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Sensory environments for behavioral health in Dementia: Diffusion of an environmental innovation at the Veterans Health Administration

December 2020
The Center For Health Design

Why does this study matter?
People living with dementia frequently lack the social and coping skills to adapt to environmental stress, resulting in maladaptive behavior and increased burden to caregivers. Veterans have a 30% lifetime prevalence of post-traumatic stress disorder (PTSD) and are therefore twice as likely to develop dementia and have an increased risk of neuropsychiatric behavioral disturbances including sleep disorders, irregular mood, anger, and aggression. These behaviors pose a critical concern for large healthcare systems like the Veterans Health Administration which estimates more than ¾ of a million U.S. Veterans will have dementia before the end of this decade. Due to the high cost, dangerous side effects, and inefficacy of drug-based interventions, nonpharmacological solutions for behavioral health in dementia are needed. In 2013, the Veterans Health Administration provided customizable multi-sensory environmental equipment in either fixed rooms or mobile cart applications and dementia training to over 53 sites to calm users by addressing stimulation preferences.

How was the study done?
A total of 32 staff from 12 sites responding to recruitment fliers participated in this study comprising 21 individual interviews and 1 group interview with 11 participants. Following the delivery of an interview guide consisting of 32 items, including multiple choice, fill-in-the-blank, Likert-type rating, and open-ended questions, interviews were conducted by phone, de-identified, transcribed, and analyzed using the rapid qualitative inquiry (RQI) method. Domains were developed based on organizing the content of the interview guide into categories including equipment, treatment, training, barriers, perceived effectiveness of MSE vs. Veteran preference, staff satisfaction, and overall lessons learned.

What do we learn from this study? 
Although a few participants experienced negative effects from MSE, all 32 participants saw some type of positive effects, including: positive distractions, increased engagement, behavior improvement, calming effect, and improved focus. Cautionary advice for unanticipated negative responses primarily related to Veterans’ heightened sensitivity and confusion resulting in fear and, sometimes, flashbacks. Being familiar with each Veteran, their diagnoses and preferences, and understanding how to regulate and customize MSE stimuli was presented as the combination for successful MSE engagement.

Participants assigned dual ratings to MSE items based upon their perception of Veteran preference and their own opinion regarding therapeutic contribution. Bubble tubes were often cited as contributing directly to the feeling of calm and a reduction of anxiety levels. Staff also believed that music and aromatherapy were important to promote engagement through reminiscence. While several other SME items were also mentioned from a therapeutic or preferential perspective, it is noteworthy that 6 of the 14 items were omitted all together.

Several staff members noted the MSE was most effectively provided in a permanent application within a dedicated room rather than using a mobile equipment cart that could be moved into various areas. Another common theme was that the size of the room needed to be large enough to accommodate Veterans who cannot get out of bed as well as small groups of patients and staff to interact in the room. Maintenance and access were cited in association with concerns about sufficient training and staff turnover.

Can we say the results definitive? 
MSE’s come in all shapes, sizes and styles. While participation may have been limited to 12 of the 53 available sites within the VA, this study offered an unprecedented opportunity to evaluate many comparable MSEs within a single organization. It should be noted that the evaluation period coincided with a significant change in VA’s approach to the environment of care for Community Living Center residents resulting in smaller residential style assisted living “households” rather than large institutional multi-floor units as well as dementia-specific training which may have effected staff’s perspectives and Veterans’ behavioral symptoms and outcomes. The research team did not use a validated instrument for staff to assess or qualifying behavior or seek input directly from the Veterans themselves. The research team also acknowledged that responses could be overrepresented or biased due to having multiple respondents from single locations. The biggest limitation to application, in my opinion, is that this study took place prior to the COVID-19 pandemic when infection prevention was not overly restrictive for accessing single-use spaces or shared equipment.

What's the takeaway 
Not all MSE stimulus or equipment is created equal and beauty is in the eye of the beholder. I can tell you from experience that the design, product selection, maintenance, training, and evaluation of MSE’s is incredibly complicated. Research is primarily anecdotal in nature and frequently lacks conclusive evidence for clinical use. For me, the biggest takeaway is the prioritization of different pieces of equipment based upon the dual rating system employed by the research team. Especially now, with the restrictive realities imposed by COVID-19, accessing single pieces of equipment may be impractical, but there is great opportunity for designers of the built environment to focus on these elements and find innovative ways to incorporate them into common spaces in a more impactful, cost-effective way that provides greater flexibility and stability in application.


Lorusso, L., Park, N.-K., Bosch, S., Freytes, I. M., Shorr, R., Conroy, M., & Ahrentzen, S. (2020). Sensory environments for behavioral health in Dementia: Diffusion of an environmental innovation at the Veterans Health Administration. HERD: Health Environments Research & Design Journal, in press. https://doi.org/10.1177/1937586720922852



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