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Maturitas 77 (2014) 305–310

Contents lists available at ScienceDirect

Maturitas

journa l homepage: www.e lsev ier .com/ locate /matur i tas

eview

onsidering the senses in the diagnosis and management of dementia

ophie Behrman, Leonidas Chouliaras, Klaus P. Ebmeier ∗

epartment of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK

r t i c l e i n f o

rticle history:eceived 3 January 2014ccepted 7 January 2014

eywords:isionearingmellouchehaviourgeing

a b s t r a c t

Associations between dementia and impairments in hearing, vision, olfaction and (to a lesser degree) tastehave been identified. Hearing impairment has been shown to precede cognitive decline, but it is not clearif the hearing loss is an early marker of dementia or a modifiable risk factor. Olfactory impairment is seenin many neurodegenerative conditions, but it has been shown that those with dementia have particulardifficulties with the recognition and identification of odours rather than the detection, suggesting a linkto impairment of higher cognitive function. Olfactory impairment has been shown to be predictive ofconversion from mild cognitive impairment to Alzheimer’s disease with 85.2% sensitivity.

As cognitive function deteriorates, the world is experienced at a sensory level, with reduced abilityto integrate the sensory experiences to understand the context. Thus, people with dementia are verysensitive to sensory experiences and their environment needs to be managed carefully to make it under-standable, comfortable, and (if possible) therapeutic. Light can be used to stabilise the circadian rhythm,

which may be disturbed in dementia. Music therapy, aromatherapy, massage and multisensory stimu-lation are recommended by NICE for the management of behavioural and psychological symptoms ofdementia (BPSD), although the mechanisms behind such interventions are poorly understood and evi-dence is limited. Sensory considerations are likely to play a greater role in dementia care in the future,with the development of purpose-built dementia care facilities and the focus on non-pharmacologicalmanagement strategies for BPSD.

© 2014 Elsevier Ireland Ltd. All rights reserved.

ontents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3062. Hearing impairment and dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306

2.1. Hearing loss and cognitive testing performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3062.2. Underlying mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 306

3. Other sensory impairments and dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3063.1. Olfactory impairment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3063.2. Taste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3063.3. Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 307

4. Sensory considerations in the management of dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3074.1. Vision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3074.2. Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3074.3. Smell . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3084.4. Touch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3084.5. Taste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308

5. Multisensory stimulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6. Technology and building for the sensory experience of dementia . . . . . . . .7. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Abbreviations: NICE, National Institute for Health and Care Excellence; BPSD, behavioraD, Alzheimer’s disease; PD, Parkinson’s disease; UPSIT, University of Pennsylvania smellith Lewy bodies; AMD, age-related macular degeneration; CBS, Charles-Bonnet syndrom∗ Corresponding author. Tel.: +44 1865 226469; fax: +44 1865 793101.

E-mail address: klaus.ebmeier@psych.ox.ac.uk (K.P. Ebmeier).

378-5122/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved.ttp://dx.doi.org/10.1016/j.maturitas.2014.01.003

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 308. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

l and psychological symptoms of dementia; MMSE, mini mental state examination;identification test; MCI, mild cognitive impairment; OR, odds ratio; DLB, dementiae; ADL(s), activities of daily living; CGI, Clinical Global Impression of Change.

306 S. Behrman et al. / Maturitas 77 (2014) 305–310

Contributors and their role. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309Competing interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309

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References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. Introduction

Hearing loss and other sensory deficits, such as olfactory andisual disturbances have been linked with cognitive decline andhe onset of dementia. It is unclear whether hearing loss and otherensory deficits are risk factors for the development of dementia,arly stages or part of a continuum of age-related degeneration1]. Studies have suggested that hearing loss can be an early signf dementia onset and suggested that hearing studies should bencorporated in routine dementia screening. In the first part of thiseview we summarise the evidence providing links between hear-ng loss and other sensory impairments with cognitive dysfunctionnd onset of dementia. In the second part we examine the man-gement of behavioural and psychological symptoms of dementiasing a sensory framework.

. Hearing impairment and dementia

Early studies have found a correlation between hearing lossnd dementia in elderly populations [2,3]. Uhlmann et al. foundn association between hearing impairment and dementia in aase–control study, the severity of hearing impairment was linkedith the relative odds of incidence of dementia [4]. Moreover, find-

ngs from a prospective cohort study have suggested that centraluditory dysfunction may precede the onset of dementia for manyears and could be used as an early risk marker for dementia [5,6].in et al. have confirmed the association between hearing loss andementia in prospective cohort study [7]. They have concluded thatuture research needs to clarify whether hearing loss is an earlytage of dementia or a modifiable factor that can affect the risk ofeveloping dementia [7]. In a cross-sectional cohort, Lin et al. foundhat a hearing loss of 25 dB correlated with cognitive loss equiva-ent to an extra 6.8 years of age [8]. Cohort studies in Japanese andtalian elderly populations have highlighted a correlation betweenuditory function and performance on MMSE score, suggesting thatearing impairment is associated with cognitive dysfunction [9,10].

.1. Hearing loss and cognitive testing performance

It has been suggested that hearing loss may impair the perfor-ance on cognitive tests without an underlying cognitive decline.owever, a study by Uhlmann et al. showed that hearing-impairedatients with dementia scored lower on both written and standardMSE tests, when compared with hearing-unimpaired patients,

uggesting that cognitive dysfunction in hearing-impaired patientss not just an artefact of the testing procedure [11].

.2. Underlying mechanisms

A common mechanism of hearing impairment and the devel-pment of age-related cognitive decline and dementia has beenroposed, involving mitochondrial dysfunction and increased

xidative stress. Treatment strategies like caloric restriction andheir underlining biological mechanisms, such as up-regulation ofirtuins, have been involved in delaying the onset of age-relatedognitive decline, as well as age-related hearing loss [12,13].

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3. Other sensory impairments and dementia

3.1. Olfactory impairment

A meta-analysis by Mesholam et al. has found an associationbetween olfactory impairment and Alzheimer’s disease (AD), aswell as Parkinson’s disease (PD) [14]. In this study, there were nodifferences between the diseases, suggesting that olfactory impair-ment may just be a marker for any of the neurodegenerativeconditions. On the other hand, in a meta-analysis of 81 publishedstudies, Rahayel et al. found that olfactory impairments are presentboth in AD and PD patients, but AD patients perform worse inodour identification and odour recognition tasks, while PD patientsperform worse in odour detection tests. Such data suggests thatAD patients are impaired in higher-level olfactory cognition tests,while PD patients are more impaired in lower-level perceptualtests [15]. Moreover, olfactory impairment, especially severe anos-mia, has been linked with the risk of developing dementia in PD[16]. Yet, in a prospective cohort study, Swan et al. showed thatolfactory impairment may also predict specific decline of verbalmemory in non-demented elderly [17]. Olfactory impairment in theelderly was further found to correlate with neurocognitive tests ofimmediate and delayed recall, category fluency and naming objectsas well as with MRI hippocampal volumes [18]. Olfactory impair-ment, using the University of Pennsylvania smell identification test(UPSIT), along with measures of verbal memory, functional activ-ities scale, MRI hippocampal volumes and MRI entorhinal cortexvolumes have been part of the combination of early markers ina study predicting the conversion of mild-cognitive impairment(MCI) to AD with 85.2% sensitivity [19].

Djordjevic et al. showed in a cohort study that patients withMCI have deficits in all domains of olfactory function, i.e. detectionthreshold, discrimination and identification, and those functionsdeteriorate further with the progression to AD [20]. In a fiveyear prospective cohort study, Schubert et al. noted that olfactoryimpairment at baseline can predict onset of cognitive decline, mea-sured by MMSE, with an odds-ratio (OR) of 6.6 [21]. Similarly, Contiet al. found that, in a two year longitudinal cohort study, olfactorydeficits in MCI subjects may be associated with an increased riskof conversion to AD, with an OR of 5.1 [22], while Sohrabi et al.showed that in a three year prospective follow up study olfac-tory impairment can predict cognitive decline in elderly individuals[23]. Seligman et al. showed that olfactory impairment in dementedpatients correlated with the levels of apathy [24]. Finally, anosmiain dementia has been strongly associated with dementia with Lewybodies (DLB), and it has been suggested that olfactory function testsmay be used for the identification of patients with DLB [25–27].

3.2. Taste

Apart from the olfactory impairment, limited evidence indicatesa link between taste impairment and dementia. A cohort study byLang et al. found a correlation between the severity of dementia and

taste impairment which was especially prominent in PD patients,even after controlling for confounding effects of age, smoking andalcohol consumption [28]. In a cohort study by Steinbach et al.taste impairment was associated with MCI and AD patients when

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ompared with control subjects, while there was no difference ofaste impairment when comparing MCI subjects with AD patients29].

.3. Vision

Various types of visual impairment have been observed inementia sufferers; however it is not yet clear whether visual

mpairment precedes dementia onset and whether it could be useds an early marker for dementia risk. A wealth of evidence hasuggested that elderly with visual impairment perform worse onhe conventional cognitive tests, and alternative versions for visu-lly impaired patients should be used [30]. Uhlmann et al. haveound that visual impairment is associated with increased risk foreveloping AD and increased severity of AD, however they couldot identify a dose–response relationship [31]. Regarding specificypes of visual impairment in dementia, contrast sensitivity haseen found to be altered in AD patients when compared with age-atched controls [32]. In concordance with this Rizzo et al. found

hat contrast sensitivity is impaired in AD patients, they found thatisual attention, colour, shape-from-motion, visuospatial construc-ion and visual memory were also affected in AD patients [33]. Inn eight years prospective cohort study of 625 elderly individuals,ogers et al. found that poor vision was associated with increasedisk of developing dementia, while subjects with unimpaired visiont baseline had a 63% reduced risk of developing dementia. In addi-ion, untreated poor vision was associated with a higher risk ofeveloping dementia, when compared with participants, who hadt least one previous eye procedure [34].

It has been proposed that age-related macular degenerationAMD) may be associated with dementia. In a large cohort of 65,894MD patients recruited from the NHS, no association was foundetween AMD and dementia, apart from the fact that dementia suf-erers were less likely to receive treatment for AMD [35]. Anotherommon age-related ophthalmologic disturbance, the Charles-onnet syndrome (CBS) has been linked with the onset of dementia.atients with CBS experience neuropsychological deficits associ-ted with early dementia stages [36]. As both CBS and DLB involveomplex visual hallucinations, it has been suggested that CBS is par-icularly associated with the development of DLB [37,38]. CBS hasn estimated prevalence of 10–15% in people with visual impair-ent and is underdiagnosed [37]; often the hallucinations are not

ecognised as such by the sufferer or clinician, or are so benign thatedical intervention is not sought or is actively avoided due to

erceived stigma of a potential diagnosis of mental illness. Givenhe high comorbidity of visual impairment with dementia in olderge groups, likely compounded by poor concordance with use oflasses, it is likely that CBS is particularly prevalent in dementia. It isossible that insight, which is usually retained in CBS, is lost in thoseith dementia due to poor cognitive function leading to hallucina-

ions being perceived as threatening and possibly incorporated intoelusional beliefs.

. Sensory considerations in the management of dementia

Management of certain aspects of dementia, in particularehavioural and psychological symptoms may also be consideredsing a sensory framework. The NICE Guidelines [39] currently rec-mmend a trial of the following interventions for patients withgitation in dementia:

AromatherapyTherapeutic use of music and/or dancingAnimal assisted therapyMassage

s 77 (2014) 305–310 307

• Multisensory stimulation

Such interventions may well be operating through their effectson the senses, whether smell, sight, hearing or touch, or a com-bination of many in multisensory stimulation. Evidence for andrationales behind different sensory therapies will be discussedbelow.

It is worth emphasising that sensory interventions may not onlybe part of a specific “therapy” but may have a role in orientat-ing people with dementia and minimising distress from confusion.Good practice of caring for patients with dementia includes fur-nishing them with appropriate sensory aids (glasses, hearing aid)and maintaining orientation with appropriate lighting for the timeof day, along with prominent windows, clocks and calendars.

The different senses and their role in the management of demen-tia will be considered in turn.

4.1. Vision

As well as their role in orientation, glasses and adequate light-ing are necessary for reducing the risk of falls in dementia. Lightingplays a key role in the co-ordination of biological and psychologicalprocesses in the body, many of which are entrained to the indi-vidual’s circadian rhythm which is influenced by light detectionand subsequent melatonin secretion. Many elderly people are notexposed to high enough luminance levels to maintain the circa-dian rhythm, due to a combination of lack of time spent outdoors,poorly lit indoor environments, and increased opacity of the lensleading to reduced transmittance of light [40]. Disruption to thecircadian pacemaker, located in the suprachiasmatic nucleus of thehypothalamus, due to insufficient light stimulus [41] or degener-ative change [42] may result in unstable circadian patterns andsubsequent cognitive, mood, and behavioural disturbances.

“Light therapy” has been proposed as a strategy for maintain-ing a stable circadian rhythms by stimulating the suprachiasmaticnucleus. This has been attempted by both increasing ambient lightin care facilities [43] and exposure to timed bright light [44]. ACochrane review examining both practices found no significant evi-dence that light therapy improved sleep, cognition or behaviouraland psychiatric symptoms in patients with dementia [42] butacknowledged that the meta-analysis was constrained by a dearthof good quality trials. A subsequent meta-analysis [45] concludesthat light therapy is effective in improving sleep, depression andagitation in older adults with dementia and goes as far as to proposea 24-h lighting scheme to improve circadian rhythm entrainmentand reduce the risk of falls, although this is yet to be evaluated bycontrolled trial.

Light therapy has also been trialled in conjunction withmelatonin therapy [41]; the authors concluded that increasing illu-mination levels improved cognitive, mood, sleep and behaviouralsymptoms in patients with dementia and that melatonin improvedsleep, but cautioned that melatonin should only be used in con-junction with light, as the light therapy seemed to ameliorate theadverse effects that melatonin had on mood.

4.2. Hearing

As mentioned above, hearing aids are important to orientpeople with dementia. Hearing loss has an impact on the quality oflife in older adults, in particular, it is associated with a significantimpairment of measures of activities of daily living (ADLs) [46].Older people with hearing loss may compensate by a combina-

tion of extrapolation from what little is heard, lip reading, andincreased attention, but a decline in cognitive function constrainsthis. There is the risk that hearing aids will be unacceptable topeople with dementia, as they may be unable to compensate for

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he indiscriminate magnification of background noise [40] ando adjust the settings appropriately. However, hearing aids mayeduce the risk of sensory deprivation [47] and have been showno be acceptable to patients with dementia and their caregivers.lthough they do not improve cognitive functioning and psychi-tric symptoms in patients with dementia, it has been shownhat they can improve global measures of functioning such as thelinical Global Impression of change (CGI) scale [48].

Music may have a therapeutic effect on people with dementia,hether this is just by listening to, playing, or dancing to music

r by engaging in “music therapy” with a trained therapist. Mem-ry for music seems robust and may be demonstrated long afterther memories and abilities have declined [49]. It is possible thatrompting such recall (through singing or dancing) may promotesense of competency and well-being in patients with demen-

ia and enable them to interact meaningfully with others [50].utobiographical recall has also been shown to be improved withackground sound, when compared with silence, with music beinglso more effective than meaningless noise [51]; it may be benefi-ial to use music to aid information gathering when interviewing aatient with dementia.

The mechanism of the effect of music on behavioural and psy-hological symptoms of dementia has not been established. It haseen suggested that a reduction of cortisol may alleviate some ofhe anxiety symptoms [50], or music may act as a positive distrac-or and regularity and predictability of the stimulus settles agitatednd “arrhythmic” behaviour [49].

.3. Smell

NICE recommends the use of aromatherapy for behavioural andsychological symptoms of dementia [39], although it has beenointed out that, as olfaction tends to decline in dementia, this mayot be an appropriate intervention [52]. The use of aromatherapyparticularly lavender and lemon balm) in dementia is widespread,ith much case-based evidence for positive effects in sleep and

gitation; however, there is a lack of high-quality trials in the field53]. It is also worth noting that in many cases the aromatherapys administered by a therapist and often by some form of physicalontact such as massage, which may have an additional therapeuticalue.

It is possible that the strong link between smells and emotionediates some of the response to aromatherapy. The olfactory bulb

inks to the amygdala and thus some smells may trigger positive oregative emotional states depending on the person’s past experi-nce of the smell [53]. Pharmacological theories of aromatherapyave also been proposed, where the direct action of the compoundsn the brain are thought to mediate the effect, with perception ofhe odour not being required [53]. This theory may explain whyromatherapy works for people with dementia, who may have anmpaired sense of smell.

.4. Touch

Touch is a vital component of caring for any dependent per-on; however, the form of touch used in everyday care tends to beinstrumental” (i.e. as “part of a technical or physical task”) ratherhan “expressive”, which is more emotional (i.e. holding a patient’sand) [54]. A Cochrane review found that “the very limited amountf reliable evidence is in favour of massage and touch interventionsor problems associated with dementia” [55], even though the needor expressive touch in dementia has been suggested for decades

56]. The evidence there is tends to focus around hand massage orhe addition of touch to verbal encouragement to eat, and interven-ions involving touch often also involve another sensory modality,.e. by combining massage with music or aromatherapy [55].

s 77 (2014) 305–310

There has been little research emphasis on the mechanism bywhich massage and touch improves symptoms for any condition[57], but one could hypothesise, that touch may enable a non-verbalcommunication, when perhaps the patient does not have the cog-nitive function to comprehend a verbal message. Touch may also bethe only way a patient with dementia may identify they are receiv-ing attention and recognition from others, which may improve theirself-esteem and sense of well-being [54].

4.5. Taste

Altered food preference and a tendency to prefer sweet food hasbeen demonstrated in dementia [58]. Given the prevalence of nutri-tional deficiencies in patients with dementia, it may be prudent tooffer sweetened foods in order to maximise nutritional intake, andperhaps specific oral nutritional supplements may be designed inthe future to be more appealing to patients with dementia.

5. Multisensory stimulation

Multisensory stimulation or “Snoezelen” is a therapy developedin the field of learning difficulties and involves the stimulation ofmultiple senses by the patient’s exploration of an environmentincluding light effects, calming sounds, smells and tactile stimu-lation. The variations in clinical practice and research protocol ofSnoezelen for dementia make the assessment of the therapeuticvalue difficult to establish in meta-analysis, which in turn impedesthe development of the therapy [59]. A Cochrane review of 4 stud-ies found insufficient evidence to make any recommendations [59]but a subsequent meta-analysis of 18 studies [60] found immediatepositive effects on behaviour and mood of people with dementiaand called for more reliable protocols to be used in future tri-als. A small study looking at interactions between patients andcarers during the morning care regime found that training car-ers in Snoezelen improved communication and reduced negativebehaviour, even though the interaction was not a “therapy” as suchor conducted in a specific multisensory environment [61].

Various theories have been proposed for Snoezelen’s mecha-nism of action. Kovach suggests that older adults with dementiaexperience an imbalance of sensory input due to prolonged peri-ods of lack of stimuli or sensory deprivation, and other periods ofhigh-stimulus (i.e. in a large, noisy communal room). She proposesthat this imbalance (or lack of “sensoristasis”) leads to discom-fort which presents as agitation and decline in social and cognitivefunction [62]; Snoezelen may address this imbalance and allevi-ate discomfort. A key feature of Snoezelen is the interactivity andthe environmental response to the patient’s actions. Patients withdementia are likely to not have much control over their envi-ronment and therefore this sense of control may improve theirself-esteem and confidence. The environment is also “demand-free” and does not require any cognitive processing, contrary tomany other activities a patient with dementia may be offered;this may be a welcome relief and therefore improve well-being.The role of the care-giver or therapist is also likely to be signifi-cant, and being able to share an experience may reduce feelingsof isolation. The evidence of improved communication followingcare-giver training in Snoezelen [61] suggests that benefits may bemediated by the style of interaction rather than requiring specificsensory equipment.

6. Technology and building for the sensory experience of

dementia

People with dementia are very sensitive to changes in environ-mental conditions [40]. For example, a rise in temperature can

turitas 77 (2014) 305–310 309

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7

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Sound

1. Smaller rooms to avoid excessive background noise butsome background music or noise aids concentration.

2. Avoid background TV-can be misinterpreted as real.3. Automatic fans/ventilation systems may be distressing and

distracting.

Touch/temperature

1. Upholstery and flooring materials should be easy to cleanbut have a “homely” feel.

2. Windows should be easy to open (but not open so wide torisk accident).

3. Clothing should be easy to remove, while maintaining dig-nity.

4. Set thermostats to only operate within a comfortabletemperature range, but having an accessible and visiblethermostat increases autonomy.

5. Underfloor heating good to increase circulation to extremi-ties and avoid burns from contact with radiators or hot water

S. Behrman et al. / Ma

rigger requests for attention, and an increase in ambient noiseevels can decrease the prevalence of strange movements [40];his may be due to perceptual disturbance or due to difficultiesrocessing sensory input. Environmental factors have been showno correlate with quality of life [63], and there is a negative rela-ionship between quality of life and buildings that are designed torioritise health and safety [64]. Some sensory technology that maye useful in theory, such as lights that turn on by motion sensor touide people to the bathroom at night [41], may be confusing andistressing to some people with dementia [40]. Therefore, a carefulalance must be struck to use technology appropriately to main-ain a comfortable and understandable environment and to keepatients safe without negatively affecting their quality of life.

. Conclusion

The association between sensory impairment, the diagnosisf dementia and the role of sensory therapy in its managementas been recognised for a long time, but has not been the focusf concerted research; current understanding is patchy due tomall numbers of underpowered and heterogeneous studies. Withhe ageing population and rising prevalence of dementia, there isidespread interest in markers of early signs of dementia and tests

o identify which patients with MCI will progress to dementia. Its possible that some form of sensory test may contribute to suchnformation. Similarly, the move away from the use of antipsychotic

edication for BPSD and the rise of purpose-built dementia homesay raise the profile of sensory considerations in the management

f dementia. Sensory processing difficulties are well recognised ineurodevelopmental conditions (e.g. Autism Spectrum Disorders)nd there is a move towards creating individual sensory profiles inrder to inform management plans [65]; perhaps similar strategiesill be indicated in the future for the management of BPSD (Box 1).

Box 1A summary of some of the sensory-related considerationswhen designing and managing living spaces for people withdementia [40,62]Olfactory

1. Use perfumed soaps when washing.2. Fragrant (non-poisonous) plants and flowers in living areas.3. Avoid potpourri (may appear to be edible).4. Kitchen adjacent to dining room-cooking smells will aid ori-

entation, and improve appetite and food intake.5. Alarms for detection of smoke, gas and fire and to alert peo-

ple if the fridge has been open too long and food may beperishing.

Visual

1. Adequate lighting to maintain circadian rhythm, reduce riskof falls, etc. but not too bright to be distressing.

2. Avoid highly polished floors – glare can be distressing.3. Avoid too many shadows, which can be distracting and

frightening.4. Open floor plans for access to daylight and improved sight

lines.5. Easy access to outdoor space.6. Avoid flickering lights (risk of agitation and seizures).7. Light switches by bed and at door.8. Heavy curtains to keep light out at night.9. Avoid highly-patterned rugs or flooring-can be confusing

and distracting.

pipes.

Contributors and their role

Sophie Behrman – First draft (part), revisions (whole). LeonidasChouliaras – First draft (part), revisions (whole). Klaus P. Ebmeier– First draft (part), revisions (whole).

Competing interest

Sophie Behrman – none; Leonidas Chouliaras – none; Klaus P.Ebmeier – reports consultation fees received from Lily in relationto Amyvid TM.

Funding

Leonidas Chouliaras – National Institute for Health Research –Academic Clinical Fellow. Klaus P. Ebmeier – UK Medical ResearchCouncil (G1001354), the Gordon Edward Small’s Charitable Trust(SC008962), and the HDH Wills 1965 Charitable Trust.

Provenance and peer review

Commissioned and externally peer reviewed.

Acknowledgements

SB is Core Trainee in Psychiatry, LC a NIHR-funded AcademicClinical Fellow.

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