Soundscape Awareness Intervention Reduced Neuropsychiatric Symptoms in Nursing Home Residents With Dementia: A Cluster-Randomized Trial With MoSART.

OBJECTIVES: Auditory environments as perceived by an individual, also called soundscapes, are often suboptimal for nursing home residents. Poor soundscapes have been associated with neuropsychiatric symptoms (NPS). We evaluated the effect of the Mobile Soundscape Appraisal and Recording Technology sound awareness intervention (MoSART+) on NPS in nursing home residents with dementia. DESIGN: A 15-month, stepped-wedge, cluster-randomized trial. Every 3 months, a nursing home switched from care as usual to the use of the intervention. INTERVENTION: The 3-month MoSART+ intervention involved ambassador training, staff performing sound measurements with the MoSART application, meetings, and implementation of microinterventions. The goal was to raise awareness about soundscapes and their influence on residents. SETTING AND PARTICIPANTS: We included 110 residents with dementia in 5 Dutch nursing homes. Exclusion criteria were palliative sedation and deafness. METHODS: The primary outcome was NPS severity measured with the Neuropsychiatric Inventory-Nursing Home version (NPI-NH) by the resident's primary nurse. Secondary outcomes were quality of life (QUALIDEM), psychotropic drug use (ATC), staff workload (workload questionnaire), and staff job satisfaction (Maastricht Questionnaire of Job Satisfaction). RESULTS: The mean age of the residents (n = 97) at enrollment was 86.5 ± 6.7 years, and 76 were female (76.8%). The mean NPI-NH score was 17.5 ± 17.3. One nursing home did not implement the intervention because of staff shortages. Intention-to-treat analysis showed a clinically relevant reduction in NPS between the study groups (-8.0, 95% CI -11.7, -2.6). There was no clear effect on quality of life [odds ratio (OR) 2.8, 95% CI -0.7, 6.3], psychotropic drug use (1.2, 95% CI 0.9, 1.7), staff workload (-0.3, 95% CI -0.3, 0.8), or staff job satisfaction (-0.2, 95% CI -1.2, 0.7). CONCLUSIONS AND IMPLICATIONS: MoSART+ empowered staff to adapt the local soundscape, and the intervention effectively reduced staff-reported levels of NPS in nursing home residents with dementia. Nursing homes should consider implementing interventions to improve the soundscape.

Soundscape Optimization in Nursing Homes Through Raising Awareness in Nursing Staff With MoSART.

Introduction: Soundscapes in nursing homes are often suboptimal for residents. This can cause them feeling anxious and unsafe, or develop behavioral and psychological problems. Residents with dementia cannot adapt nursing home environments to their needs due to cognitive and physical limitations. It is up to the staff of psycho-geriatric wards to improve the soundscape. We evaluated the effect of the sound awareness intervention Mobile Soundscape Appraisal and Recording Technology (MoSART+) on soundscapes in nursing homes. Methods: The MoSART+ intervention was carried out in four nursing homes and took three months in each home. The MoSART+ intervention involved training ambassadors, assessing the soundscape with the MoSART application by the nursing staff to raise their sound awareness on random time points, discussing the measurements, and implementing micro-interventions. Soundscapes were assessed from 0 to 100 on four attributes: pleasantness, eventfulness, complexity, and range of affordances. Based on these scores, soundscapes were classified in four dimensions: calm, lively, boring, and chaotic. Nursing staff graded the environment on a scale of 0 to 10. T-test and Z-tests were used to analyze data. Results: Staff recorded 1882 measurements with the MoSART app. "People," "music, TV, and radio," and "machines and appliances" were the most prevalent sound sources before and after the implementation of micro-interventions. Post-implementation of micro-interventions, soundscapes were pleasant (median 69.0; IQR 54.0-81.0), of low complexity (33.0; 18.0-47.0), uneventful (27.0; 14.0-46.5), and gave moderate affordances (50.0; 35.0-67.0). Changes in attributes were statistically significant (p < 0.01). The proportion of the dimension calm increased (z = 12.7, p < 0.01), the proportion of chaotic decreased (z = 15.0, p < 0.01), and the proportion of lively decreased not statically significant (z = 0.68, p = 0.79). The proportion of boring was unchanged. The proportion of grades ≥6 increased after implementation of the micro-interventions (z = 15.3, p < 0.01). The micro-interventions focused on removing or reducing disturbing sounds and were unique for each nursing home. Discussion: The MoSART+ intervention resulted in a statistically significantly improvement of soundscapes, and more favorable evaluations of the nursing staff. The intervention empowered staff to adapt soundscapes. Nursing homes can improve soundscapes by raising sound awareness among staff. Trial Registration: Netherlands National Trial Register (NL6831).

Sounds in nursing homes and their effect on health in dementia: a systematic review.

OBJECTIVES: Nursing home residents with dementia are sensitive to detrimental auditory environments. This paper presents the first literature review of empirical research investigating (1) the (perceived) intensity and sources of sounds in nursing homes, and (2) the influence of sounds on health of residents with dementia and staff. DESIGN: A systematic review was conducted in PubMed, Web of Science and Scopus. Study quality was assessed with the Mixed Methods Appraisal Tool. We used a narrative approach to present the results. RESULTS: We included 35 studies. Nine studies investigated sound intensity and reported high noise intensity with an average of 55-68 dB(A) (during daytime). In four studies about sound sources, human voices and electronic devices were the most dominant sources. Five cross-sectional studies focused on music interventions and reported positives effects on agitated behaviors. Four randomized controlled trials tested noise reduction as part of an intervention. In two studies, high-intensity sounds were associated with decreased nighttime sleep and increased agitation. The third study found an association between music and less agitation compared to other stimuli. The fourth study did not find an effect of noise on agitation. Two studies reported that a noisy environment had negative effects on staff. CONCLUSIONS: The need for appropriate auditory environments that are responsive to residents' cognitive abilities and functioning is not yet recognized widely. Future research needs to place greater emphasis on intervention-based and longitudinal study design.

Validation of a modified ambiance scale in nursing homes.

OBJECTIVES: We translated and modified an ambiance scale for use by (in)formal caregivers in Dutch nursing homes. We tested validity and reliability of the modified Ambiance Scale. METHOD: Convenience sampling was used to enrol (in)formal caregivers in three nursing homes in the Netherlands. 104 questionnaires were filled in; 45 by informal caregivers, 46 by formal caregivers. Ten caregivers filled in the questionnaire twice for test-retest purposes. Three original items were used, and seven newly were added to form the modified Ambiance Scale. Each item consisted of an adjective pair assessing an aspect of ambiance on a scale of 1 (homelike) to 5 (institutional). Caregivers filled in the questionnaire on two different days to assess intra rater reliability. Differences in scoring between formal and informal caregivers and between original and new items were analyzed. RESULTS: The questionnaire was easy to comprehend and fill in. Internal consistency was good (a = 0.93). Validity was found to be good. Factor analysis demonstrated that eight items identified as one factor. No differences in scoring between the first and second assessment were found (p<.001). Formal caregivers scored ambiance more chaotic than informal caregivers did (p<.01). No differences in scoring between original and new items were found (p =.06). CONCLUSION: This study demonstrated that the modified Ambiance Scale had good internal consistency, moderate replicability and both informal and formal caregivers' overall ratings were comparable. The modified Ambiance Scale is a valid, reliable and easy to use tool to assess ambiance in nursing home settings.

The Evolution of Soundscape Appraisal Through Enactive Cognition.

We propose a framework based on evolutionary principles and the theory of enactive cognition ("being by doing"), that addresses the foundation of key results and central questions of soundscape research. We hypothesize that the two main descriptors (measures of how people perceive the acoustic environment) of soundscape appraisal ('pleasantness' and 'eventfulness'), reflect evolutionarily old motivational and affective systems that promote survival through preferences for certain environments and avoidance of others. Survival is aimed at ending or avoiding existential threats and protecting viability in a deficient environment. On the other hand, flourishing occurs whenever survival is not an immediate concern and aims to improve the agent's viability and by co-creating ever better conditions for existence. As such, survival is experienced as unpleasant, and deals with immediate problems to be ended or avoided, while flourishing is enjoyable, and therefore to be aimed for and maintained. Therefore, the simplest, safety-relevant meaning attributable to soundscapes (audible safety) should be key to understanding soundscape appraisal. To strengthen this, we show that the auditory nervous system is intimately connected to the parts of our brains associated with arousal and emotions. Furthermore, our theory demonstrates that 'complexity' and 'affordance content' of the perceived environment are important underlying soundscape indicators (measures used to predict the value of a soundscape descriptor). Consideration of these indicators allows the same soundscape to be viewed from a second perspective; one driven more by meaning attribution characteristics than merely emotional appraisal. The synthesis of both perspectives of the same person-environment interaction thus consolidates the affective, informational, and even the activity related perspectives on soundscape appraisal. Furthermore, we hypothesize that our current habitats are not well matched to our, evolutionarily old, auditory warning systems, and that we consequently have difficulty establishing audible safety. This leads to more negative and aroused moods and emotions, with stress-related symptoms as a result.

Learning autonomy in two or three steps: linking open-ended development, authority, and agency to motivation.

In this paper we connect open-ended development, authority, agency, and motivation through (1) an analysis of the demands of existing in a complex world and (2) environmental appraisal in terms of affordance content and the complexity to select appropriate behavior. We do this by identifying a coherent core from a wide range of contributing fields. Open-ended development is a structured three-step process in which the agent first learns to master the body and then aims to make the mind into a reliable tool. Preconditioned on success in step two, step three aims to effectively co-create an optimal living environment. We argue that these steps correspond to right-left-right hemispheric dominance, where the left hemisphere specializes in control and the right hemisphere in exploration. Control (e.g., problem solving) requires a closed and stable world that must be maintained by external authorities or, in step three, by the right hemisphere acting as internal authority. The three-step progression therefore corresponds to increasing autonomy and agency. Depending on how we appraise the environment, we formulate four qualitatively different motivational states: submission, control, exploration, and consolidation. Each of these four motivational states has associated reward signals of which the last three-successful control, discovery of novelty, and establishing new relations-form an open-ended development loop that, the more it is executed, helps the agent to become progressively more agentic and more able to co-create a pleasant-to-live-in world. We conclude that for autonomy to arise, the agent must exist in a (broad) transition region between order and disorder in which both danger and opportunity (and with that open-ended development and motivation) are defined. We conclude that a research agenda for artificial cognitive system research should include open-ended development through intrinsic motivations and ascribing more prominence to right hemispheric strengths.