Significance

Population and public health/occupational needs

Dementia is a medical condition that affects a person’s thinking, memory, and social
abilities, which can have negative effects on everyday life (Mayo Clinic, 2021). There are
several risk factors for dementia which include, but are not limited to, age, family history,
ethnicity, and heart health (CDC, 2019). According to the Mayo Clinic (2021), dementia
symptoms involve cognitive and psychological changes. Some cognitive changes include
memory loss, difficulty with word-finding, reasoning, and problem-solving; psychological
changes may include personality changes, anxiety, agitation, and inappropriate behavior (Mayo
Clinic, 2021). These cognitive and psychological changes may greatly affect the individual’s
routines and ability to complete self-care tasks and other valued occupations.
The Centers for Disease Control (CDC) conclude that there are currently approximately 5
million individuals with dementia who are 65 or older, and it is projected to increase to 14
million individuals by 2060 (CDC, 2019). Rovner et al. (2005) identified as much as 80% of new
admits across 454 nursing homes had a mental health disorder, with dementia being the most
common diagnosis. Depression is also a very common condition in individuals with forms of
dementia such as Alzheimer’s Disease (Alzheimer’s Association, n.d).
Gaps in services
There are numerous gaps in services that dementia patients face. According to Nygaard
and Ruths (2003), dementia is an underdiagnosed condition, and many do not receive proper
treatment and resources due to their diagnosis being overlooked. This negatively impacts the
quality of life of the patients and caregivers. Another gap involves a lack of staff training in
facilities with dementia patients. According to Zimmerman et al. (2005), dementia patients had
better outcomes and improved quality of life when cared for by staff that underwent additional
direct-care training. While many dementia-specific programs exist, few address the complex
sensory needs of dementia patients. This often leads to overprescribing medications to offset
challenging behaviors, which in turn results in increased falls, strokes, or even death (Mileski et
al., 2018). Nonpharmacological means such as sensory and memory stimulation can promote
physical and emotional comfort to residents (Mileski et al., 2018). The following proposal aims
to address these gaps by screening residents for dementia symptoms and providing a
nonpharmacological intervention to address their sensory needs and improve outcomes.
Current/Existing programs
Typical treatment of dementia is to slow the progression of symptoms, while managing
behaviors, and maintaining mental and physical functions (National Institute on Aging, 2017).
This is accomplished through prescription drugs, changes to the patient's routine and
environment, and therapies including cognitive stimulation therapy (CST), cognitive
rehabilitation, and reminiscence therapy (Mayo Clinic, 2021). In recent years, multi-sensory
environments (MSEs) have been researched and used in the treatment of dementia (Collier &
Jakob, 2017). MSEs, also known as sensory rooms or Snoezelen rooms, are used with patients
with dementia and other mental health disorders, including anxiety and depression. According to
information provided by Snoezelen Multi-Sensory Environments (2021), MSEs are “relaxing
spaces that help reduce agitation and anxiety, but they can also engage and delight the user,
stimulate reactions and encourage communication" (para. 1). The Orem Rehabilitation and
Skilled Nursing Facility utilizes pharmacological and other interventions that address physical
and cognitive symptoms of dementia. However, they do not currently have any interventions that
address sensory needs for patients with dementia or other relevant mental health disorders. This
results in a gap in care which the sensory room aims to address.
Multi-sensory Environments
Sensory rooms provide participants with the opportunity to select different sensory items
to help regulate distress, increase self-esteem, calm emotions, and improve well-being (Lindberg
et al., 2019). MSEs also provide stimulation to the senses in a demand-free environment that may
be controlled by the patient, leading to increased perceived control over their environment
(Bjorkdahl et al., 2016). MSEs were originally created and researched for mental health settings,
however, they have been researched in recent years with positive results for the treatment of
dementia (Collier& Jakob, 2017).
Recent research suggests that MSEs are an intervention that is as effective, or more
effective, than other common treatments at increasing patient quality of life (Maseda et al.,
2014). Research also shows that MSEs effectively increase patient relaxation, contentment,
alertness, attentiveness, and improve communication compared to other treatment approaches
(Maseda et al., 2014). MSEs are also shown to reduce wandering and restlessness (Bauer et al.,
2015), and may provide a positive effect on the quality of sleep in dementia patients (Todder et
al., 2016). Research suggests that MSEs may also reduce anxiety, agitation, and the overall
severity of disease in dementia patients (Sanchez et al., 2016). Research by Ma et al. (2021)
suggests that MSEs improve a patient’s self-care ability. According to van Weert et al. (2005),
dementia patients who participated in a sensory program demonstrated significant improvements
in mood, aggressive behaviors, adaptive behaviors, and depression. This research demonstrates
the various positive effects MSEs have on dementia patients.
While the benefits of MSEs are apparent in treating patients with dementia, they are not
well utilized. The Orem Rehabilitation and Skilled Nursing facility offer a dementia-specific
program that focuses on cognitive changes of the resident; however, it does not specifically
address the complex sensory integration and mental health needs for their large at-risk
population of residents with dementia. The facility would greatly benefit from this
nonpharmacological and evidence-based approach to address the sensory integration and mental
health needs of dementia residents. An MSE would also benefit residents with other common
mental illnesses found in skilled nursing facilities, such as depression and anxiety (Creighton et
al., 2015; Horwath and Szezerbinska, 2017).
Models and Theories
Occupational Therapy practice models and theories support the implementation of MSEs.
The Dunn Sensory Model (Dunn, 2007) describes an individual's neurological thresholds,
sensory processing patterns, responses to the environment, and how sensation can support or
inhibit participation in valued daily tasks. Understanding each person's unique sensory needs and
responding with personalized strategies or environmental modifications can minimize frustration,
discomfort and increase quality of life (Dunn, 2007). The Person, Environment, Occupation
(PEO) Model is used to understand the relationship between an individual’s daily tasks
(occupations), their environment, and their person, which includes their skills, abilities, roles,
and sensory processes that affect everyday life (Law et al., 1996).
Finally, the Allen Cognitive Disabilities Model (Allen, 1992) was used to inform the
development of a sensory program to be carried out by an occupational therapist in the sensory
room. This model is used to assess and determine which type of sensory program best fits the
individual. Depending on the resident’s cognitive level, the therapist can direct intervention
towards sensory exploration versus learning specific strategies for coping or emotional
regulation. These models suggest that addressing the resident’s personal sensory needs, along
with their environment, leads to changes in their ability to participate in valued occupations.
Priority Areas
MSEs have many benefits, as outlined above. They also address many public health
priority areas as identified by the Centers for Medicare & Medicaid Services (CMS). CMS and
its partners prioritize finding new practices that enhance the quality of life for patients with
dementia and promote person-centered care for every nursing home resident. Its mission is to
significantly reduce the prevalence of antipsychotic medication use by implementing
nonpharmacologic approaches and person-centered care practices (CMS, 2021). The research
found that sensory modulation strategies and treatment in a sensory room have been shown to
reduce the need for forced medications, restraints, and seclusion (Andersen et al., 2017; Seckman
et al., 2017). MSEs are a nonpharmacologic, sensory-based method, which aligns with CMS
priorities.

Innovation
MSEs are an innovative approach to dementia care because they incorporate sensory
integration and modulation into dementia care. Providing education and strategies regarding
individual sensory preferences and how sensations affect participation in valued tasks is a need
that is not being met by any other dementia program. Therapists determine each resident's unique
sensory needs and provide client-centered interventions through the use of MSEs. This enables
participants to achieve increased participation in valued tasks, thus overall affecting quality of
life. There are currently no other approaches that address the complexity of sensory needs that
dementia patients have. An MSE is equipped with the tools necessary to address those needs.

Approach
Needs Assessment Results
A needs assessment was conducted with key stakeholders at the Orem Rehabilitation and
Skilled Nursing facility. This assessment uncovered the large population of individuals,
including dementia patients, with sensory needs that are not currently being addressed. There are
currently no programs or therapies at the facility that address the sensory needs of patients.
Results also found that residents have poor self-care abilities, poor mobility, and increased
isolation and mental health concerns due to COVID-19 precautions in place. The assessment also
demonstrated that staff has had difficulty managing patients with behavioral issues, leading to
increased levels of staff burnout.
The facility has a great desire to create a sensory room to implement interventions to
address the sensory needs of its residents. They are also committed to taking the necessary
actions to sustain the sensory room over time. Utilization of a sensory room offers alternative
methods for addressing patient isolation, mental health challenges, and dementia behaviors. The
sensory room is a tool that staff can use to assist with the prevention of burnout for themselves
and the residents.
Sensory Room Use
The sensory room will be used as a treatment area for individual one-on-one occupational
therapy (OT) interventions, as well as for future sensory group programs run by the occupational
therapist. Residents will be recruited routinely as part of their OT evaluation. Current residents
may be referred to the sensory group by other nursing or therapy staff, as appropriate. An in-
service will be given to staff which will provide education on the purpose of sensory rooms,
residents that may benefit from sensory rooms, and qualifications needed to use the room in
interventions with residents. A semi-structured interview will be administered to the staff after
the in-service to gauge understanding (see Appendix A).
All participants will be screened by the occupational therapist for eligibility. Eligibility
will be determined based on if the resident has a diagnosis of dementia or if they have dementia-
like symptoms that currently interfere with participation in daily occupations. The Dementia
Behavior Disturbance Scale (Gauthier, Baugmgarten & Becker, 1997) will be used to report how
often challenging behaviors associated with dementia occur. Residents will then complete the
Allen Cognitive Level Screen (ACLS) to evaluate their cognitive level and in turn, guide
intervention (Allen et al., 2007). Results of this assessment, as well as clinical judgment by the
therapist, will determine if individual or group sensory intervention is necessary.
Two sensory group classes will be offered. The first is for those with an ACLS score of
4.6 or below, and focuses primarily on sensory exploration and understanding what is calming or
alerting for the individual. The second group class is for individuals with an ACLS score above
4.6, which will focus on teaching specific skills for emotional regulation. Each group class will
take place for one hour, once per week, for eight weeks. The frequency, length, and intensity of
individual OT sessions in the sensory room will be determined by the needs of each resident.
Goals and Objectives
Goals and objectives were developed in tandem with the facility’s lead occupational
therapist, who will be developing the sensory programs and providing intervention in the sensory
room. The goals are as follows.
Goal 1: Participants will demonstrate improved emotional regulation skills.
● Objective 1a (process): Occupational therapist will provide an 8-week sensory program
in the sensory room and individual one-on-one therapy sessions that provide education on
sensory modalities that promote emotional regulation.
 ● Objective 1b (outcome): After participating in the sensory program two or more times,
ACLS level 4.6 and above group participants will identify two or more sensory strategies
for emotional regulation.
● Objective 1c (outcome): After participating in the sensory program two or more times,
ACLS level 4.6 and below group participants will identify personal sensory preferences.
Goal 2: Participants will demonstrate improved quality of life as measured by the Quality of Life
Enjoyment and Satisfaction Questionnaire- Short Form (Q-LES-Q-SF).
● Objective 2a (process): The program will reach at least ten long-term care residents with
indicators of poor quality of life within the first year of program implementation.
● Objective 2b (outcome): Upon completion of sensory classes, participants will engage in
self-directed use of sensory items to stimulate senses, promote increased arousal states,
and increase their perceived sense of control.
Potential Problems and Alternative Strategies
Potential problems that may arise through the implementation of a sensory room may
include misuse of sensory equipment, lack of equipment cleanliness, and limited resident
participation. Strategies to avoid misusing equipment include only allowing residents in the room
when supervised by an occupational therapist or specially-trained staff member regarding the
sensory room protocols. Sensory room equipment will need to be cleaned regularly abiding by
COVID-19 regulations. Repeated cleaning of equipment may lead to break down, which may
require repurchasing items over time. The facility is aware of this and has agreed to absorb all
additional costs for items beyond what is explicitly outlined in the grant.
Although there will be a sensory room and equipment available to residents to improve
negative behaviors and quality of life, residents may refuse to participate due to personal
concerns or lack of mobility. This presents a problem because individuals cannot benefit from
the sensory program if they are not willing to participate. Strategies to promote resident
participation may include having sensory demonstrations and providing education in the
resident's room. This will allow residents to explore some of the different equipment available,
which may help spark their interest in participating in sensory classes or interventions. Another
option would be to have group classes where residents can learn and explore together and not
feel the pressure of one-on-one sessions.
Evaluation of Program
The sensory programs will be evaluated continuously through data collection before and
after each class or individual treatment session in the sensory room. Data will be collected by the
occupational therapist through a resident behavior report form, which describes observations of
resident behaviors before and after each treatment session (see Appendix B). Overall program
usefulness will be measured by administering the Q-LES-Q-SF at the beginning of the program,
after four weeks, and at the end of the programs (Endicott, J., Nee, J., Harrison, W, &
Blumenthal, R., 1993). The Dementia Behavior Disturbance Scale will be performed at the start
and finish of the programs to track potential long-term changes in dementia-related behaviors.
The programs will also be evaluated through OT observation of participants both during use of
the sensory room and in typical OT sessions. This will measure if and how the sensory programs
correlate with resident performance in functional tasks.
Personnel and Resources Needed
Personnel required to run the sensory room effectively includes an occupational therapist
to plan and direct group program classes and carry out individualized intervention plans in the
sensory room. Certified Nursing Assistants (CNAs) or the therapy aid may be needed to bring
residents to and from group classes. The Director of Rehabilitation, along with other
stakeholders at the facility, has sanctioned a space to be used for the sensory room. In this room,
basic furniture and equipment, including a table, chairs, and sanitizing equipment, are needed.
Sensory-specific assessments and equipment are also needed to follow evidence-based protocols.
Please see the budget form (Appendix C) and the budget justification (Appendix D) for a
comprehensive list of assessments, sensory equipment, and other supplies necessary.
Sustainability
The Orem Rehabilitation and Skilled Nursing facility supports the sensory room and has
demonstrated its dedication to creating and maintaining the sensory room and programs. The
sensory room will remain in use by the facility's three occupational therapists, who are trained
and qualified to administer treatments in the sensory room. The facility will provide training to
other employees on sensory room protocol to increase referrals to the programs and thus sustain
utilization of the room. The hourly wages of these staff members will be covered through the
facility or billed through insurance, requiring no further funding from the grant. The Orem
Rehabilitation and Skilled Nursing facility have demonstrated their commitment to this and
many other internal programs that they have independently funded. The facility's key
stakeholders support the program, which positively impacts the overall sustainability of the
sensory room and sensory programs.
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 Appendix A: Semi-Structured Interview Questions

Semi-Structured Interview Staff Questions: post-training

1. Describe what you learned about the purpose of a sensory room.
2. Describe characteristics of a patient that would benefit from a sensory room.
3. On a scale of 1-5, with 1 being not likely at all and 5 being very likely, how likely are
you to refer a resident to be assessed for eligibility to participate in sensory room group
classes?

Semi-Structured Interview Resident Questions: post-intervention

1. How have the preliminary sensory classes made you feel?
2. What have you learned in the sensory classes?
3. On a scale of 1-5, with 1 being not likely at all and 5 being very likely, how likely are
you to participate in a sensory group class in a new sensory room?
 Appendix B: Behavior Report Form: Daily Data Collection

This tool was created to be performed before and after multi-sensory room participation by an
occupational therapist or sensory-room trained staff member. Research by Muller-Spahn (2003)
shows that 30%-90% of dementia patients suffer from behavioral disorders such as the behaviors
listed in this tool.

Type of Behavior Frequency Duration

Agitation

Confusion

Mood Swings

Aggression

Anxiety

Other: _______________
 Appendix C: Budget Form

Budget Item Cost

Space

Space for Sensory Room (Sun Room) In-kind contribution

Long table In-kind contribution

2 folding chairs $44

Assessment Tools

Adult Sensory Profile $159

(Includes User’s Manual, 25 Questionnaires, 25 Summary Reports)

Pool Activity Level Assessment $45

Muti-Sensory Room Equipment

Projector $2,064

Bubble Tube $1,563

Bubble Tube Balls $39

Colored lights $26

Infinity Bead Chain- maybe not $429

TheraGym Lounger $1,075

Ceiling mount/support for swing $22

Rocking chair $150

Vibrating tube $27

Weighted blanket $50

Switches (Big mac, timer) $65

$135

LED light curtain $1,300

Essential Oils $691
Lavender $33 x 3 bottles ,15 ML
Peace & Calm $29 x 3 bottles, 5 ML
Inner Child $42 x 2 bottles, 5 ML
Dream Catcher $101 x 1 bottle, 15 ML
Brain Power $92 x 2 bottles, 5 ML
Aroma Life $68 x 2 bottles, 15 ML

Diffuser $37

Sound machine $34

Supplies

Hand sanitizer In-kind contribution

Sanitizing supplies In-kind contribution

Taste class supplies In-kind contribution

Printed materials (visual stimuli, educational pamphlets, flyers In-kind contribution

given to residents advertising room)

Personnel

Occupational Therapist In-kind contribution

Housekeeping/cleaning sun room In-kind contribution

CNAs to be trained to help residents use sensory room In-kind contribution

Total Requested $7,955

 Appendix D: Budget Justification

Budget Item Cost Rationale

Space

Space for Sensory Room (Sun In-kind Space to provide intervention and
Room) contribution group classes, must house equipment
and materials required for
intervention.

Long table In-kind Table to be used in intervention, hold

contribution materials.

2 folding chairs $44 Chairs for use by residents and

therapists while engaging in group
classes, intervention.

Assessment Tools

Adult Sensory Profile $159 Measures sensory processing patterns

(Includes User’s Manual, 25 and effects on functional
Questionnaires, 25 Summary performance. Classification system is
Reports) based on normative information.

Pool Activity Level $45 Valid and reliable tool that supports
Assessment intervention planning for people with
cognitive impairments, including
dementia. Includes checklist to carry
out sensory interventions

Multi-Sensory Room
Equipment

Projector $2,064 Projects between 6-20 feet, LED

bulbs, focusing lens, wide angle lens.
Includes effect wheels, panoramic
rotator.

Bubble Tube $1,563 Bubble tube with constant effects of

color change and vibratory tactile
stimulation.

Bubble Tube Balls $39 White balls to be placed in bubble

tubes to increase calming effect
 through repetitive movements.

Colored lights $26 LED light strips with soft,

customizable lighting in order to
provide alerting or calming sensation.
Includes dimming and flashing
features, controlled with remote.

Infinity Bead Chain- maybe $429 Provides simultaneous tactile, visual,

not and auditory stimulation through
cool, smooth beads and lights.

TheraGym Lounger $1,075 Provides vestibular input through

gentle swinging motion. Includes
harness for support and safety. Tested
for up to 250 lbs.

Ceiling mount/support for $22 Heavy duty swing hanger and ceiling
swing support required to safely mount
Theragym Lounger.

Rocking chair $150 Provides vestibular input through

gentle swaying motion. Includes foot
rest for positioning options.

Vibrating tube $27 Provides proprioceptive and tactile

input at 2 speeds. Can be wrapped
around different areas of the body.

Weighted blanket $50 Provides proprioceptive input.

Switches (Big mac, timer) $65 Switch requires a light touch to

$135 activate. Button can be used with
battery operated devices, or
electronics. Can be placed within
reach of the client's functional
movement. LITTLEmack switch has
different levels that can be used to
play music or give instructions.

LED light curtain $1,300 Light rotates gently through 8

different colors. Person may control
the speed of color changes with a
dial.
Essential Oils $691 Essential oils selected to create a
Lavender $33 x 3 bottles ,15 calm, soothing environment for the
ML resident
Peace & Calm $29 x 3
bottles, 5 ML
Inner Child $42 x 2 bottles, 5
ML
Dream Catcher $101 x 1
bottle, 15 ML
Brain Power $92 x 2 bottles,
5 ML
Aroma Life $68 x 2 bottles,
15 ML

Diffuser $37 Portable, spill proof diffuser to

diffuse essential oils

Sound machine $34 Sound machine plays soothing

sounds such as white noise, ocean,
rain. Has an optional timer, volume
control, headphone jack for personal
use, and a memory button to replay
the last sound.

Supplies

Hand sanitizer In-kind Facility to provide hand sanitizer for

contribution residents

Sanitizing supplies In-kind Sanitizing wipes to clean equipment

contribution after each use.

Taste class supplies In-kind Facility to cover budget to purchase

contribution food items for taste class- includes
plasticware as needed

Printed materials (visual In-kind Facility to cover cost of

stimuli, educational contribution ink/paper/printer
pamphlets, flyers given to
residents advertising room)

Personnel

Occupational Therapist In-kind Hourly wage of OT to be covered by

 contribution the facility

Housekeeping/cleaning sun In-kind Hourly wage of janitorial staff to be

room contribution covered by the facility

CNAs to be trained to help In-kind CNAs and other staff will be trained
residents use sensory room contribution during working hours and will be
compensated by the facility.

Total Requested $7,955