPS delta scores MSE group Gardening group Sessions

25 Percentage improvers Percentage % p <.05 Motor 4 5 % 4 7 % 3 0 % Process MSE Gardening Motor scores t(30) = 2.28, p =.030 Process scores, ns differences

26 Baseline to last treatment session MSE Gardening NRS scores improved (reduced) by the interventions NRS Mean score No group differences Before After MSE Gardening Scores equally improved for MSE and gardening

27 Sensory stimulation and Snoezelen in the management of people with dementia Dr Lesley Collier Senior Lecturer

28 What do we mean by sensory stimulation and Snoezelen Snoezelen Sensory stimulation

29 Sensory challenges experienced by people with dementia Sensory processing Person with dementia Environmental demand Just right challenge

30 Assessment tools to assess sensory needs Adult sensory profile (Brown & Dunn) Sensory profiling tool (Rompa) The Pool Activity Levels occupational Profiling Tool (Pool, 2012)

31 Adult sensory profile

32 The model of sensory processing Dunn, 2002 Sensory processing patterns are based on how the nervous system reacts to input and how the person responds to that input. Nervous system thresholds thresholds for responding along a continuum based on sensory preference Self regulation strategies - active management of sensory input

33 Patterns of sensory processing assessed by the Sensory Profile Responding strategies Threshold / reactivity Passive Active High threshold with low reactivity Low registration (Bystander) Does not notice sensory events or is slow to respond Sensory seeking (Seeker) Looks for sensory experiences Low threshold with high reactivity Sensory sensitivity (Sensor) Readily notices sensory stimuli, may be distracted by them Sensory avoider (Avoider) Deliberately acts to reduce or prevent exposure to sensory stimuli

34 The sensory profiling tool

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36 Implementing the Pool Activity Level Occupational Profiling Tool Life History Profile A Checklist of how the person carries out everyday tasks Activity Profile which assists the translation of understanding into practice Individual Action Plans for personal ADL Outcome Sheet for recording results

37 The Pal Planned Complete activity Search for objects Follow simple instruction Can use memory prompts Exploratory Complete familiar task Concerned about the effect of doing the task May not have an end result in mind Need activity broken down into steps Sensory No thoughts regarding the purpose of the task Concerned with sensation One step at a time Verbal and non-verbal direction Planned No aware of the environment Movement is in response to stimulus Can only process one sensation at a time Communication is predominately non-verbal

38 The sensory tool box Sight - visual Sound - Auditory Touch - Somatosensory / vibration Taste - Gustatory and texture Smell - Olfactory Movement - Vestibular / proprioception

39 Analysing the Snoezelen environment Intensity Amount Consistency Any competing stimuli Familiarity Level of arousal Environmental cues

40 Organising a session Identifying focus for the session based on assessment outcomes Techniques for specific needs Timing and the therapeutic intervention Measuring outcome Reflection on the session

41 Using the PAL to guide the session Positioning of objects eye line, direct contact, one sense at a time Verbal directions Allow time to settle and explore, guide movements, reinforce response with verbal and non-verbal cues Directions Breakdown to one step at a time, session length approximately 10 minutes, one to one sessions, end session by gradually increasing light Activity characteristics To arouse conscious awareness of self and immediate environment

42 Achieving sensory modulation within session Balance of excitation & inhibition Excitation over-response eg. release brain injury & stroke. phenomena in Inhibition under-response, fail to notice stimulation eg. Neglect Role of feedback system to regulate balance

43 Arousal & alerting systems Sensory system Arousal / alerting descriptors Discriminating/ mapping descriptors For all systems Unpredictable unfamiliar, cannot anticipate the sensory experience Somatosensory Light touch Pain sharp, pinch Temperature Small surface contact Predictable familiar, can anticipate what will happen next Pressure touch Long duration stimuli Large body surface contact Vestibular Head position change Speed change Direction change Rotary head movement Linear head movement rocking, bouncing Repetitive

44 Arousal & alerting systems Sensory system Arousal / alerting descriptors Discriminating/ mapping descriptors Proprioception Quick stretch brisk tapping Sustained tension constant action on muscles, heavy objects Visual Auditory High intensity bright visual stimulus High contrast difference between stimulus & environment Variable changing characteristics Variable changing characteristics High intensity loud Competitive conflicting sound Pressure touch Long duration stimuli Large body surface contact Linear head movement rocking, bouncing Repetitive Olfactory / gustatory Strong intensity Mild intensity

45 Incorporating sensory qualities into integrated therapy programmes Visual Arousal High intensity to increase arousal & attention High contrast to enhance location & attention Variability Maintain alertness & attention Discrimination Low intensity generate searching behaviours Low contrast discrimination Competitive increase tolerance and inhibitory response

46 Auditory Arousal Variable maintain arousal or interest in the task High intensity Alerting, location Discrimination Rhythmic predictable / organising / orientation Constant Environmental orientation Competitive Orientation & tolerance

47 Olfactory / Gustatory Arousal Strong intensity - arousal Discriminatory Noncompetitive focus attention Low intensity generate searching behaviour Mild intensity recognition & memory

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

49 Simon 67 year old man with Alzheimer s disease and attempted insulin overdose Sensory seeker using the Sensory Profile Sensory level using the PAL Graded introduction Sensory package for use at home

50 Claire 80 year old woman with vascular dementia and R CVA Sensory sensitive using the Sensory Profile Exploratory using the PAL Graded exposure and relaxation techniques Sensory soothing kit

51 Research Burns, I., Cox, H., & Plant, H. (2000). Leisure or therapeutics? Snoezelen and the care of older persons with dementia. Int.J.Nurs.Pract., 6, Baker, R., Bell, S., Baker, E., et al. (2001). Randomised controlled trial of the effects of multi-sensory stimulation (MSS) for people with dementia. BJClinPysch 40, Chung, J. C., Lai, C. K., Chung, P. M., & French, H. P. (2002). Snoezelen for dementia. Cochrane.Database.Syst.Rev., CD Schofield, P. (2002). Evaluating Snoezelen for relaxation within chronic pain management. Br.J.Nurs., 11, Staal, J., Pinkney, L., & Roane, D. (2003). Assessment of Stimulus Preferences in Multi-sensory Environment Therapy for Older People with Dementia. British Journal of Occupational Therapy, 66, Heyn, P. (2003). The effect of a multisensory exercise program on engagement, behavior, and selected physiological indexes in persons with dementia. Americal Journal of Alzheimer's disease and Other Dementias, 18, Baillon, S., Van Diepen, E., Prettyman, R., et al. (2004). A comparison of the effects of Snoezelen and reminiscence therapy on the agitated behaviour of patients with dementia. Int.J.Geriatr.Psychiatry, 19, Ball, J. & Haight, B. K. (2005). Creating a multisensory environment for dementia: the goals of a Snoezelen room. J.Gerontol.Nurs., 31, 4-10.

52 Research cont. Baillon, S., Van Diepen, E., Prettyman, R., et al. (2004). A comparison of the effects of Snoezelen and reminiscence therapy on the agitated behaviour of patients with dementia. Int.J.Geriatr.Psychiatry, 19, van Weert, J. C., van Dulmen, A. M., Spreeuwenberg, P. M., Bensing, J. M., & Ribbe, M. W. (2005). The effects of the implementation of snoezelen on the quality of working life in psychogeriatric care. Int.Psychogeriatr., 17, Ball, J. & Haight, B. K. (2005). Creating a multisensory environment for dementia: the goals of a Snoezelen room. J.Gerontol.Nurs., 31, Staal, J. (2007). The Effects of Snoezelen (Multi-sensory Behavior Therapy) and Psychiatric Care on Agitation, Apathy, and Activities of Daily Living in Dementia Patients on a Short Term Geriatric Psychiatric Inpatient Unit. Journal of Psychiatry in Medicine, 37, Collier, L., McPherson, K., Ellis-Hill, C., Staal, J., & Bucks, R. (2010). Multisensory Stimulation to Improve Functional Performance in Moderate to Severe Dementia-Interim Results. American Journal of Alzheimers Disease and Other Dementias, 25, Klages, K., Zecevic, A., Orange, J. B., & Hobson, S. (2011). Potential of Snoezelen room multisensory stimulation to improve balance in individuals with dementia: a feasibility randomized controlled trial. Clin.Rehabil., 25,

53 Thank you for listening Dr Lesley Collier Centre for Innovation and Leadership Faculty of Health Sciences University of Southampton SO17 1BJ