S YS T E M AT I C R E V I E W P R O T O C O L

Effectiveness of multisensory stimulation in managing

neuropsychiatric symptoms in older adults with major
neurocognitive disorder: a systematic review protocol
Rosa Silva 1  Daniela Cardoso 2  Joao Apostolo 2
1
Centre for Interdisciplinary Research in Health: Catholic University of Portugal, The Portugal Centre for Evidence Based Practice: a Collaborating
Centre of the Joanna Briggs Institute, 2Health Sciences Research Unit: Nursing, Nursing School of Coimbra, The Portugal Centre for Evidence Based
Practice: a Collaborating Centre of the Joanna Briggs Institute

Review question/objective: This review aims to identify and synthesize the effectiveness of multisensory
stimulation in managing neuropsychiatric symptoms in older adults with major neurocognitive disorder.
More specifically, this review focuses on the following questions: what are the effects of multisensory stimulation in
managing neuropsychiatric symptoms such as delusion, hallucination, agitation, aggression, mood liability, anxiety,
apathy, motor disturbances, night-time behavior and eating disorders in elderly patients with major neurocognitive
disorder?
Keywords Neurocognitive disorder; multisensory stimulation; neuropsychiatric symptoms; older adults

Background earlier.1,2 Therefore, it is characterized by a

ajor neurocognitive disorder (major NCD),
M which corresponds to the condition referred
to as dementia1,2 in the recently published fifth edition
of the American Psychiatric Associations Diagnostic
and Statistical Manual of Mental Disorders (DSM-5),
is a clinical syndrome caused by neurodegeneration
with the following etiological subtypes: Alzheimers
disease, frontotemporal lobar degeneration, Lewy
body disease and vascular disease, among others.1
Prevalence of major NCD increases exponentially
with age.2,3 In 2010, there were an estimated 35.6
million people with dementia worldwide. By 2030,
it is estimated that there will be 65.7 million people
with major NCD.3 At the moment, major NCD
is considered a pandemic in developed countries.3
Major NCD affects more often older adults and
the DSM-5 describes six cognitive domains that may
be affected: complex attention, executive function,
learning and memory, language, perceptual-motor
function and social cognition.1
Major NCD requires evidence of significant cog-
nitive decline from a previous level of performance
in one or more of the cognitive domains outlined
Correspondence: Joao Apostolo, apostolo@esenfc.pt
There is no conflict of interest in this project.
DOI: 10.11124/JBISRIR-2016-2638
progressive deterioration in cognitive ability and
capacity for independent living.1,3 The neuropsychi-
atric symptoms (NPS) affect patients with major
NCD almost across all stages and etiologies.4 Most
patients have one or more concomitant symptoms,
such as agitation or aggressive behavior, depression,
apathy, psychosis, hallucinations and disinhibi-
tion.4 These NPS are associated with poor
outcomes, decreased quality of life and increased
caregiver burden.4,5
In patients with major NCD, the pharmacological
treatment of the NPS focuses on the use of sedatives,
neuroleptics or antidepressants, but the result is
unsatisfactory in many patients and side-effects
are common.5,6 So, in the past decades, evidence
has shown that pharmacological treatments have
been ineffective in controlling all symptoms.69 As
a result, nonpharmacological interventions have
attracted more investigation.4,6,7,9 Encouraging the
use of nonpharmacological therapies is related to
pharmacological safety concerns, especially in
advanced stages of major NCD.4,7,10
As an example, the multisensory stimulation
(MSS) environment known as Snoezelen was
developed in the 1970s in the Netherlands.9 11
It was initially developed as a therapy for young
people with learning difficulties,12 but since the
beginning of the 1990s, it was introduced in the

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SYSTEMATIC REVIEW PROTOCOL
care of people with dementia.9,10 This technique is
applied in a darkened and comfortable room,
where all senses are stimulated using aromather-
apy, water columns of different colors, fiber-optic
cables and tactile objects, among others.9,10 This
room is known as MSS room or Snoezelen
room. There is also the sensory garden, where
patients can experience different forms of sensory
stimulation such as sunshine, warmth, fresh air
and birdsong.13 The idea is to use resources
found in nature to stimulate senses such as sight,
hearing, smell and touch.14 At the moment, Snoe-
zelen is a registered trademark.9,15 Therefore, we
will use the term MSS not just for this reason,
but also because this concept is much more
comprehensive.12,15 17
Multisensory stimulation has been applied as a
nonpharmacological therapy in older adults with
major NCD (or dementias).16 It is based on a non-
directive approach that does not focus on cognitive
stimulation, but encourages older people to engage
with sensory stimuli of their choice.9,10,15 Its use is
based on the biopsychosocial model, as NPS are
influenced not only by the disease itself, but also
by the physical and psychosocial environment sur-
rounding the elderly.9
Older adults with major NCD, especially those
who are in nursing homes or housebound, suffer
from environmental understimulation. However,
sensory stimulation can often be as excessive as
in a hospital ward.9,10,12,17 Balancing the pace of
sensory-stimulation or sensory-calming activities is
necessary for all people, but particularly elderly
people.912 Multisensory stimulation aims to
stimulate the primary senses to achieve a balance
between sensory-stimulating and sensory-calming
activities.9,11,18 Therefore, the professional works
one-on-one with patients to stimulate different
senses, such as visual, auditory, proprioceptive
and olfactory, through a variety of sensory activities,
such as different types of food, clothes, tactile
objects, light and music.11,15
Furthermore, MSS is one of the interventions
that can be applied at any stage of major NCD
(dementia), including the severe or very severe
stage.9,10,19 For that reason, it can be targeted at
patients with memory impairment, personality
change, and limited social and verbal communi-
cation skills.9,10 Multisensory stimulation provides
an atmosphere of trust and relaxation without
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R. Silva et al.
the need for intellectual activity of one-on-one
attention.9,10,12 The ultimate goal of MSS is to
improve the patients well being and quality of
life, which are assessed through changes in the
following behaviors or mood status, among others:
apathetic, aggressive, adaptive and agitated behav-
iors, and depression, happiness, enjoyment and
sadness.20,21
The use of MSS in the field of dementia has seen
rapid development,6,15,16 although the effectiveness
of this intervention still seems to be limited.9,16,22
The results of some studies in this area have indi-
cated that MSS can have a positive short- and long-
term impact on the NPS of older adults with major
NCD.7,9,10,17 19 Hence MSS is effective in reducing
some NPS such as apathy or agitation, attention/
concentration, mood status, communication and
cognitive status.7,9,17 19,21
A preliminary search of the JBI Database of
Systematic Reviews and Implementation Reports,
the Cochrane Database of Systematic Reviews,
Prospero, CINAHL and MEDLINE has revealed
that there are some systematic reviews on non-
pharmacological interventions that make reference
to the effectiveness of MSS in their results. How-
ever, in these systematic reviews, the effects of MSS
in all stages23 or in all etiologic subtypes24 of
dementias (major NCD) have not been fully
explored. These reviews have only examined the
effectiveness of nonpharmacological interventions
on specific outcomes, such as apathy and agita-
tion.14,25,26 There are currently no systematic
reviews (neither published nor in progress) on
the use of MSS in older adults with dementia
(major NCD). It is necessary to examine the effec-
tiveness of MSS in people with major NCD in
managing NPS, which involves an intense evi-
dence-based critical analysis. Therefore, the main
objective of this study is to identify the effects of
MSS, in the short and long term, on NPS such as
behavior, mood, cognitive status and functional
status in activities of daily living (ADLs) in older
adults with major NCD (or dementia).
Inclusion criteria
Types of participants
This review will consider studies that include older
adults (female and male) aged 65 years in any type
of setting, with diagnosis of major NCD (or demen-
tia), meeting the criteria of the DSM 4th edition
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(DSM-IV) or 5th edition (DSM-5), or the Inter-
national Classification of Diseases-10.
Studies that do not specify methods of clinical
diagnosis or that include adults (<65 years old) in
their samples will be excluded.
Types of intervention(s)
This review will consider studies that assess the
effects of MSS in the short term (assessment during
and after each session) and long term (any follow-
up) on the NPS in older adults with major NCD
(dementia). This type of stimulation must include
two or more therapies, that is, music therapy, aro-
matherapy, light therapy, therapeutic or massage
touch, stimulation of taste or another sensory inter-
vention, and different settings, that is, the Snoezelen
room and MSS room, sensory gardens or any other
setting.
We will include any structured program of MSS
provided or supervised by any health professional
and of any duration per session. We will exclude
studies that only report results from single-session
interventions.
This review will consider studies that assess the
effectiveness of MSS versus usual care or another
intervention. Usual care will be defined as no
intervention/stimulation (e.g. no occupational
therapy, no cognitive training and no art therapy,
but with possible control of activities such as looking
at photographs or doing quizzes). Another interven-
tion will be defined as an intervention/stimulation
(e.g. occupational therapy, cognitive training and
art therapy).
Outcomes
Primary outcomes
Primary outcomes will be neuropsychiatric symp-
toms such as delusion, hallucination, agitation,
aggression, mood liability, anxiety, apathy, motor
disturbances, night-time behavior and eating
disorders, measured by any validated scale or
measurement or index, such as Cohen-Mansfield
Agitation Inventory, Neuropsychiatric Inventory,
Geriatric Depression Scale, and Cornell Scale for
Depression in Dementia.
Secondary outcomes
Secondary outcomes will be quality of life, ADLs
(basic ADLs and instrumental ADLs), caregiver
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R. Silva et al.
burden and functional capacity assessed by any
validated scale or measurement or index.
Types of studies
The quantitative component of this review will
consider experimental study designs, including
randomized controlled trials, non-randomized
controlled trials, quasi-experimental and before and
after studies.
In the absence of research studies, other text such
as opinion articles and reports will be considered
in this review.
Search strategy
The search strategy aims to find both published and
unpublished studies. A three-step search strategy will
be utilized in this review. An initial limited search
of MEDLINE via PubMed and CINAHL will be
undertaken followed by analysis of the text words
contained in the title and abstract, and the index
terms used to describe the article. A second search
using all identified keywords and index terms will
then be undertaken across all included databases.
Third, the reference list of all identified reports and
articles will be searched for additional studies.
Studies published in English, Spanish and Portuguese
will be considered for inclusion in this review.
Since MSS was introduced as an intervention for
people with dementia in the beginning of the 1990s,
studies published after 1990 will be included in this
review.
The databases to be searched include MEDLINE
via PubMed; CINAHL via EBSCOHost; Scopus;
Cochrane Central Register of Controlled Trials
and Scielo.
The search for unpublished studies will include
RCAAP Repositorio Cientfico de Acesso Aberto
de Portugal; ProQuest Theses and Dissertations;
OpenGrey; Banco de teses da CAPES (www.capes.-
gov.br) and Dissertation Abstracts Online (e-Thos).
Initial keywords to be used will be elder,
old, snoezelen, sensory stimulation, multi-
sensory stimulation, multi-sensory stimulation,
sensory gardens, emotion-oriented, multisen-
sory environmental therapy, music therapy,
aromatherapy, touch, phototherapy,
light, taste, gustatory, behavior, neuro-
psychiatric symptoms, behavioral and psychologi-
cal symptoms of dementia, disturb, aggressi",
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axiet", mood, depression, agitat, studies are included in the meta-analysis, it will
dementia and major Neurocognitive Disorder.
Assessment of methodological quality
Quantitative articles selected for retrieval will be
assessed by two independent reviewers for methodo-
logical validity prior to inclusion in the review using
standardized critical appraisal instruments from the
JBI Meta-Analysis of Statistics Assessment and Review
Instrument (JBI-MAStARI) (Appendix I). Any dis-
agreements that arise between the reviewers will be
resolved through discussion or with a third reviewer.
In the absence of research studies, textual articles
selected for retrieval will be assessed by two inde-
pendent reviewers for authenticity prior to inclusion
in the review using standardized critical appraisal
instruments from the JBI Narrative, Opinion
and Text Assessment and Review Instrument
(JBI-NOTARI) (Appendix I). Any disagreements
that arise between the reviewers will be resolved
through discussion or with a third reviewer.
Data extraction
Quantitative data will be extracted from articles
included in the review using the standardized data
extraction tool from JBI-MAStARI (Appendix II). The
extracted data will include specific details about the
interventions, populations, study methods and out-
comes of significance to the review question and
specific objectives. The authors of the primary studies
will be contacted to provide missing or additional
data. Any disagreements that arise between the
reviewers will be resolved through discussion or with
a third reviewer.
In the absence of research studies, textual data
will be extracted from articles included in the review
using the standardized data extraction tool from JBI-
NOTARI (Appendix II). The extracted data will
include specific details about the interventions,
populations, study methods and outcomes of signifi-
cance to the review question and specific objectives.
Data synthesis
Quantitative articles, wherever possible, will be
pooled in statistical meta-analysis using JBI System
for the Unified Management, Assessment and Review
of Information (JBI_SUMARI). The meta-analysis
will be performed using the random-effects model
to allow generalization. However, if less than five
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R. Silva et al.
be performed using the fixed-effects model.27
All results will be subject to double data entry.
Effect sizes expressed as odds ratio (for categorical
data) and weighted mean differences (for continuous
data) and their 95% confidence intervals will be
calculated.
The I2 statistic can be used to quantify the amount
of dispersion and I2 values of 25%, 50%, and 75%
are interpreted as representing small, moderate and
high levels of heterogeneity. Heterogeneity and
inconsistency will be explored using subgroup
analyses based on the different quantitative study
designs, short- or long-term interventions and differ-
ences in intervention programs of MSS included in
this review. Where statistical pooling is not possible,
the findings will be presented in narrative form
including tables and figures to aid in data presen-
tation wherever appropriate.
In the absence of research studies, textual articles,
wherever possible, will be pooled using JBI-
NOTARI. This will involve the aggregation or syn-
thesis of conclusions to generate a set of statements
that represent that aggregation, through assembling
and categorizing these conclusions on the basis of
similarity in meaning. These categories will then be
subjected to a meta-synthesis to produce a single
comprehensive set of synthesized findings that could
be used as a basis for evidence-based practice. Where
textual pooling will not be possible, the conclusions
will be presented in narrative form.
Acknowledgements
The authors would like to acknowledge the support
provided by the Health Sciences Research Unit:
Nursing (UICISA: E), hosted by the Nursing School
of Coimbra (ESEnfC).
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Appendix I: Appraisal instruments

MAStARI appraisal instrument

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NOTARI appraisal instrument

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Appendix II: Data extraction instruments

MAStARI data extraction instrument

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SYSTEMATIC REVIEW PROTOCOL R. Silva et al.

NOTARI data extraction instrument

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