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By Brett Tomlinson
Can a placid scene of a farmhouse, projected on plain beige walls, calm an agitated dementia patient? Does a simple plastic tube of bubbling water, illuminated by colored lights, have the power to stimulate elderly patients who are withdrawn and uncommunicative?
Rochelle Robbins, PhD, Associate Professor of Psychology, aims to find out. She is conducting research at a long-term care facility in suburban Philadelphia to examine the effects of a multi-sensory environment on people with dementia, a deterioration of cognitive function often accompanied by anxiety and agitation.
Specifically, Dr. Robbins’ research centers on Snoezelen (pronounced SNOO-zeh-len), a concept developed by two Dutch therapists in the 1970s. Snoezelen introduces a variety of sights, smells, sounds, and tactile sensations—everything from aromatic oils to brightly lit sprays of fiber-optic tubes—in a controlled, calming environment. Snoezelen rooms are used broadly in Europe, and to a lesser extent in the United States, to help children with developmental disabilities, particularly non-verbal children.
“These sensory stimulation devices can engage a person in a way that’s not verbal, and not social in a way that is intimidating,” Dr. Robbins explains. “These stimuli are not going to criticize you. You interact with this equipment in a way that gives you some self-effectiveness.”
Given Snoezelen’s efficacy with children, some proponents believe the concept could be a useful addition to senior living centers, particularly for residents who have experienced memory loss or have difficulty communicating. So far, the scientific literature on the therapy’s success with older patients is sparse. Only a handful of studies exist, Dr. Robbins says, and in most cases, the subjects received only brief exposure to Snoezelen rooms.
Working with the staff at Southampton Estates, part of ACTS Retirement-Life Communities, Dr. Robbins is studying dementia patients in 13-week cycles, with each subject visiting the community’s Snoezelen room at least once a week. Aides help patients explore the room and record data on things like behavior and attitude before, during, and after the session.
From that information, Dr. Robbins hopes to paint a clearer picture of whether or not Snoezelen therapy benefits dementia patients.
Dr. Robbins, who earned her PhD in psychology from the State University of New York at Stony Brook in 1994, took an accidental route to her specialty of working with older adults. She traces the journey back to a single patient, an 82-year-old woman she treated during her internship at Jacobi Medical Center in New York.
The woman had attempted suicide. At the time, her actions seemed odd to Dr. Robbins, who did not realize that older adults have relatively high suicide rates. Some of the tried and true coping mechanisms they relied on for years begin to break down, and that was the case with Dr. Robbins’ patient. But Dr. Robbins enjoyed helping the woman recover some of her coping skills.
“I loved working with her because she had so many life experiences to draw on,” she says.
Before long, Dr. Robbins found herself seeking out older patients and studying the specific needs of that population. When she moved to Pennsylvania a few years later, she began working in psychological services for a group of long-term care facilities. Today, she maintains a small practice devoted to older adults.
Shortly after coming to Pennsylvania, Dr. Robbins discovered a parallel calling when she began teaching a course on adult development and aging at Holy Family. In 2004, she joined the full-time faculty in the Counseling Psychology program.
Teaching, research, and clinical practice “work well together,” Dr. Robbins says, because real-world examples illustrate the complex challenges that mental-health professionals face. That is especially useful at Holy Family, where most of the master’s degree students already work in the field.
In 2007, ACTS Retirement-Life Communities began working on a pilot project using Snoezelen with older adults who have dementia. Peggy Brenner, Director of Education and Special Care Programs at ACTS, says the therapy looked promising in several areas: decreasing anxiety and agitation; addressing restlessness and pain; and encouraging more responsiveness from non-communicative residents. It also seemed like a potential alternative, or complement, to the medications used to reduce adverse behaviors.
ACTS wanted to evaluate its pilot project, and for that, Brenner turned to Dr. Robbins, an academic researcher with extensive professional experience in the field.
“There was little, if any, research done on Snoezelen’s efficacy with the long-term population with dementia,” Brenner says. “We thought we could be pioneers in this arena.”
When Dr. Robbins first heard the idea, she had a limited knowledge of Snoezelen, but she liked what she saw at ACTS. The staff was well-trained in dementia care, and the administrators consulted Snoezelen experts from FlagHouse, an Ontario-based company that specializes in sensory products, to make sure they were setting up the new room with the correct specifications. Brenner and her colleagues visited two other Snoezelen rooms at long-term care facilities, paying attention to major priorities, like selecting adult-appropriate equipment, and taking note of small but significant details such as paint color (walls painted in relaxing colors such as lilac, apricot, or beige are ideal, Brenner says).
Dr. Robbins used the same sort of care when designing her study. But ultimately, many of the important jobs are in the hands of the staff at Southampton Estates. They work with each resident on a weekly basis, so they have to be careful, engaged observers.
In the first session, a resident is encouraged to explore. Some of it is directed. The staff know whether this person needs relaxation or stimulation, and is aware of any physical limitations, such as severe visual impairment, that would rule out certain equipment. Beyond that, the idea is to let people examine whatever catches their eye.
“We have all these sensory modalities, and we don’t know yet what this person will gravitate towards,” Dr. Robbins explains.
Elsie Baum, a Certified Nursing Assistant at Southampton Estates, has worked with older adults for more than two decades. She says that trial and error can be discouraging to some residents. When one or two pieces of equipment fail to hold the person’s attention, the aide has to encourage that person to try another. The trusting relationship between a resident and a familiar staff member can help in those cases, Baum says.
In subsequent sessions, residents often return to a familiar activity—working their hands through a spray of thin fiber-optic tubes, lit in brilliant shades of pink, or relaxing in a recliner, listening to music and feeling the vibrations from speakers built into the chair.
Aides try to elicit some social interaction while in the Snoezelen room, Dr. Robbins says, but the idea is to stimulate the senses, not test cognition. Snoezelen, by design, is a low-demand situation. One popular device is the bubble tube, a tube of water with a simple control panel. Four buttons on the panel’s perimeter—red, blue, yellow, green—control the colored lights illuminating the tube. A button in the center starts and stops the bubbles. When the bubbles stop, small plastic fish trickle down through the water.
A dementia patient might not be able to articulate how the device operates, but non-verbal cues like a knowing smile can indicate pride in controlling the colors and bubbles.
“They can affect these stimuli in a way that they recognize they did that,” she says.
When working with patients, the staff take notes on mood, attitude, and behavior, as well as what equipment was used and anything to avoid in future sessions. On Fridays, staff members meet with Dr. Robbins to talk about the week’s results. The exchanges have been productive, according to Baum.
“Shelley listens to us and she’ll take our ideas [into consideration],” Baum says. “She works really closely with us.”
The study, which began in April 2008, has a relatively small cohort so far—11 residents have met the criteria for inclusion, and more than half have completed the 13-week research cycle. While the weekly data collected for those residents forms the foundation of Dr. Robbins’ research, patient charts document other useful information, such as medication taken for agitation and attendance at group activities. Dr. Robbins says that if agitated patients show a reduction in medication and withdrawn residents begin attending more activities, those could be signs that Snoezelen has a positive effect.
The research seems straightforward, but there are peripheral challenges. For the busy staff, it can be hard to carve out time for Snoezelen sessions, which sometimes last 30 minutes. Finding residents who will complete the 13-week research cycle is also difficult, Dr. Robbins says, because of a sad reality of working with dementia patients: Many are nearing the end of their lives. Three patients have died before completing one month in the study.
Does Snoezelen therapy work for dementia patients? Anecdotally, Dr. Robbins says, the staff at Southampton Estates is “seeing some good results,” but the data will tell a more complete story. She has not formally analyzed the information from the first handful of cases because she does not want to bias her remaining research.
If Dr. Robbins’ study shows that Snoezelen does work, it could have a significant impact on dementia care by encouraging more research, more funding for Snoezelen rooms, and a potential reduction in the medications given to dementia patients.
If the data shows no measurable change, Dr. Robbins says, “That’s important to know, too, because…then maybe it’s just not for this population.”
Regardless, Dr. Robbins plans to continue helping older adults. Many mental-health professionals seem to shy away from elderly clients, and when Dr. Robbins first started working with older patients, particularly those with memory loss, she admits that she also wondered if a psychologist had the right tools to help them.
But over time, she found that she could make a difference by paying close attention to both behavior and environment. One must discover what’s going wrong in a patient’s environment that is triggering problematic behavior, and then find a way to change the environment.
“I enjoy that—trying to understand how this person with dementia sees the world,” Dr. Robbins says. “People are doing the best they can with what they understand. They just understand things so differently than we do.”