Sensory Stimulation as a Means of Managing behavioral and Psychological Symptoms of Dementia

Sensory Stimulation as a Means of Managing Behavioral and Psychological Symptoms of Dementia A Brief Literature Review Updated with Findings from a New Multi-Sensory Approach.

04/2022

Memoro, Inc. 15 Cottage Road Suite 2223 South Portland, ME 04116 USA Contact Alban Maino, CEO am@memory-lane.tv

Sensory Stimulation as a Means of Managing Behavioral and Psychological Symptoms of Dementia A Brief Literature Review Updated with Findings from Memory Lane TV

Background One of the greatest challenges of our time is the growing crisis of dementia, of which Alzheimer’s Disease is only one form. Today, more than 5.8 million people are impacted in the U.S. in 2021, and 130 million projected by 2050 globally. The disease burden is significant. In 2021, dementia cost the U.S. 355 million dollars (Alzheimer’s Association, 2022). Although much has been learned about Alzheimer’s and other related dementias, breakthrough medications are some distance away. Of paramount importance is the need for non-pharmalogical approaches to assist in the management and support of quality of life and well-being for people living with dementia.

The Journey Dementia is not a disease in itself but a term use to describe symptoms such as loss of memory, judgement, and other intellectual functions. Alzheimer’s disease is the most common cause of dementia, and is a progressive brain disorder that impacts memory, thinking, language skills, and the ability to carry out simple tasks. Although manifestations can vary, common symptoms include: Þ Memory loss, most recent memory (names, events, places, and new information). Þ Confusion of time and location. Þ Changes with mood and personality, with stress and anxiety. Þ Struggling to complete familiar tasks. Þ Difficulty in finding appropriate words. Þ Difficulty in judging specific situations.

The National Institutes of Health’s National Institute on Aging describes the disease in three stages: mild or early stage, moderate or middle stage, and severe or late-stage: •

In the early stage a person may function independently, may still drive, work and be part of social activities. Despite this, the person may feel as if he or she is having memory lapses, such as forgetting familiar words or the location of everyday objects. Symptoms may not be widely apparent at this stage, but family and close friends may take notice and a doctor would be able to identify symptoms using certain diagnostic tools.

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Sensory Stimulation as a Means of Managing Behavioral and Psychological Symptoms of Dementia A Brief Literature Review Updated with Findings from Memory Lane TV

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Middle-stage Alzheimer’s is typically the longest stage and can last for many years.

As the disease progresses, the person will require a greater level of care with more pronounced dementia symptoms. The person may confuse words, get frustrated or angry, and act in unexpected ways, such as refusing to bathe, encounter difficulty expressing thoughts, and performing routine tasks without assistance.

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In the final stage, dementia symptoms are severe. Individuals lose the ability to respond to their environment, carry on a conversation and, eventually, control movement. They may still say words or phrases, but communicating pain becomes difficult. As memory and cognitive skills continue to worsen, significant personality changes may take place and individuals need extensive care.

Dementia, including Alzheimer’s disease, is not yet fully understood, and patients and caregivers are offered limited treatment options, mostly oriented to the management of symptoms. Dementia causes unique challenges for those living with it, but can also be the source of economic hardship and physical, emotional, and psychological burdens on caregivers. In the United States alone, over 15 million informal caregivers provide unpaid care to people with Alzheimer’s disease. Compared with others in their age group, they describe fatigue as their primary concern, have higher rates of stress, and greater risk of medical and psychiatric illnesses. Psychosocial interventions improve the health of both people living with dementia and caregivers; however, constraints of time, distance, and availability inhibit the use of these services.

There is also a significant unmet need for approaches to assist formal caregivers (e.g. residential care staff) in the management of those living with this or other forms of dementia. Indeed, dementia, although very prevalent, is not well understood by many caregivers and families, so there is also need for more education and support.

Therapeutic Value of Sensory Stimulation for Managing Symptoms of Dementia There is a growing body of research focused on patient outcomes showing that sensory stimulation improves physical, psychological, and cognitive conditions in individuals with Alzheimer’s disease, and can be an effective method to improve an individual’s

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Sensory Stimulation as a Means of Managing Behavioral and Psychological Symptoms of Dementia A Brief Literature Review Updated with Findings from Memory Lane TV

overall general condition and quality of life. The review of the Literature by Julia Wilbarger and Tracy Murnan Stackhouse summarized the primary notions related to the concept of sensory modulation within the field of occupational therapy. Two important concepts of modulation reviewed in the study related to the ideas of sensory reactivity and optimal arousal. Also, randomized studies such as that of M. Mahboubinia, et al in 90 Alzheimer’s disease patients in the Nasimshahr elders’ center in Iran, showed that multisensory stimulation significantly improved their quality of life in all dimensions, including physical activity, self-care, depression, anxiety levels, social function, sexual function, and life satisfaction; the study also demonstrated a positive trend in intellectual function, but no improvement in cognitive status domain.

Snoezelen multi-sensory stimulation uses the primary senses of sight, hearing, touch, taste, and smell, through the use of lighting effects, tactile surfaces, meditative music, and the aromas of relaxing essential oils. Practitioners are keen to use Snoezelen in dementia care, and some encouraging results have been documented in the area of promoting adaptive behaviors. However, its clinical application often varies in form, nature, principles, and procedures. Such variations make examination of the therapeutic value difficult. A systematic review of evidence for the efficacy of Snoezelen in the care of people with dementia was performed by Chung, et al in 2002, which identified 2 randomized clinical trials in people living with any type of dementia.

Although both studies examined the short-term values of Snoezelen on people with dementia, a firm conclusion could not be drawn due to very limited data and different methodology and control conditions adopted in the two trials. A more recent literature review by Sanchez, et al in 2012, evaluated 18 studies using multisensory stimulation in patients with dementia and concluded that it can be a useful, non-pharmacological intervention on neuropsychological symptoms, though more reliable protocols would be necessary.

A 2-year Norwegian study by Lykkeslet, et al showed that sensory stimulation may improve the quality of dementia care by expanding the care workers’ repertoire of potential methods for making contact with patients experiencing Behavioral and Psychological Symptoms of Dementia (BPSD). Sensory stimulation seems to provide opportunities for accommodating the individual person's needs because the intervention can be tailored for each individual.

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Sensory Stimulation as a Means of Managing Behavioral and Psychological Symptoms of Dementia A Brief Literature Review Updated with Findings from Memory Lane TV

Research has demonstrated that different sensory channels may provide different and potentially complementary benefits for people living with dementia, which we summarize below:

Audiovisual Cinematic perception - Use of visual media Benefits of guided imagery and chronobiology Ko and Ally describe how Alzheimer’s’s Disease entails impairments to visual cognition, which encompasses processes that help us to understand what we see. The decline of visual abilities can have a very profound effect on an individual’s daily experience and the development of subsequent interventional strategies, where their visual environment could be optimized to suit their psychological changes and enhance their quality of life. Furthermore, changing their visual environment or using realworld pictures can potentially facilitate the individual’s performance on everyday visual tasks.

O’Connor and Ally (2010) found that recognition memory in people with mild Alzheimer’s disease was superior when the perceptual and conceptual aspects of studied items were preserved from study to test, compared to when only the conceptual aspects were preserved from study to test. Importantly, this advantage was much greater when the stimuli were pictures rather than words. These findings show that storing information as pictures leads to greater success of long-term memory retrieval in these individuals.

Reminiscence therapy is one of the most popular psychosocial interventions in dementia care, and is highly appreciated by staff and participants. It involves the discussion of past activities, events, and experiences with another person or group of people. This approach is often assisted by aids such as videos, pictures, archives, and “life story” books. The practice has attracted considerable attention in recent years and there is a growing body of literature that supports using this technique with people with mild to moderate dementia. Studies undertaken with those living with severe dementia have yielded mixed, but occasionally encouraging results (Hoerster, et al, 2001; McPherson, et al, 2001). Evidence suggests that it can lead to overall

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Sensory Stimulation as a Means of Managing Behavioral and Psychological Symptoms of Dementia A Brief Literature Review Updated with Findings from Memory Lane TV

improvements in depression and loneliness, and promote psychological well-being. A Cochrane review by Woods, et al included 5 trials, but only four of them, with a total of 144 participants, had extractable data. The results were statistically significant for cognition and mood 4 to 6 weeks after the treatment, and on a measure of general behavioral function. Caregiver strain showed a significant decrease, and staff knowledge of group members' backgrounds improved significantly. Importantly, no harmful effects were identified on the outcome measures reported. However, several of the investigations were very small studies, or were of relatively low quality, and each examined different types of reminiscence work; there is a need for more quality research in the field.

A study by Chiang, et al found that participants involved in reminiscence therapy were more sociable, less depressed, and showed stronger signs of well-being than control group members. The relatively small sample size, its composition (all male), and shortterm nature of the study (three months) mean that the results, although favorable, cannot be generalized to the whole population. A study in 10 individuals with Alzheimer’s disease by Kamaruzaman identified the role of dynamic visual as a mode to enrich reminiscence psychoanalysis therapy for patients with dementia. Separately, a study by Meléndez-Moral exhibited the usefulness of reminiscence intervention in 34 elderly adults living in 2 different retirement homes. The intervention was conducted as a group, lasted 8 sessions, and included a control group. It demonstrated a significant impact on participants’ depressive symptomatology, self-esteem, life satisfaction, and psychological well-being.

Although cinematic films and television programming are frequently used in nursing homes, there is limited knowledge of how they affect people with dementia. However, a study by Bjørnskov, et al supported that “Life in the Memories”, a collection of 50 short films targeted at people with dementia, could be used for reminiscence purposes in nursing home settings.

Workshops were carried out in seven nursing homes, followed by four weeks of testing. Data were obtained from 63 professional caregivers working with residents with dementia through a cross-sectional survey and focus group interviews. Results consistently indicated that these films can maintain the attention of people with dementia, evoke memories, and create conversation. Compared to classic reminiscence activities, caregivers rated the use of the films as easier and less time consuming.

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Sensory Stimulation as a Means of Managing Behavioral and Psychological Symptoms of Dementia A Brief Literature Review Updated with Findings from Memory Lane TV

Sense of Hearing Personalized music programs have been proposed as an adjunct therapy for patients with Alzheimer’s disease-related dementia. King, et al studied 17 individuals with this form of dementia using functional MRI following a training period in a personalized music listening program; their findings support a mechanism whereby attentional network activation in the brain’s salience network may lead to improvements in brain network synchronization.

Also, multicenter trials have now demonstrated improvements in agitation, anxiety, and behavioral symptoms. A study conducted by Vinoo, et al in 4 Memory care units with 108 residents at a long-term nursing care facility between 2014 and 2016 demonstrated that the use of music and memory resulted in a significant reduction in the transfer of residents to psychiatric ER for Behavioral and Psychological Symptoms of Dementia, falls, and physical altercations (resulting in less transfers to acute hospital for further management), and in 1:1 observation (from 5 to 1 in 2016). It also showed a downward trend in antipsychotic usage. Notably, it also showed positive impact on the nursing care facility staff: improved morale, enhanced bonding between staff, residents and family, enhanced team work, reduction in staff call-in, and expanded opportunity for more meaningful, interpersonal connections with individuals in their care.

Sense of smell Severe deficits have been described in individuals with Alzheimer’s Disease in each of the three olfactory domains (identification, recognition, or threshold). Smell is also described as one of the most powerful ways to trigger memory activation via sensory stimulation in the literature. Olfactory deficits in Alzheimer’s disease have been well established, as described by a systematic review by Raquelle, et al. Also, aromatherapy, using fragrant oils from plants, can enhance the experience and therapeutic benefits for the person living with dementia. It is used in attempts to reduce behavioral symptoms, promote sleep, and stimulate motivational behavior in people with dementia.

The literature on aromatherapy however mostly describes qualitative research and small scale non-randomized trials. For example, the systematic review by Connor

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Sensory Stimulation as a Means of Managing Behavioral and Psychological Symptoms of Dementia A Brief Literature Review Updated with Findings from Memory Lane TV

focused solely on aromatherapy, but only one RCT met its inclusion criteria, which included 72 participants with severe dementia in 8 nursing homes. The four-week study examined the effects of topical Melissa oil, and sunflower oil was used at control nursing homes. Though the study found a significant decrease in measures of agitation and neuropsychiatric symptoms, there was no significant decrease in aggression, and medication use was not reported. A study of 15 individuals cited in another review by Holt, et al also found that aromatherapy was associated with decreased agitation in dementia patients: 2% lavender oil or water vapor was sprayed in a communal area of a dementia ward for 2 hours a day, on alternating days for 10 sessions. Agitation was assessed using the Pittsburgh Agitation Scale by an observer who wore a nose clip in a blinding effort. Median behavior scores were 20% lower while exposed to lavender compared to water vapor, and the difference was statistically significant.

Most people experience enhanced benefits with regard to managing behavioral symptoms when leveraging the reinforcing the power of harmonized multi-sensory stimulation.1

Building on the Literature with an Integrated, Multi-Sensory Approach Findings in the literature consistently suggest mitigation of behavioral and psychological symptoms is central to optimizing dementia care. Sensory stimulation approaches have been studied for several decades to date and various techniques are currently used in many adult care communities, and to a lesser degree, in private home settings. The evidence in the literature also suggests there may be compounding benefits from a more integrated, multi-sensory (as opposed to mono-sensory) approach, but there are two main challenges: creating a beneficial intervention, and implementing it in a consistent way. This dual challenge is true in professionally managed care environments, and perhaps even more so in the private (i.e. informal) home care setting.

O Glachet, M El Hadj, “Emotional and phenomenological properties of odor-evoked autobiographical memories in Alzheimer’s’s disease”; Brain Science 2019 June 9(6): 135 1

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Sensory Stimulation as a Means of Managing Behavioral and Psychological Symptoms of Dementia A Brief Literature Review Updated with Findings from Memory Lane TV

Building on this theory and testing the hypothesis that a multi-sensory-based approach could yield superior positive benefits in this regard, Memoro, Inc., a private, US-based firm, developed a unique, multisensory intervention, which it calls “Memory Lane TV”.

Like the various mono-sensory interventions explored in these studies, it targets the behavioral and psychological symptoms associated with Alzheimer’s and other forms of dementia, and seeks to lessen the frequency and/or intensity of those symptoms (such as wandering, calling out, decreased alertness, anxiety, and agitation). It is intended to offer a supplemental, complimentary approach to traditional care. The solution incorporates visual and aural stimuli – short, purpose-built “films” – delivered via a streaming media service and “consumed” via any conventional TV screen (effectively the same form factor as Netflix). Significantly, many of the films are designed to be paired with specific aromas so that the individual (or group) may experience a true, fully integrated, multi-sensory stimulation experience and the potentially increased benefits that come from such an approach. The user utilizes specific aromas matched to the specific digital media via personal diffuser dots applied to clothing, or via aerosol diffusers that mist the aroma into the air at the time the audio-visual programming is activated.

Developed by a broadly interdisciplinary team, the protocols were iteratively refined in successive, clinical, geriatric settings with guidance and supervision from Dr. Raffin, a geriatric physician, and Dr Windfield, geriatric psychologist, with Tours General Hospital, France (150 patients observed for 6 months); Dr. Herbert Benson and Dr. Greg Fricchione at the Benson-Henry Mind Body Institute, Mass General Hospital, Boston, USA (75 individuals observed 1 month); and Larry Gross and Diane Kimbin, Southern Maine Agency on Aging and Ocean View, USA (80 patients observed for 3 months).

Memoro, Inc.’s internal findings from the early development phase (2015 to 2017,) have shown similarly positive impacts to those studies referenced above with regard to dementia patient engagement and neuroplasticity, lessoning of sundowning syndrome, and inducement of the relaxation response2.

The approach was further evaluated during testing at various sites, primary of which was the Cedars, a managed care facility located in Portland, ME in collaboration with the University of Southern Maine. A team of graduate students in the Master of 2

See works of Dr Henry Benson for more information on the relaxation response.

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Sensory Stimulation as a Means of Managing Behavioral and Psychological Symptoms of Dementia A Brief Literature Review Updated with Findings from Memory Lane TV

Occupational Therapy Program, under the supervision of Tammy Bickmore (Program Director, OTD, OTR/L), were paired with residents at the various sites to observe and evaluate the impacts of the intervention on the residents. To standardize the observations a questionnaire was developed, and the graduate students were orientated and trained on its use. Residents were then observed before, during, and after use of the Memory Lane TV program for changes in mood, level of engagement, impact on staff, and levels of stress and anxiety. While not a formal, clinical trial, this investigation did yield useful insights into the residents’ experience using the Memory Lane TV intervention.

Overall, between 2016 and 2021, 5 US nursing homes caring for over 500 patients evaluated the experience of program test users on quality of life, well-being, and certain symptoms of dementia. A positive impact was observed in a diverse panel of Memory Lane TV users (the sample included individuals with diverse levels of dementia severity, range of cultural backgrounds, and range of ages, among other factors). The results of the dimensions that were measured in this uncontrolled study were as follows: • • • •

74% reported improvement in both resident and staff mood and anxiety levels 67% reported improved resident engagement 70% reported more positive interaction between staff and resident 70% reported they observed reductions in stress levels

While anecdotal in nature, the Cedars/University of Maine findings raise the intriguing prospect of being able to positively impact some of the common behavioral and psychological symptoms associated with Alzheimer’s and other forms of dementia with an easy-to-use, cost-effective digital health tool that could potentially democratize memory care, both in the home and in formal care settings. Given the consistency of these findings with those reported in the literature, further, more formal study of true multi-sensory approaches seems warranted.

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Sensory Stimulation as a Means of Managing Behavioral and Psychological Symptoms of Dementia A Brief Literature Review Updated with Findings from Memory Lane TV

Cited Works JC Chung et al, “Snoezelen for dementia”; Cochrane Database Systematic Review 2002;(4):CD003152.

E. Lykkeslet et al, “Sensory stimulation—A way of creating mutual relations in dementia care”;Int J Qual Stud Health Well­being. 2014; 9: 10.3402/qhw.v9.23888; Published online 2014 Jul 8.

A Sanchez et al, “Multisensory Stimulation for People With Dementia: A Review of the Literature”; American Journal of Alzheimer’s Disease & Other Dementias 28(1) 7-14 Kamaruzaman et al, Procedia - Social and Behavioral Sciences 105 (2013) 258 – 264).

Chiang K J, Chu H, Chang H J et al (2010) The effects of reminiscence therapy on psychological well-being, depression, and loneliness among the institutionalized aged, International Journal of Geriatric Psychiatry,25,380-388 Vinoo et al., Int J Neurorehabilitation Eng 2017, 4:2 Stina Bjørnskov et al, Usability of films designed for people with dementia in a nursing home setting; Dementia 0(0) 1–19 ! The Author(s) 2018 Julia Wilbarger and Tracy Murnan Stackhouse, “Sensory Modulation: A Review of the Literature”; 24/9/2014 OT-Innovations.com M. Mahboubinia et al, “The effect of Multisensory Stimulation on cognitive disturbances and quality of Life of male patients with Alzheimer’s disease”; IRJ 2012, 10(15): 50­55 I Raquelle et al, “Olfaction in Neurodegenerative Disease: a Meta-analysis of Olfactory Functioning in Alzheimer's and Parkinson's Diseases”; Arch Neurol.

1998;55(1):84-90. doi:10.1001/archneur.55.1.84.

O’Connor DW, Ames D, Gardner B, King M. Psychosocial treatments of behavior symptoms in dementia: a systematic review of reports meeting quality standards. Int Psychogeriatr. Apr 2009;21(2):225-240.

Holt FE, Birks TPH, Thorgrimsen LM, Spector AE, Wiles A, Orrell M. Aroma therapy for dementia. Cochrane Database of Systematic Reviews. 2009 (3).

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