Effectiveness of Environment-Based Interventions for People With Alzheimer’s Disease and Related Dementias

Environmental Interventions

Two studies involved occupational therapy in the provision of environmental strategies. Dooley and Hinojosa (2004; Level I, N = 80) examined whether adherence to occupational therapy recommendations increased the quality of life of people with AD living in the community and decreased caregiver burden. Among other things, the intervention program included recommendations for environmental modifications (such as posting of visual cues and emergency telephone numbers, labeling of drawers and cabinets, bells on doors). Later, Graff et al. (2006; Level I, N = 135) included educational sessions on similar compensatory and environmental strategies in their study of the effectiveness of community-based occupational therapy on daily functioning of people with AD. Graff et al. concluded that such interventions were effective when combined with caregiver approaches and community resources as part of individualized programs.

Several studies focused on the effectiveness of interventions that may be described as environmentally based. Opie, Rosewarne, and O’Connor (1999; Level I, N = 43); Price, Hermans, and Grimley Evans (2001; Level I, N = 0); and Livingston, Johnston, Katona, Paton, and Lyketsos (2005; Level I, N = 162) included studies on environmental changes in their systematic reviews of psychosocial approaches to behavior disorders in dementia. Studies were based on the premise that the physical environment can exacerbate the confusion and disorientation experienced by people with dementia. Although most studies showed beneficial effects, few had moderate validity. Studies concluded that placing strips of tape on the floor to give the illusion of a barrier was ineffective and may actually increase unwanted exiting by drawing attention to the doors. The only intervention that reduced exiting was the complete occlusion of doorknobs or doors using curtains or blinds. Full-length mirrors over doorways led to a significant decrease in exiting behavior, but also increased agitation in some participants. The studies’ small sample sizes limited their generalizability. Because the possibility of psychological distress could not be excluded from these interventions, their use should be preceded by research on their subjective impact.

Nolan, Mathews, and Harrison (2001; Level IV, N = 3) tested the impact of placing two external memory aids outside participants’ bedrooms in a nursing home. A laminated card with a statement indicating who lived in the room was taped to the participant’s door. A photograph of the participant was attached to the back of the memory card. Participants all improved in their ability to locate their bedrooms during the intervention phase, and their ability to accurately locate their room showed a >50% mean increase after the intervention. In contrast, Livingston et al. (2005) concluded that signposting was effective only in combination with reality orientation therapy.

Heyn (2003; Level III, N = 13) tested a program that consisted of a focused attention and warm-up session that included storytelling and imagery, flexibility and aerobic exercise, a strength-training session, and a closing session focusing on relaxation and breathing techniques. Results showed an improvement in overall mood and in engagement in physical activity, although such change did not reach statistical significance. The small convenience sample, lack of comparison group or follow-up, and limited impact on active engagement in functional activities make it difficult to draw conclusions about the intervention’s effectiveness.

Multisensory Approaches

Evidence demonstrating the detrimental effects of sensory deprivation on normal people has led to hypotheses that behavioral problems of people with dementia may be related to progressive neuronal losses that result in impaired processing of sensory stimuli, making normal stimuli confusing (Thomas et al., 2008). Several forms of intervention available for people with dementia involve concurrent application of multiple sensory stimuli. Research has mostly focused on two particular types of programs, Snoezelen (Botts et al., 2008) and Montessori (Camp, 2007).

Snoezelen rooms for sensory stimulation in dementia units have gained ground as an enhancement to patient care in recent years. These environments stimulate the primary senses by permitting the person free exploration of a variety of objects and materials (such as a fan blowing scraps of paper, ink mixed with water and projected onto a screen, musical instruments, tactile objects, scent bottles, soaps, and flavorful foods).

Six studies that reported on the effects of Snoezelen for people with dementia were located. Baillon et al. (2004; Level I, N = 20) randomized dementia day care patients into either a Snoezelen or a reminiscence group. They measured agitation behaviors and mood and concluded that Snoezelen was not any more effective than reminiscence. Both interventions resulted in only short-term changes in mood and agitation. The systematic reviews reached similar conclusions in relation to the effectiveness of Snoezelen compared with ambient music, usual daily routines, or standard activity sessions (Lancioni, Cuvo, & O’Reilly, 2002; Level I, N = 21; Livingston et al., 2005; Level I, N = 162). Verkaik, vanWeert, and Francke (2005; Level I, N = 19) concluded that although Snoezelen showed some evidence of effectiveness with depressed, aggressive, and apathetic behaviors of people with dementia, the evidence was quite modest and further research is needed. Chung and Lai (2002; Level I, N = 5), however, found no evidence of the efficacy of Snoezelen on the mood or behavior of people with dementia in the studies they reviewed. Robinson et al. (2007; Level I, N = 11) also concluded that the evidence to recommend Snoezelen as an intervention to reduce wandering in dementia was not robust. Although these reviews reported some positive within-session effects related to communication, engagement, and self-injury measures, long-term effects were inconclusive because they were either not directly measured or relied largely on qualitative or unstructured (not always unequivocal) data. Selection, performance, attrition, and detection biases rendered results of the studies unreliable.

Therapeutic Montessori programs also use environments rich in manipulative materials. Unlike Snoezelen, however, these materials consist of learning games suited to a person’s abilities and interests. Montessori materials, such as games, household utensils, and so on, are suggestive of a purpose. Montessori-based activities have been claimed to engage people in learning through task breakdown, guided repetition, progression in difficulty from simple to complex, and careful matching of demands to levels of competence (Lillard, 2008). Because they can be easily adapted to the interests and skills of people with AD, Montessori activities have been applied for the purpose of socialization, meaningful activity, and diversion. Activities are designed to tap procedural memory, which is better preserved than verbal memory, while minimizing language demands and providing external cues to compensate for cognitive deficits. Familiar objects provide cues to their own use (e.g., playing cards suggest sorting them in a sequence; mixing bowls and cooking ingredients suggest combining them and mixing them), and the presence of objects in the person’s environment is thought to prompt participants to follow suit and use them (Camp, 2007).

Four studies (Lee, Camp, & Malone, 2007; Level I, N = 29; Jarrott, Gozali, & Gigliotti, 2008; Level II, N = 10; Orsulic-Jeras, Judge, & Camp; 2000, Level II, N = 16; Vance & Johns, 2002; Level II, N = 15) reported that the average amount of time people spent constructively engaged in Montessori activities was significantly higher than that spent engaged in negative occupations. Pleasure scores were significantly higher and anxiety scores lower during Montessori programming in contrast with regular unit activities, but these gains declined after participants became familiar with the activities. Gains were made in attention, object permanence, and memory. No apparent benefit in vocabulary, spatial attention, spatial reasoning, or abstract reasoning or in activities of daily living (ADL) measures were observed. These researchers concluded that because of the small sample size and multiple subjective outcome measures, results should be considered with caution. Lin et al. (2009; Level I, N = 133) randomized institutionalized residents with dementia into three treatment sequences that included Montessori, acupressure, and presence (attention on intrapersonal processes) in varying order. The acupressure and Montessori-based-activities groups, but not the presence group, saw a significant decrease in agitated, aggressive, and physically nonaggressive behaviors. Sample size, nonheterogeneous control participants, and extraneous factors presented significant limitations for this study, and negative effects were not investigated.

Other Interventions

Ambient music and nature sound therapy aim to create a secure, stimulating environment that helps to meet the social and emotional needs and reduce the problem behavior displayed by people with AD and related dementias (Cohen-Mansfield, 2001). Generally, the desired outcome is the modulation of agitation. Evidence from 6 systematic reviews and 1 nonrandomized controlled study suggest that ambient music may indeed help decrease agitation and, therefore, indirectly contribute to improved attention, but its effect is modest. Methodological problems (small sample size, nonequivalent control groups, lack of blinding, lack of control of extraneous variables, reliance on observational and self-report outcome measures) contribute to the limited evidence of effectiveness. Kong, Evans, and Guevara (2009; Level I, N = 14) and Kverno, Black, Nolan, and Rabins (2009; Level I, N = 21) concluded that only sensory interventions, including calming ambient music, had efficacy in comparison with other types of interventions but noted that such outcomes should be interpreted cautiously because music was paired with hand massage, no effort was made to control the social environment in which the intervention took place, and benefits were short lived. They concluded that ambient music is more helpful in calming situational anxiety than in significantly changing reactions to internal or external triggers. Livingston et al. (2005; Level I, N = 162) and Robinson et al. (2007; Level I, N = 11) reviewed small trials that showed improvements in disruptive behavior during or immediately after a session, but no evidence was found that benefit carried over in the longer term. Sherratt, Thornton, and Hatton (2004; Level I, N = 21) found active and receptive (ambient) music interventions to be effective in a variety of ways.

Although active music intervention appeared to improve engagement and reality orientation, passive or ambient interventions reduced wandering, repetitive vocalizations, and irritability. Ambient music was applied unevenly across the reviewed studies, however. Sometimes participants were instructed to directly attend to the music, and at other times the music was playing in the background while participants engaged in a manual task. Studies in which participants were permitted to select their preferred music were more likely to report positive effects. Opie et al. (1999; Level I, N = 43) reviewed studies that tested the effect of music in residential facilities and also concluded that aggression (yelling, abusive language, and verbal and physical resistance) was likely to be reduced when residents’ preferred music was played during various activities. Beyond the calming effect during a session, however, Opie et al. found no long-term effect.

Swanson, Maas, and Buckwalter (1994; Level II, N = 22) compared the effects of a special care unit (SCU) and of a traditional (integrated) nursing home on residents with AD. The SCU included open spaces, a secured courtyard to permit free wandering, locked storage spaces, reduced ambient noise, quiet but pleasant decor, and soothing ambient music. Swanson et al. found no significant differences in cognitive or functional abilities scores for the groups over time. However, the SCU participants’ socially accessible behaviors (catastrophic reactions and social interactions) were better than those of participants in traditional units. The SCU sample size was small and the control group nonequivalent, making the results tentative.

Aromatherapy is reported to be one of the most widely applied complementary therapies used for people with dementia (Cohen-Mansfield, 2001). Several clinical trials have compared inactive treatment with aromatherapy, principally using either lavender (Lavandula angustifolia or Lavandula officinalis) or lemon balm (Melissa officinalis) in diffusers or lotions applied topically. Seven systematic reviews were located (Holt et al., 2003; Kong et al., 2009; Kverno et al., 2009; Nguyen & Paton, 2008; Opie et al., 1999; Robinson et al., 2007; Thorgrimsen, Spector, Wiles, & Orrell, 2003; all Level I). As with ambient music, results were inconclusive because of small samples, lack of control of intervening variables, unevenly applied interventions, and inconsistent effects. However, as an aggregate, these studies suggest that aromatherapy may be useful in inducing relaxation and reducing agitation and other NPS. Some studies reported negative consequences (skin rash, anxiety), suggesting caution in the use of these interventions until the side effect profile of commonly used oils is better understood.

Sleep fragmentation, common in AD, is associated with excessive daytime napping and sleepiness and with other behavioral symptoms such as sundowning syndrome and nocturnal agitation (Wu & Swaab, 2007). Evidence is mixed as to whether BLT is an effective treatment in restoring the wake–sleep pattern and thus supporting more active engagement in life during the day. Skjerve, Bjorvatn, and Holsten (2004; Level I, N = 21) and Forbes, Morgan, Bangma, Peacock, and Adamson (2004; Level I, N = 3) deduced that no conclusions could be drawn about BLT’s efficacy or about its safety and practicability in clinical settings. Opie et al. (1999; Level I, N = 43); Ayalon, Mc Gum, Feliciano, and Arean (2006; Level I, N = 9); Kong et al. (2009; Level I, N = 14); and Kverno et al. (2009; Level I, N = 21) reviewed BLT studies that tested various light boxes, evening and morning overhead lights, and light provided through adapted headgear. Statistically significant positive results were reported only in studies using light boxes, but methodological problems (nonequivalent experimental and control groups, high attrition, unequal application of intervention, etc.) with these studies led these researchers to conclude that although BLT showed promise, more research was needed.

Dowling, Graf, Hubbard, and Luxenburg (2007; Level I, N = 70); Dowling, Mastik, Hubbard, Luxenberg, and Burr (2005; Level I, N = 70); Hickman et al. (2007; Level II, N = 66); and Sloane et al. (2007; Level II, N = 66) compared bright light exposure to usual room light with residents with AD in nursing homes. Overall, BLT did not improve residents’ performance on most measures of sleep–wake (circadian) or rest–activity (time spent engaged in purposeful tasks in comparison with dozing or staring) disruptions compared with control participants. However, experimental groups, as a whole, did appear to receive sufficient light to prevent their rest–activity rhythm from deteriorating, unlike the control groups. Dowling et al. (2008; Level I, N = 50) tested whether the addition of melatonin would enhance the efficacy of BLT in treating rest–activity disruption in institutionalized patients with AD. The group that received melatonin showed significant decreases in daytime somnolence, increases in daytime activity, and an improvement in day–night sleep ratio. Because the researchers did not test melatonin alone, ascertaining the degree to which BLT contributed to the changes is not possible.