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A Comparison of

on Inpatient Psychiatry and Geriatric Neuropsychiatry Units


ABStRACt Sensory rooms and the use of multisensory interventions are becoming popular in inpatient psychiatry. The empirical data supporting their use are limited, and there is only anecdotal evidence indicating effectiveness in psychiatric populations. The specific aims of this observational pilot study were to determine whether multisensory-based therapies were effective in managing psychiatric symptoms and to evaluate how these interventions compared to traditional ones used in the milieu. The study found that multisensory interventions were as effective as traditional ones in managing symptoms, and participants Brief Psychiatric Rating Scale scores significantly improved following both kinds of intervention. Medication administration did not affect symptom reduction. This article explores how multisensory interventions offer choice in symptom management. Education regarding multisensory strategies should become integral to inpatient and outpatient group programs, in that additional symptom management strategies can only be an asset.

Margaret Knight, PhD, RN, PMHCNS-BC; Lesley Adkison, MSN, RN; and Joan Stack Kovach, RNPC, MS
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atients experiencing distress in psychiatric settings typically have few options for symptom management. Usual interventions include staff contact, medication, decreased stimulation, and room schedules aimed at limiting space and time in the milieu. Sensory interventions, including sensory rooms, have become more visible in psychiatric settings as an additional tool for individuals to manage symptoms; however, there is only anecdotal evidence indicating their effectiveness in psychiatric populations (Champagne & Stromberg, 2004; Costa, Morra, Solomon, Sabino, & Call, 2006). This pilot study sought to determine whether sensory interventions would be successful in reducing acute psychiatric symptoms in general psychiatry inpatient and geriatric neuropsychiatry populations.

BACKgRouND Individuals with mental health problems want to be involved in their treatment decisions. Individual choice is central to sensory interventions, in which individuals can choose from a variety of sensory experiences. Such interventions place less demand on patients intellectual abilities and capitalize on sensorimotor ones (Chung & Lai, 2002). Sensory interventions stimulate sight, smell, hearing, touch, and taste, and they can initiate the symptom reduction process through alternative neural pathways. Sensory interventions are adjunctive and sometimes alternative interventions for individuals who are overcome with unmanageable emotions. They promote choice in symptom management and empower individuals to choose coping strategies that areor can becomeimportant activities in illness management. For exam-

ple, an individual overwhelmed with traumatic memories may be grounded by squeezing a frozen orange, or an individual hearing disturbing voices may calm down with the sound of thunder and rain. LiteRAtuRe Review Sensory stimulation refers to a variety of techniques that arouse the senses. These are provided most effectively in the context of engaging in meaningful activity (Bundy & Murray, 2002). Occupational therapists have used sensory stimulation with children and adults experiencing mental health problems (Anzalone & Murray, 2002; Champagne & Stromberg, 2004). These activities are referred to as sensory-based treatments and take place in what are termed multisensory environments. Multisensory environments include stimuli for all of the senses, including bright lights, textures, and motion 25

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2009 iStockphoto/Aliaksandr Stsiazhyn

tABLe 1 StuDy iNteRveNtioNS Traditional Group


Alone time or quiet time Increased supervision One-on-one staff time Pacing Space restrictions Removal from stimulation Room schedules

Sensory Groupa
Aromas Candy (i.e., sweet and sour tastes)b Colored eyeglasses Kaleidoscopes Lava lamps Music recordings Rocking or gliding chairs Scented candles Sound recordings (e.g., waves, beach, rain, drums) Tactile stimulation (e.g., squeeze balls, sand table, tactile surfaces) Wall images Weighted blankets

a b

These interventions could occur in a sensory room or other area. Used on the general psychiatry unit only.

activities. Sensory rooms are modeled on Snoezelen.


Snoezelen

Snoezelen was coined to describe the outcome of a pleasant sensory experience (Ball & Haight, 2005) and the feeling of relaxation. Sensory rooms developed for Snoezelen consider the physical environment and the participation of the care provider; the therapeutic relationship becomes an important part of the experience. The environment promotes stimulation of all of the senses through multiple activities and experiences. Individuals choose aromas, sounds, colors, tactile experiences, and tastes. Snoezelen is relaxation. Multisensory stimulation, including Snoezelen, has gained some acceptance as a care option for older adults with cognitive problems. Despite the increasing popularity of the approach, relatively few studies have analyzed the effect of Snoezelen or multisensory stimulation. Research trials using a multisensory approach vary widely. 26

Baker et al. (2003) and Baillon et al. (2004) found no evidence that multisensory stimulation was more effective than traditional interventions when used in a dementia population, while Kragt (as cited in Chung & Lai, 2002) and van Weert, van Dulmen, Spreeuwenberg, Ribbe, and Bensing (2005) found that mood and well-being improved.
Sensory interventions and Psychiatry

The use of multisensory therapies in adult psychiatry is new and understudied. Sensory environments are demand-free environments where patients can explore different modalities without expectations of accomplishment or understanding. Neither cognition nor memory is required; for patients experiencing confusion, depression, or anxiety, this in itself may be soothing. In this safe and failure-free space, individuals choose what to use or explore, thus diminishing the helplessness that often accompanies illness, disability, and hospitalization.

Although these sensory-based therapies are aimed at the patient, some authors reported improvement in both patient and staff morale (Baillon, van Diepen, & Prettyman, 2002). The use of essential oils is a sensory-based therapy that has a history in the literature, primarily in the form of aromatherapy. Inhaled essential oils have been reported to be effective in enhancing relaxation (Buckle, 2003), increasing alertness, and decreasing anxiety (Lehrner, Eckersberger, Walla, Ptsch, & Deecke, 2000). Music has also received significant attention in the nursing literature. Music has been demonstrated to decrease anxiety in individuals with dementia (Hicks-Moore, 2005; Sung & Chang, 2005). In addition, music has been reported to decrease depression and disability (Siedliecki & Good, 2006) and improve sleep (Lai & Good, 2006). The use of sensory rooms pioneered by Champagne (2003) broadened the notion of sensorybased therapies in the adult psychiatry population. Champagne and Sayer (n.d.) and Champagne and Stromberg (2004) noted that sensory room sessions had a selfreported positive effect on the majority of individuals who used them; the greater the distress as reported by the patient, the greater the self-reported effectiveness. Further, these authors reported that the rate of seclusion and restraint on their treatment unit decreased by 54% during the year of implementation (Champagne & Stromberg, 2004). StuDy PuRPoSe This pilot study sought to determine whether sensory interventions would be successful in reducing psychiatric symptoms in general psychiatry inpatient and geriatric neuropsychiatry populaJPNoNliNe.com

tions. Such approaches to symptom management in these populations remain in the early stages of implementation and without measurable indications of effectiveness; therefore, as-needed medication administration was considered in the study design. Specific research questions were: l Do sensory interventions reduce acute psychiatric symptoms as measured by the Brief Psychiatric Rating Scale (BPRS) (Overall & Gorham, 1988) in individuals hospitalized on a general psychiatry unit and geriatric neuropsychiatry unit? l Are sensory interventions more effective than traditional interventions in reducing acute psychiatric symptoms as measured by the BPRS in these populations? l Does as-needed medication administration enhance psychiatric symptom response to nursing interventions as measured by the BPRS? l If sensory interventions are effective in reducing symptoms, which acute symptoms respond to sensory interventions? MetHoD McLean Hospital in Massachusetts was in the process of introducing sensory rooms and sensory-based tools in adult and geriatric milieus. We designed the current pilot study to prospectively evaluate the effectiveness of these proposed sensorybased interventions. This study used a nonexperimental, two-group design that compared traditional nursing interventions and psychiatric symptom response with sensory interventions and psychiatric symptom response. Table 1 lists the interventions that could be used in each group. Symptom response was measured using the BPRS, which is described below. Individual response to traditional interventions was collected first,

prior to the introduction of any sensory rooms or sensory tools. Once sensory rooms were developed and sensory tools were purchased, individual responses to sensory interventions were collected. Data from each group were collected at different points in time, and each group was composed of different individuals.
Protection of Participants

An Institutional Review Board (IRB) application was submitted and approval was obtained. The IRB waived written informed consent because the research involves no procedure for which written consent is normally required outside of the research context (U.S. Department of Health and Human Services, 2005, 46.117). This study involved the collection and documentation of psychiatric symptom data from the BPRS at two points in time: prior to and following a nursing intervention. Individuals gave verbal consent prior to being rated by nurses using the BPRS. No data linked an individual to the pilot study. Individuals who agreed to participate were assigned a study number, and data collection included demographic data and two BPRS ratings. Individual names never appeared on any study document. The names of those who participated were documented separately to assure that each individual participated for only one rating set (pre- and postintervention). This document was destroyed at the completion of the study.
Measures

the 18 items are easily evaluated in the context of nurses assessing psychiatric patients. The BPRS contains items such as anxiety, tension, hostility, uncooperativeness, and conceptual disorganization. Good reliability of the BPRS has been achieved. Effort and practice at administering the BPRS improves overall reliability (American Psychiatric Association [APA], 2000). Reliability coefficients ranging from 0.52 to 0.90 were reported by the APA (2000) for individual items and 0.72 to 0.91 for overall scores. The reported validity of the BPRS is high when compared with similar measures. Concurrent validity with other measures has been demonstrated (APA, 2000). In our experience, many of the items on the BPRS can be improved with nursing interventions; therefore, pre- and postintervention scores could be compared. To evaluate overall change as a result of any intervention (traditional or sensory), the sum of ratings on the 18 items was calculated before and after an intervention.
Sample and Setting

The BPRS was used for this study. This measure was chosen because each of the scales 18 items represents a sign or symptom of acute psychiatric disturbance. The BPRS is rated on a 7-point scale from not present to extremely severe. The majority of

The pilot study took place at McLean Hospital in Belmont, Massachusetts. Two treatment areas participated; one general psychiatry unit and one geriatric neuropsychiatry unit. Thirty-six individuals comprised the traditional intervention group (20 from the geriatric neuropsychiatry unit and 16 from the general psychiatry unit) and 24 individuals comprised the sensory intervention group (11 from the geriatric neuropsychiatry unit and 13 from the general psychiatry unit) (Table 2). Individual patients in each group were rated one time onlybefore and after an intervention. This study was designed to show psychiatric symptom 27

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tABLe 2 DeMogRAPHiCS of tHe SAMPLe Variable by Unit


Geriatric neuropsychiatry unit Participants Age, in years (mean, range) Gender Men Women General psychiatry unit Participants Age, in years (mean, range) Gender Men Women
a

Traditional Group (N = 36)


n = 20 73.8 (53 to 92) n=7 n = 13 n = 16 40.6 (24 to 61) n=8 n=8

Sensory Group (N = 24)


n = 11 78.3 (66 to 92) n=4 n=7 n = 13 32.8 (18 to 51) n=5 n=7

Gender was not specified for 1 individual in the sensory group.

change directly following a nursing intervention.


Procedures

Prior to beginning the study, RNs in both treatment units attended workshops designed to teach symptom evaluation using the BPRS. The workshops were purposefully small to allow nurses multiple opportunities for dialogue. An overview of the measure and discussion of each item was followed by video vignettes of symptomatic individuals that the nurses rated. Responses were compared and discussed until agreement was reached. Several vignettes were used until the nurses ratings were within 1 point per item. Interrater reliability was not calculated. Next, information about the pilot study was shared with all patients and posted in several locations in both treatment areas. Patients were made aware that they could inform staff they did not wish to have their symptoms recorded on the BPRS for pilot study data collection, although 28

documentation about their mental status in the medical record (i.e., nursing shift notes) was a necessary aspect of treatment. All data measuring response to traditional interventions (traditional group) were collected first, as sensory interventions were not yet available for individuals to use. Patients were selected for participation in two ways: self-identifying their need for additional assistance to manage symptoms or through nurse observation of an individuals difficulty managing symptoms and approaching that individual to offer help. Psychiatric symptoms requiring nursing interventions included anxiety, sadness, tension, suspiciousness, hostility, withdrawal, disorganization, and agitation. For example, a patient may approach a staff member complaining of increased restlessness and anxiety; this patient would be selected to participate if he or she agreed to and engaged in a traditional intervention. The nurse and patient would determine a traditional intervention to be in-

corporated into care at that time (Table 1), including as-needed medication if ordered by a physician and indicated for the level of symptom escalation. BPRS measures were recorded immediately before and 30 minutes following initiation of the intervention. Interventions lasted approximately 20 to 30 minutes. Thirty minutes was chosen as an adequate time for an individual to respond to a nursing intervention whether traditional or sensory based. The researchers were interested in an individuals direct response to an intervention. Sensory rooms and sensorybased tools were then introduced into the milieu and made available to all individuals in both treatment areas, becoming part of usual treatment for symptom relief. All staff were provided an orientation to the sensory supplies and sensory room. Patients who participated in the traditional intervention group were not invited to participate in the sensory intervention group; the researchJPNoNliNe.com

ers wanted only one set of data from each person. Participants in the sensory group were selected for participation in the same way as described for the traditional intervention group: identified by nurse or self as having difficulty managing psychiatric symptoms. Again, if the individual agreed to participate, he or she needed to select any sensory intervention to help with symptom management in order to become a participant in the sensory group. Once a sensory intervention was chosen, the individual was rated using the BPRS immediately before and 30 minutes after intervention initiation. Typically, the individual would use the chosen sensory intervention for 20 to 30 minutes. Individuals could also choose a traditional intervention, but they would not be included in the pilot study at this point. The literature suggests that each individual would naturally select sensory tools according to their preferences (Champagne, 2003). Further, it is important to note that because little is known about any sensory intervention in psychiatric settings, we allowed for selection of any sensory-based intervention. We were aware this decision had implications for the specificity of the study results and that little would be able to be determined about the effectiveness of any one intervention. Administration of as-needed medication for acute psychiatric symptoms was allowed at the initiation of either intervention. Clearly, several classes of medication are known to have a positive effect on acute psychiatric symptoms, and this is an important component of care. Benzodiazepines are readily absorbed and act quickly. Onset of action can take as little as 20 to 30 minutes, while peak effect can occur in 1 hour (Frisch & Frisch, 2002). Al-

ternatively, antipsychotic drugs can take longer, up to 1 hour or more for an initial effect (Frisch & Frisch, 2002). We were aware that medication administration could affect the outcome of any intervention and therefore identified those individuals who received as-needed medication, including the kind and dosage.
Data Analysis

SPSS version 13.0 was used to analyze the data in this study. The researchers entered data as they were collected. Descriptive data, pre- and postintervention scores of each item on the BPRS, pre- and postintervention total BPRS scores, asneeded medication, and the intervention used (traditional or sensory) were entered into the database. Descriptive statistics were used to describe the sample. Paired t tests compared preand post-BPRS scores for each group (traditional and sensory); independent t tests compared the changes in BPRS scores of the traditional group with the BPRS score changes of the sensory group. Finally, t tests comparing changes in BPRS scores of those who received as-needed medication were compared with the BPRS score changes of those who did not receive as-needed medication. ReSuLtS Most individuals in the traditional intervention group chose one-on-one staff contact as an intervention (n = 14), and 7 chose quiet time or a decrease in stimulation. Other interventions used less frequently included self-release lap belts and increased supervision. Those in the sensory intervention group most often chose music (n = 6), items that could be squeezed or manipulated (n = 6), rocking chairs (n = 4), visual activities (e.g., fish tanks, calming videos)

(n = 3), sound (e.g., chirping birds, water) (n = 2), scent (n = 1), and touching/building with wooden blocks (n = 1). There was a significant difference in pre- and post-BPRS scores for both the traditional and sensory intervention groups (p = 0.000); both kinds of interventions were effective in managing psychiatric symptoms, yet neither was more effective. Of the 18 symptoms evaluated on the BPRS, 7 demonstrated significant reduction pre- and postintervention regardless of group: anxiety, excitement, tension, uncooperativeness, hostility, conceptual disorganization, and depression. Three additional symptoms showed significant change (p = 0.000) in the sensory group: blunted affect, emotional withdrawal, and somatic concerns. As noted previously, individuals who were assessed as needing medication received it on an asneeded basis. Twenty-four of the 36 individuals in the traditional group received as-needed medication; in the sensory group, 15 received asneeded medication (total = 39). Fewer as-needed medications were administered on the geriatric neuropsychiatry unit. Given the range in kind and dosage of medication administered across all individuals, t tests were computed only to determine whether there was a difference in BPRS score change between those who received as-needed medication and those who did not. No significant difference in BPRS score changes was found when comparing the two groups. Similarly, medication administration had no significant effect on any individual item on the BPRS. DiSCuSSioN AND CLiNiCAL iMPLiCAtioNS This pilot study suggests that sensory interventions are effective methods to help individuals in inpatient psychiatric settings 29

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K e y P o i N t S
1. 2. 3. 4. Sensory interventions are effective methods to help individuals in inpatient psychiatric settings manage psychiatric symptoms. A major benefit of sensory interventions is individual choice. Using sensory interventions in practice can offer common solutions for those learning to cope with complex symptoms and illnesses. Sensory interventions can redirect attention from intellectually based activities to one of the senses.
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manage their psychiatric symptoms. Although these interventions were no more effective than traditional ones, they offered alternatives for individuals who were experiencing distressing psychiatric symptoms. A major clinical benefit of sensory interventions is the notion of choice. Individuals can determine whether sound, aroma, taste, tactile, or visual stimulation is most effective. Choice allows individuals to control and learn alternative methods of symptom management. When considered in the context of everyday living, sensory interventions seem intuitive. Many individuals retreat to sound and music after a hectic day or light a scented candle while taking a hot bath, reading, or doing routine activities at home. A rocking chair is common in many homes; it is an ageless and timeless method of soothing. Others sensory tools are novel, particularly those relying on touch, such as frozen oranges or textured fabrics. Using these interventions in practice can offer common solutions for individuals who are learning to cope with complex symptoms and illnesses. Sensory interventions can redirect attention from intellectually based activities to one of the senses. While the activity may be calming, it also may be distracting for the individual, 30

contributing further to symptom reduction. Pinkney (2002) stressed the importance of developing a therapeutic relationship through the use of multisensory environments. Facilitating the exploration and use of the environment establishes trust. In mental health nursing practice, being with the patient cannot be underestimated. Staff members were an integral part of the intervention in both treatment areas. They assisted with choice of a sensorybased intervention or were present during the intervention. In this study, there was no difference in symptom reduction between individuals on the geriatric neuropsychiatry and general psychiatry units, but both had access to staff members. On the geriatric neuropsychiatry unit, staff stayed with the patient in the sensory room during the intervention; on the general psychiatry unit, patients accessed sensory tools available on the unit. Sensory-based therapies are novel in the psychiatric setting, and thus patients may benefit from one-on-one demonstration and practice to effectively use them. This may have been a hidden benefit of the intervention process on both units. Sensory intervention groups may be an effective way to introduce these tools to the milieu.

Choices can be explored, and preferences that may be effective for an individual can be identified. Through the demonstration and practice of sensory-based interventions, the sensory group can become another vehicle for establishing trust between patient and provider. Symptom management education is already underway in most psychiatric milieus, and adding sensory tools to the education program can only be beneficial. While education groups may not be an appropriate strategy for individuals with cognitive problems, their ability to use the interventions was apparent. Individuals with cognitive impairment may already rely more on their senses, and therefore moving away from verbal and cognitive approaches may be less difficult. Finally, drug administration did not affect BPRS scores. Scores decreased significantly whether or not patients received as-needed medication. This has significant implications for practice. All of the individuals in this study were able to demonstrate symptom reduction within 30 minutes of initiating any nursing intervention. The specific onset of drug effect for the medication given in this study is not known, but knowledge of peak plasma levels would suggest that 30 minutes may not be sufficient to receive significant clinical benefit. Although psychopharmacological agents are clearly an important aspect of the ongoing and long-term treatment of serious mental health problems, empowering individuals to develop skills to calm themselves sends an important symptom management message. Further, using fewer as-needed medications supports steady state drug levels. When medication dosage changes occur too frequently, secondary effects (i.e., side effects) may further complicate the clinical picture. JPNoNliNe.com

LiMitAtioNS AND ReCoMMeNDAtioNS Limitations in this study include a small sample, one-time intervention, one measure of change per individual, and the use of asneeded drug administration if the nurse or individual determined a need. In addition, this study did not address the contribution of the patient-staff relationship. Future studies should include more individuals, multiple ratings per individual, various mental health populations, designs that exclude as-needed medication use, and designs that evaluate the length of time the intervention remained effective. CoNCLuSioN Communication, the cornerstone of psychiatric nursing, depends on cognition, intellect, and the verbal expression of feelings. When a patient is stressed, capacity for thinking and problem solving is diminished, leaving the patient less able to take advantage of cognitive-based therapies. Sensory interventions can play a role in nursing care and treatment. Much more research is needed to determine which sensory interventions are most effective and in what circumstances. There is a long road ahead to establish empirical support for sensory-based therapies. They may be perceived as out of the ordinary, even trendy. However, in this pilot study, sensory interventions helped individuals manage symptoms and were effective tools in the psychiatric nurses toolbox. RefeReNCeS
American Psychiatric Association. (2000). Handbook of psychiatric measures. Washington, DC: American Psychiatric Publishing. Anzalone, M.E., & Murray, E.A. (2002). Integrating sensory integration with other approaches to intervention. In A.C. Bundy, S.J. Lane, & E.A. Murray (Eds.), Sensory integration: Theory

and practice (2nd ed., pp. 371-391). Philadelphia: Davis. Baillon, S., van Diepen, E., & Prettyman, R. (2002). Multi-sensory therapy in psychiatric care. Advances in Psychiatric Treatment, 8, 444-450. Baillon, S., van Diepen, E., Prettyman, R., Redman, J., Rooke, N., & Campbell, R. (2004). A comparison of the effects of Snoezelen and reminiscence therapy on the agitated behaviour of patients with dementia. International Journal of Geriatric Psychiatry, 19, 1047-1052. Baker, R., Holloway, J., Holtkamp, C.C.M., Larsson, A., Hartman, L.C., Pearce, R., et al. (2003). Effects of multi-sensory stimulation for people with dementia. Journal of Advanced Nursing, 43, 465-477. Ball, J., & Haight, B.K. (2005). Creating a multisensory environment for dementia: The goals of a Snoezelen room. Journal of Gerontological Nursing, 31(10), 4-10. Buckle, J. (2003). Clinical aromatherapy: Essential oils in practice (2nd ed.). Philadelphia: Churchill Livingstone. Bundy, A.C., & Murray, E.A. (2002). Sensory integration: A Jean Ayres theory revisited. In A.C. Bundy, S.J. Lane, & E.A. Murray (Eds.), Sensory integration: Theory and practice (2nd ed., pp. 3-29). Philadelphia: Davis. Champagne, T. (2003). Creating nurturing environments for a culture of care. Advance for Occupational Therapy, 19(19). Retrieved from http:// occupational-therapy.advanceweb. com/Article/Creating-NurturingEnvironments-for-a-Culture-of-Care. aspx Champagne, T., & Sayer, E. (n.d.). The effects of the use of the sensory room in psychiatry. Retrieved from the OTInnovations.com website: http://www. ot-innovations.com/images/stories/ PDF_Files/qi_study_sensory_room. pdf Champagne, T., & Stromberg, N. (2004). Sensory approaches in inpatient psychiatric settings: Innovative alternatives to seclusion and restraint. Journal of Psychosocial Nursing and Mental Health Services, 42(9), 34-44. Chung, J.C.C., & Lai, C.K.Y. (2002). Snoezelen for dementia (Article No. CD003152). Cochrane Database of Systematic Reviews, Issue 4. Costa, D.M., Morra, J., Solomon, D., Sabino, M., & Call, K. (2006, March). Snoezelen and sensory-based treatment for adults with psychiatric disorders. OT Practice, pp. 19-23. Frisch, N.C., & Frisch, L.E. (2002). Psychiatric mental health nursing

(2nd ed.). Albany, NY: Delmar Learning. Hicks-Moore, S.L. (2005). Relaxing music at mealtime in nursing homes: Effects on agitated patients with dementia. Journal of Gerontological Nursing, 31(12), 26-32. Lai, H.L., & Good, M. (2006). Music improves sleep quality in older adults. Journal of Advanced Nursing, 53, 134144. Lehrner, J., Eckersberger, C., Walla, P., Ptsch, G., & Deecke, L. (2000). Ambient odor of orange in a dental office reduces anxiety and improves mood in female patients. Physiology and Behavior, 71(1-2), 83-86. Overall, J.E., & Gorham, D.R. (1988). The Brief Psychiatric Rating Scale (BPRS): Recent developments in ascertainment and scaling. Psychopharmacology Bulletin, 24, 97-99. Pinkney, L. (2002). Commentary. Advances in Psychiatric Treatment, 8, 451-452. Siedliecki, S.L., & Good, M. (2006). Effect of music on power, pain, depression and disability. Journal of Advanced Nursing, 54, 553-562. Sung, H., & Chang, A.M. (2005). Use of preferred music to decrease agitated behaviours in older people with dementia: A review of the literature. Journal of Clinical Nursing, 14, 1133-1140. U.S. Department of Health and Human Services. (2005). Protection of Human Subjects, 45 C.F.R. pt. 46. Retrieved from http://www.hhs. gov/ohrp/humansubjects/guidance/ 45cfr46.htm van Weert, J.C.M., van Dulmen, A.M., Spreeuwenberg, P.M.M., Ribbe, M.W., & Bensing, J.M. (2005). Behavioral and mood effects of Snoezelen integrated into 24-hour dementia care. Journal of the American Geriatrics Society, 53, 24-33. Dr. Knight is Assistant Professor, University of Massachusetts, Lowell, Lowell, Massachusetts. Dr. Knight is also Clinical Specialist, Ms. Adkison is Nurse Director, Geriatric Neuropsychiatry Unit, McLean Hospital, Belmont, and Ms. Kovach is Nurse Director, McLean Southeast, Brockton, Massachusetts. The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support. Address correspondence to Margaret Knight, PhD, RN, PMHCNS-BC, PO Box 328, West Groton, MA 01472; e-mail: Margaret_Knight@uml.edu. doi:10.3928/02793695-20091204-03

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