Geriatric Nursing 36 (2015) 462e466

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Geriatric Nursing
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Feature Article

An evaluation of SnoezelenÒ compared to ‘common best practice’

for allaying the symptoms of wandering and restlessness among
residents with dementia in aged care facilities
Michael Bauer, PhD, RN a, *, Jo-Anne Rayner, PhD, RN a, Judy Tang, PhD b,
Susan Koch, PhD, RN c, Christine While, BSc (Hons), RN a, Fleur O’Keefe, BNsg, RN c
a
Australian Centre for Evidence Based Aged Care, Australian Institute for Primary Care and Ageing, La Trobe University, Bundoora, Victoria, Australia
b
Lincoln Centre for Research on Ageing, Australian Institute for Primary Care and Ageing, La Trobe University, Bundoora, Victoria 3086, Australia
c
Helen Macpherson Smith Institute of Community Health, Royal District Nursing Service, St Kilda, Victoria, Australia

a r t i c l e i n f o a b s t r a c t

Article history: Snoezelen has become an increasingly popular therapy in residential aged care facilities in Australia and
Received 16 April 2015 elsewhere, despite no conclusive evidence of its clinical efficacy. This paper reports on an evaluation of
Received in revised form the use of Snoezelen compared to ‘common best practice’ for allaying the dementia related behaviors of
15 July 2015
wandering and restlessness in two residential aged care facilities in Victoria, Australia. Sixteen residents
Accepted 18 July 2015
Available online 17 August 2015
had their behavior and responses to Snoezelen or ‘common best practice’ observed and recorded over
three time periods. The Wilcoxon signed-rank test showed there was a significant improvement in be-
haviors immediately after the intervention and after 60 min. However, no significant differences were
Keywords:
Dementia
found between residents receiving Snoezelen and ‘common best practice’ interventions for the reduction
Wandering of the dementia related behaviors.
Restlessness Ó 2015 Elsevier Inc. All rights reserved.
Snoezelen
Standard care
Evaluation

Introduction The Snoezelen sensory experience has also been transported to

Originally developed in the 1970s as a leisure resource for
Dutch children with learning disabilities, Snoezelend is a term
coined to describe the use of multi-sensory rich environments to
stimulate the primary senses of sight, smell, hearing, taste and
touch. Traditionally Snoezelen has been delivered in a dedicated
room equipped with a variety of lights, moving objects, music,
aromas, and tactile objects. Snoezelen environments have become
very sophisticated incorporating “high tech” fiber optics, bubble
tubes, strobe lights, aroma steamers, image projectors and ceiling
mounted mirror balls.1 The costs associated with setting up a
Snoezelen room can be high, ranging from $10,000 to $30,000 or
higher depending on the type and quantity of equipment used.2,3
Conflict of interest statement: No conflict of interest has been declared by the
authors.
Funding: The JO and JR Wicking Trust funded the project on which this paper
reports.
* Corresponding author. Tel.: þ61 03 9479 6003; fax: þ61 3 9479 5977.
E-mail address: m.bauer@latrobe.edu.au (M. Bauer).
d
Snoezelen is a registered trademark of ROMPA.
the individual resident’s bedside via a mobile cart4 or incorpo-
rated as an outdoor garden.5
The use of multi-sensory therapies including Snoezelen have
become increasingly popular in Australian residential aged care
facilities (RACFs)5e8; and elsewhere1,4,9e13 for the management of
the behavioral and psychological symptoms of dementia
(BPSD).2,3,14e18 It also has been suggested that Snoezelen improves
cognition, mood,12,15,19 communication10 and wandering behav-
iors.20 The rationale for the use of Snoezelen in dementia is that
people with dementia are more vulnerable to the effects of sensory
deprivation which can play an important, but often neglected role
in maladaptive behaviors.14,21,22 A multi-sensory environment
places fewer demands on cognitive abilities and capitalizes on
sensorimotor abilities. Snoezelen is seen as a way to reach people
with dementia who may lack higher order processing abilities, by
providing an accessible and enabling environment that can both
stimulate and relax the person.
In dementia care, Snoezelen has been delivered as a group or
individual therapy22,23 or as a 24-h care experience.24 The delivery
of Snoezelen as a group activity is common in aged care facilities
where scarce resources mean therapists are often only able to
administer group programs.2

0197-4572/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.gerinurse.2015.07.005
 M. Bauer et al. / Geriatric Nursing 36 (2015) 462e466
A Cochrane Review of the use of Snoezelen25,26 found no clear
evidence of its clinical efficacy for people with dementia; and a
recent trial examining the impact of a ‘Snoezelen’ room interven-
tion compared to one-to-one activity sessions on agitated behavior,
mood, cognitive and functional status for residents with dementia,
found no significant differences between the two interventions.27
This paper reports on Stage Two of a larger project (Description
and Evaluation of SnoezelenÒ for Managing Dementia Related Be-
haviours in Victorian Aged Care Facilities). Stage One findings are
reported elsewhere.6 The aim of Stage Two was to evaluate the
impact of Snoezelen delivered in a dedicated room by an activity
therapist compared to ‘common best practice’ interventions as
provided by care staff (nurses and personal care assistants), in
allaying the dementia related behaviors of wandering and rest-
lessness. Wandering and restless are two commonly occurring
dementia related behaviors which are known to contribute to care
staff stress and burden28 as they can be present for long periods and
can be very demanding of staff time.29 We did not investigate the
impact of the type of dementia, comorbidities, or effects of medi-
cations on these behaviors but rather, set out to understand what
changes these two distinct approaches may have had on the
severity of behaviors over time.
Materials and method
A descriptive observational method was used in two RACFs in
Victoria, Australia, one of which had a dedicated Snoezelen room.
Observation studies are commonly used in the aged care setting,
especially with people who are living with dementia.30,31
When dealing with the BPSD, care staff have at their disposal a
number of ‘common best practice’ interventions including psycho-
social strategies such; as speaking with the resident to determine
the cause of their behavior; diversion and distraction activities;
engagement of the resident in meaningful and appropriate pas-
times; rest; one-on-one social interactions, and pain assessment
and management.32 Care staff used their knowledge of the resident
and clinical judgment to determine which strategies to use on a case
by case basis. A qualified diversional therapist was solely responsible
for the organization and delivery of the Snoezelen in this study.
Snoezelen sessions were implemented on the basis of the diver-
sional therapist’s knowledge of the resident and prior experience.
Approval to conduct the study was obtained from the La Trobe
University, Faculty of Health Sciences Research Ethics Committee
(FHEC08/20) and the participating RACFs.
Sample
Purposeful sampling was used to recruit sixteen older people
with dementia from two RACFs. Care managers at each partici-
pating facility identified residents who were known to exhibit the
BPSDs in question. All had moderate to severe cognitive impair-
ment (Psychogeriatric Assessment Scale scores between 10 and 21)
and were unable to provide informed consent to participation.
Consent was therefore obtained from their authorized represen-
tative, usually a family member or guardian prior to commence-
ment of data collection. The Nurse Unit Manager in each facility
identified possible participants, approached their authorized
representative on behalf of the research team and asked if the
research nurses could contact them about the study. The research
nurses contacted all those families that expressed an interest in
participation to explain the study.
Data collection
Two research nurses experienced in aged care and dementia
who did not work at the facilities, observed and recorded the
463
dementia related behaviors of interest in participating residents,
and their responses to the interventions (Snoezelen or ‘common
best practice’) over four weeks. The observations were undertaken
from discrete positions at each facility, including from within the
Snoezelen room, and the research nurses continually assessed the
awareness of participants to their presence, withdrawing if they
thought the resident was being unsettled.
Participating residents were kept under observation by the
research nurses across morning, afternoon and evening shifts for
any signs of the behaviors in question and care staff also alerted the
research nurses when behaviors were noted. Data were collected
using a simple behavioral observation chart adapted from the
Queen Elizabeth Behavioural Assessment Graphical Scale
(QEBAGS).29 The QEBAGS utilizes three categories of behavioral
disturbances (wandering, restlessness and aggression) which may
occur in isolation or may co-exist.29 The QEBAGS allows for the
description of four types of behavioral typologies within each of the
categories, with each representing an increase in the level of
disturbance. The wandering typology included ‘aimless wander-
ing’; ‘wandering with some purpose’; ‘wandering in an asocial
manner’ and ‘wandering, not amenable to reason.’ The restlessness
typology comprised ‘restless but cooperative’; ‘restless, uncooper-
ative’; restless, interfering with others’ and restless with continu-
ously disruptive behavior.’
The research nurses spent two days at each facility establishing
an understanding of Snoezelen and ‘common best practice’ in-
terventions used to manage behavior and introducing themselves
to staff, participants and families; and repeat observation days were
incorporated into the study design. Both were given training in
observation techniques prior to data collection, including learning
to standardize recording using the QEBAGS and achieving inter-
rater reliability33 by piloting the modified QEBAGS form with two
residents over two days. A consensus of the coding schema was
reached after independent coding of the QEBAGS and discussion of
observations and 80% concordance was achieved.
The behaviors and interventions used to manage the behaviors
of the 16 residents diagnosed with dementia were observed and
recorded for two days per week over a twelve-week period by a
research nurse stationed at each site. Some residents had their
behavior and the interventions observed on more than one occa-
sion. Observational data were collected at four time points for each
episode of behavior: T0 ¼ observation when the behaviors occurred
and before any intervention by staff; T1 ¼ immediately after the
initiation of an intervention; T2 ¼ 30 min after the intervention;
and T3 ¼ 60 min after the intervention. The research nurses rated
the behaviors of interest, wandering (W) and restlessness (R), at
each time point on a 4-point scale: 1 ¼ behavior stopped or person
settled, 2 ¼ behavior improved, 3 ¼ behavior on going, or
4 ¼ behavior worsened.
Data analysis
Descriptive statistics were used to compare the effects of
Snoezelen or ‘common best practice’ (grouped as ‘non-Snoezelen’)
in allaying the dementia related behaviors of interest over the
measured time periods. Due to the small number of participants,
non-parametric tests were used in conjunction with observational
data. All statistical analyses were completed using the Statistical
Package for the Social Sciences.34
Results
The characteristics of the study participants are outlined in
Table 1.
464 M. Bauer et al. / Geriatric Nursing 36 (2015) 462e466

Table 1
Characteristics of study participants (n ¼ 16).

Characteristics Snoezelen Non-

(n ¼ 9) Snoezelen
(n ¼ 7)

n % n %
Gender
Male 3 33.3 2 28.5
Female 6 66.6 5 71.5
Age
<75 years 1 11.1 0 0
76e80 years 2 22.2 1 14.3
81e85 years 4 44.4 1 14.3
>85 years 2 22.2 5 71.4
Dementia type
Alzheimer’s disease 4 44.4 3 43
Vascular dementia 1 11.1 0 0
Parkinson’s disease 2 22.2 0 0
Unspecified 2 22.2 4 57
Length of stay
<12 months 2 22.2 3 42.9 Fig. 1. Behavioral ratings different time points.
12e18 months 3 33.3 2 28.6
19e24 months 3 33.3 1 14.3
>24 months 1 11.1 1 14.3 The median behavioral score was 3 (wandering/restlessness on-
Co-morbidities going) at pre-intervention (T0), and this decreased to 1 (wandering/
Mood disorders including depression 3 33.3 2 28.5
Disorders causing pain 4 44.4 7 100
restlessness stopped) at both T1 and T3. Table 3 shows the total
Disorders that reduce enjoyment of 9 100 7 100 number of episodes and their directional change at T1 and T3.
daily living For the Snoezelen group, a Wilcoxon signed-rank test showed a
statistically significant improvement in wandering and restlessness
both immediately after the intervention (T1) (Z ¼ 3.95, p < .001),
and 60 min after the intervention (T3) (Z ¼ 2.94, p < .01). The
Twice as many females compared to males participated in the median behavioral score of 3 (wandering/restlessness on-going) at
Snoezelen and non-Snoezelen groups. Residents in the Snoezelen pre-intervention (T0), decreased to 2 (wandering/restlessness
group were younger (median age 81 years, range 70e99 years) and improved) at T1 and then to 1 (wandering/restlessness stopped) at
had been living in the residential aged care facility for a longer T3. Table 3 shows the number of episodes and their directional
period (median 16.5 months, range 5 monthse3 years) compared change at T1 and T3 for the Snoezelen group. For the non-
to the non-Snoezelen group (median age 88 years, range 80e95 Snoezelen group a Wilcoxon signed-rank test also showed a sta-
years) and (median length of stay 12 months, range 1.5 monthse8 tistically significant improvement in wandering and restlessness
years). Diagnoses varied between the two groups although a similar both immediately after intervention (T1) (Z ¼ 4.64, p < .001), and
proportion of residents in the Snoezelen (43%) and non-Snoezelen 60 min after intervention (T3) (Z ¼ 4.08, p < .01). The median
(44%) groups were diagnosed with Alzheimer’s disease. Comor- behavioral score of 3 (wandering/restlessness on-going) at pre-
bidities in both groups included mood disorders particularly intervention (T0), decreased to 1 (wandering/restlessness stopped
depression; pain causing diseases such as osteoarthritis; and con- or improved) at both T1 and T3. Table 3 shows the number of ep-
ditions which reduce enjoyment of daily living for example sensory isodes and their directional change at T1 and T3 for the Snoezelen
impairments, cardiovascular disease and urinary and digestive and non-Snoezelen groups. The Wilcoxon signed-rank test found
ailments such as incontinence, dysphagia and constipation. no significant differences between Snoezelen and non-Snoezelen
A total of 54 episodes of wandering and restlessness were wandering and restlessness rating scores at T0 (Z ¼ 0.91,
observed over the twelve weeks, 23 in the Snoezelen group and 31 p ¼ .37), immediately post-intervention (T1) or 60 min post-
in the non-Snoezelen group (see Table 2). After consideration of the intervention (T3) (T1: Z ¼ 0.51, p ¼ .61; T3: Z ¼ 0.26, p ¼ .80).
small numbers of observations, ratings of the behaviors of interest
were collapsed into a three-point scale to more effectively reflect
the findings in each group at each time point: 1 & 2 ¼ wandering/ Discussion
restlessness stopped or wandering/restlessness, 3 ¼ wandering/
restlessness on-going, or 4 ¼ wandering/restlessness worsened. This study compared Snoezelen with ‘common best practice’ for
A Wilcoxon signed-rank test showed that both Snoezelen and allaying the dementia related behaviors of wandering and
non-Snoezelen interventions led to a statistically significant
improvement in wandering and restlessness both immediately af- Table 3
ter the intervention (T1) (Z ¼ 6.01, p < .001), and 60 min after the Number of behaviors at T0 and change in number/severity at T1 & T3 (after
intervention (T3) (Z ¼ 5.00, p < .001) (see Fig. 1). intervention).

T0 Snoezelen group Non-Snoezelen Total

n ¼ 23 group n ¼ 54
n ¼ 31
Table 2
Number and type of behavior observed by participant group. QEBAGS score 1 & 2a 3b 4c 1 & 2a 3b 4c 1 & 2a 3b 4c
T1 19 4 0 28 2 1 47 6 1
Behavior type Snoezelen Non-Snoezelen Total
T3 14 6 1 26 1 4 40 7 5
Wandering 7 9 16
a
Restlessness 16 22 38 1& 2 ¼ Behaviour stopped or improved.
b
Total 23 31 54 Behavior ongoing.
c
Behavior worsened.
 M. Bauer et al. / Geriatric Nursing 36 (2015) 462e466
restlessness in two residential aged care facilities (one with a
dedicated Snoezelen room). We found that there was a significant
reduction in reported behavioral symptoms between pre-
intervention (T0) and immediately post-intervention (T1) for both
Snoezelen and non-Snoezelen (‘common best practice’) in-
terventions. However, no further differences between these two
types of interventions were found at any subsequent time points
(T2 and T3) which suggests that there are no advantages to the use
of Snoezelen over ‘common best practice’ interventions for allaying
the observed BPSD of wandering or restlessness. This finding is
consistent with the best available evidence.25,26
Our observations indicated that the use of Snoezelen as a thera-
peutic intervention for people with dementia was typically not
preceded by a comprehensive assessment of the person’s needs at
that time. This is counter to recommendations for the use of Snoe-
zelen as an individualized intervention,35 but not totally surprising
given that we found in Stage One of the larger project that sensory
interventions, including Snoezelen, were often delivered by staff
who have little or no education and training in the therapeutic use of
Snoezelen, the use of interventions was adhoc, and there was no
routine formal evaluation of interventions undertaken.6 The use of
multi-sensory interventions, including Snoezelen, in many RACFs
can be seen as more of a recreational activity, rather than a targeted
therapeutic intervention for the care of people who exhibit the
behavioral symptoms of dementia.
Given the considerable expense involved in establishing a
dedicated Snoezelen room, this result offers some food for thought
for service providers who may be considering creating such a space.
Multi-sensory environments are often used in promotion material
for residential aged care facilities, as they are seen as desirable
features. However, the cost involved in establishing specific multi-
sensory environments, like Snoezelen rooms, needs to be weighed
against the evidence to support their effectiveness and therapeutic
value.
While the popularity of Snoezelen and other multi-sensory in-
terventions may be consistent with the move to a more holistic and
person-centered approach to the care of older people, aged care
facilities need to be wary of implementing interventions without
education and training of staff and evidence of therapeutic efficacy
and safety. In the absence of a robust evidence base to support the
efficacy of multi-sensory interventions including Snoezelen for
people with dementia, careful assessment and monitoring of resi-
dents who receive these interventions is crucial, as is the need for
evaluation and appropriate education and training of staff
responsible for their administration.
Limitations
There were a number of limitations with this study. As overt
observations were used as a form of data collection, participants
and staff were aware of the research nurses and may have altered
their behavior accordingly.
Because the study was limited by time and resources and only a
small purposive sample of residents were recruited, we cannot rule
out the impact of a number of variables such as the type of de-
mentia under observation which varied within and between
groups, and the co-morbid conditions and medication regimes of
the participants. The time of day the observations were undertaken
may also have had an effect on the participants’ behavior and the
impact or otherwise of either interventions. There is evidence that
wandering and restlessness are more frequent and or severe in the
evening.36 With this in mind we did endeavor to be consistent in
timing the observations between set periods of the day. The limited
data set also made the analysis difficult to interpret objectively.
465
Our finding that Snoezelen had no benefits over the ‘common
best practice’ interventions may be related to the manner in which
the Snoezelen was delivered in the participating facility. As the
diversional therapist worked set hours, Snoezelen was confined to
weekdays during the day and the Snoezelen room was locked after
hours. Although the diversional therapist had endeavored to
involve care staff in the Snoezelen program prior to the study so
that more residents might participate in the activity, this had only
had limited success. As has been reported by others,2 involving care
staff in Snoezelen programs is extremely difficult due to the
perception that Snoezelen is not a care priority, or ‘real work’ and
this view was reflected in this facility.
A further consideration was that there were no consistent
‘common best practice’ interventions used with the non-Snoezelen
group and even within the Snoezelen group as the type of activity/
therapy varied for each participant. Although the adoption of
different approaches reflects person-centered care in that in-
terventions are tailored to meet the unique needs of the individual
at that time; this makes comparison and interpretation more
difficult. To overcome this, several observations were made of
participants that may have received up to three different ‘common
best practice’ interventions at different points in time.
Conclusion
This study adds further evidence to what is known about the use
of Snoezelen in the management of dementia related behaviors in
the Australian setting. Although there were no obvious ill-effects
observed as a result of the use of Snoezelen in this study, the
absence of any significant observable benefit over and ‘above
common best practice’ for the dementia related behaviors of
wandering and restlessness nevertheless raises questions about the
therapeutic and economic value of this intervention.
Acknowledgment
We would like to acknowledge the participating residential aged
care facilities and residents.
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