Sensory processing assessment in Alzheimer's disease and related dementias: Opportunities for improved care

Abstract

Background

Sensory stimulation, such as sight, hearing, and smell influence healthy neurological processing evident by the growing literature which demonstrates that sensory loss increases Alzheimer's disease and related dementias (ADRD) risk. While these associations are critical in advancing the field, less is known related to cortical-level sensory processing and ADRD as a primary mechanism in functional performance and behavioral regulation. However, it is unclear how sensory processing assessment is used in clinical practice related to intervention.

Objective

This systematic review explores the current state of evidence of sensory processing assessment before sensory-based interventions in ADRD care.

Methods

A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 update to exhaustively examine published literature (1999–2024) regarding sensory processing assessment in ADRD prior to sensory-based intervention delivery.

Results

The systematic search identified 14,928 articles, all of which were screened for inclusion. No studies specifically assessed sensory processing prior to providing sensory-based interventions in older adults with ADRD.

Conclusions

Findings of this systematic review illustrate a substantial gap in the field of ADRD care as sensory interventions are used in clinical care, yet there is insufficient evidence of sensory processing assessment to appropriately guide safe use for individuals with ADRD.

Keywords

Alzheimer's disease and related dementias assessment sensory processing

Introduction

Nearly 90% of individuals with Alzheimer's disease and related dementias (ADRD) experience behavioral and psychiatric symptoms of dementia (BPSD), such as agitation, depression, anxiety, and apathy.¹ There are limited US Food and Drug Administration (FDA) approved medications to treat BPSD,² and many pharmacological options that are used off-label have an FDA Black Box warning due to increased risk of death when used in people with ADRD.³ Non-pharmacological intervention options have a growing evidence base as means to improve BPSD.⁴ Of non-pharmacological options for BPSD, multi-sensory and/or sensory-based modalities such as music,⁵ aromas,⁶ and light therapies⁷ are promising to improve BPSD. However, current evidence in ADRD care lacks consensus as there are limited clinical effectiveness trials and of those, there are varying results delineating mixed findings (i.e., some studies illustrate effectiveness while others do not).^4,8–11 Further, it is unknown how sensory processing is assessed prior to intervention use in the ADRD population.

Sensory processing and integration theory describe cortical networks involved in neurophysiological detection, modulation, and integration of sensation from internal and external stimulation in order to adapt behavior and respond appropriately.^12,13 While numerous professional disciplines address sensory components, such as vision or vestibular rehabilitation, occupational therapy is the primary allied health discipline which systematically and holistically evaluates the culmination of sensory inputs through means of sensory processing. As such, this review centers around the work of occupational therapy in exploration of sensory processing within ADRD. As noted in the Choosing Wisely¹⁴ campaign and the Occupational Therapy Practice Framework, 4^th edition,¹⁵ the assessment of neurological functioning, sensory processing, and behavioral disturbances within the context of care are necessary for proper intervention for individuals across the lifespan.¹⁶ For example, assessment of sensory processing and integration is critical to the success of sensory-based intervention in pediatric neurodevelopmental behavioral intervention (occupational therapy [OT]), such as that seen for individuals with autism spectrum disorder.^17,18 Thorough assessment of sensory processing capacity for individuals with ADRD may be necessary to contextualize and intervene using non-pharmacological, sensory-based approaches.^11,19 The breadth of sensory processing assessments in ADRD is unknown, creating a substantial gap in the field. Available sensory processing assessments are limited, but have included the Adult Sensory Profile and²⁰ the Sensory Modulation Program.²¹

The importance of sensory processing assessment may be even more critical as emerging evidence indicates impaired sensory processing capacity in ADRD.¹¹ Implications of impaired sensory processing while living with ADRD can dramatically alter effectiveness and safety of sensory-based interventions. As such, systematic understanding of evidence-based assessments related to sensory processing in ADRD is needed. Currently, it is unclear how sensory processing assessments are utilized in clinical research within occupational therapy for this population. The purpose of this systematic review is to assess the state of evidence on sensory processing assessment in ADRD interventional research while answering the review question: What is the evidence for sensory processing and integration assessments used in occupational therapy clinical research for older adults with mild cognitive impairment or dementia?

Methods

Design

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 update,²² a systematic review was undertaken by a team, to exhaustively examine the published literature and assess the quality of the literature regarding sensory processing assessment in ADRD. In accordance with PRISMA,²² a protocol was developed and registered in Open Science Framework.²³

Eligibility criteria

Inclusion criteria: 1990–2024, English language, peer reviewed, intervention studies, systematic reviews, control trials, pre-post interventions, descriptive research, assessments within the scope of OT (do not need an additional degree or licensure), diagnosis of mild cognitive impairment or dementia, aged 55 years or older (to adequately capture early onset dementia types, such as frontotemporal lobe dementia), and inclusive of at least one MESH term related to sensation/sensory.

Exclusion criteria: before 1990 and after 2024, non-English language, dissertations, conference proceedings, study protocols, editorials, blogs, commentary papers, epidemiological burden, drug interventions (i.e., outside scope of OT), pediatrics, no sensory processing/integration assessments, participants under the age of 55 years.

Information sources and search strategy

A comprehensive search strategy was developed collaboratively between the first author and the medical librarian. The final search strategy (Supplemental Material) was developed using a MeSH analysis of 4 sentinel articles.²⁴ These sentinel articles were also used throughout development to test the reliability of the search string. The PubMed search string was translated by the medical librarian. The databases searched included PubMed, CINAHL, PsycInfo, Cochrane Library, and OT Seeker. Original searches of the databases were run on July 5, 2020. Updated searches were run on January 13, 2022. Additional hand searches were conducted in October 2023. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Searching extension (PRISMA-S), databases searched are defined in Table 1.²² In addition, the medical librarian created and maintained a table recording essential search information including the date searches were conducted, search strategies, number of search results, and any updates conducted.

Table 1.

Database coverage.

Database	Platforms	Coverage Start
CINAHL with Full Text	EBSCO	1963
PubMed	NIH	1966
PsycInfo	EBSCO	Coverage dating back to the 17^th and 18^th centuries, with extensive coverage from the 1800s to the present
Cochrane Library	Wiley	1992
OT Seeker	AOTA	2003

Participants/population

Assessment validation and intervention studies within the scope of occupational therapy addressing sensory processing and sensory-based intervention for older adults with neurodegenerative cognitive impairment (aged 55 years or over; mild cognitive impairment and all dementia types) were included.

Study selection

The resulting citations were exported to and deduplicated using EndNote. The “Groups” function was used to organize articles so that additional reviewers would be able to review their assigned articles. A minimum of two reviewers completed the title/abstract review for all the articles found. After the completion of the title/abstract review, three authors secured PDFs of selected articles which were shared with the research team. All remaining PDFs were fully reviewed for inclusion criteria by three reviewers and meetings were conducted to come to a consensus regarding final inclusion. Any inclusion discrepancies were discussed by the team until agreement was reached.

Data collection, evaluation, and synthesis

Data collection

Three reviewers of the research team independently screened titles and/or abstracts based on the inclusion criteria described above. Differences between reviewers’ results were resolved by discussion and, if necessary, consultation with an external party. Full article copies of the remaining studies were obtained. A screening tool was developed for reviewers to independently review the articles based on inclusion criteria and then discuss their decisions. As before, differences were resolved by discussion and, if necessary, consultation with a third party. Reasons for excluding studies were documented. A PRISMA flow chart was used to summarize the number of papers included/excluded at each stage of the review.

In this review, authors were unable to find any articles that fit the parameters of inclusion. When no studies are found that meet the inclusion criteria for a systematic review, it can be referred to as an empty review.²⁵ The following steps were planned but not accomplished due to lack of evidence fitting the parameters of the review.

Evaluation of risk of bias

Risk of bias for randomized and non-randomized controlled trials would be assessed using the Cochrane tool²⁶; for non-controlled trials the tool developed by the National Heart, Lung, and Blood Institute²⁷ would be used. Three authors conducted the appraisal independently. Disagreements were discussed and a third party consulted, if necessary.

Synthesis and level of certainty

A qualitative analysis of the data was planned. Data extracted from the studies were to be analyzed and summarized to answer the stated review question. Results were to be divided into thematic groups related to assessment types. The setting and patient diagnosis were to be described throughout the findings. The thematic groupings were to be analyzed in terms of strength of evidence and clinical recommendations, using the formula based on number of studies, level of evidence, quality/risk of bias and significance of the findings. The strength of evidence designation used is based on the U.S. Preventive Services Task Force²⁸ guidelines. Strengths of evidence designations are a synthesis of a number of studies, level of evidence, risk of bias, and the significance of the findings. The final assessment results in the level of certainty of the findings. Levels of evidence were to be assigned as listed in Table 2.

Table 2.

Levels of evidence.²⁹

Level of Evidence	Description
1B	Well-designed individual RCT (Not a pilot or feasibility study with a small sample size)
2A	Systematic review of cohort studies
2B	Individual prospective cohort study, low quality RCT (e.g., < 80% follow-up or low number of participants, pilot and feasibility studies), ecological studies and two group nonrandomized studies
3A	Systematic review of case-control studies
3B	Individual retrospective Case-control study, one group nonrandomized pre-posttest study, cohort studies
4	Case series (and low quality cohort and case-control study)
5	Expert opinion without explicit critical appraisal

Results

With the goal of illustrating evidence for assessment of sensory processing and integration prior to use of sensory-based in interventions in clinical research, this review screened a total of 14,928 articles (PRISMA flow chart in Figure 1). Following rigorous analysis as described above, there were no studies that met the inclusion criteria to describe sensory processing assessment prior to providing sensory-based interventions in persons with ADRD in clinical research within occupational therapy.

Figure 1.

PRISMA 2020 flow diagram for new systematic reviews which included searches of databases, registers and other sources. From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71. For more information, visit: http://www.prisma-statement.org/.

Discussion

The findings of this review identified an overwhelming void of sensory processing assessment in ADRD clinical research. The search revealed evidence implementing sensory interventions (i.e., music, touch, aromatherapy, etc.)³⁰; however, there were no studies identified which used assessment methods to determine sensory processing capacity in persons with ADRD prior to implementing an intervention. Despite an increasing use of sensory interventions in ADRD care, a gap in the field exists for evidence-based interventions that are administered with respect to sensory processing capacity, as evidenced by this empty systematic review.³¹ Systematic reviews such as this one without findings are important as they highlight important gaps and have the potential to illustrate potential harms of an intervention.³²

Recent evidence has illustrated a link between peripheral sensory impairment and ADRD risk as both vision³³ and hearing³⁴ are now included among the potentially modifiable risk factors for dementia.³⁵ Two articles were found that evaluated peripheral sensory acuity prior to taking part in an intervention. Cohen-Mansfield and others³⁶ conducted a two-arm prospective non-randomized control trial studying the effects of a non-pharmacological intervention to treat agitation in persons with dementia who resided in nursing facilities. Medical records were used to determine vision and hearing capacity for enrolled participants. Additionally, Leroi et al.³⁷ conducted a two-arm, open-label, non-controlled trial providing a home-based sensory intervention for persons with mild to moderate ADRD and hearing and/or vision impairment along with their primary caregiver. Sensory acuity assessments were conducted for hearing and vision. Assessment of sensory acuity is only a segment in the sequency of sensory input, cognitive processing, and behavioral output. Without awareness of processing capacities, it is challenging at best to investigate mechanisms at play with sensory-based intervention.

While interdisciplinary health professions (i.e., nursing,⁸ psychology) recognize behavioral implications of sensory-based interventions, the vast majority of clinical intervention related to sensation and sensory processed has derived from occupational therapy. Current evidence within occupational therapy is centered around sensory processing assessments and individualized intervention almost exclusively in pediatric settings. In the Choosing Wisely campaign, the American Occupational Therapy Association (AOTA) developed an evidence-based recommendation to conduct assessment and documentation of deficits in sensory processing and integrating prior to intervention as intervention can lead to ineffective and potentially negative reactions.¹⁴ Assessing and documenting specific sensory processing difficulties before providing intervention is vital in pediatric settings and equally as important in later stages of the life course and particularly in the presence of neurodegenerative conditions.

Due to complex neurological processes involved in neurodegenerative conditions, assessment of sensory processing capacity may substantially influence the use and effectiveness of sensory-based interventions for persons with ADRD. Multiple neuroanatomical areas involved in sensory processing are impacted and/or altered due to ADRD at various stages.³⁸ For example, at basic levels, the parietal lobe is involved in visuospatial processing, while the occipital lobe processes visual input. The temporal lobe is active in auditory processing, while the cerebellum is involved in vestibular processing. Further, most sensory inputs are filtered through the dorsolateral prefrontal cortex, a critical component of the circuitry involved in sensory processing. Neurodegenerative conditions, such as dementias, impact these areas at varying rates and regionality.³⁹ In physical rehabilitation, measurement of range of motion and strength are paramount prior to intervention delivery. A similar importance of evaluation is likely as necessary when using sensory-based interventions in neurologically impaired individuals. Thorough assessment is warranted to protect the individual, as well as gain the most benefit from intervention.

Without assessment, skilled and individualized interventions lack direction grounded in neurobiological underpinnings of the individual's capacity and needs. To optimize therapeutic progress and outcomes, interventions must assess sensory-related neurological dysfunction, not yet typical in ADRD care. Occupational therapy has a unique role in addressing this gap in ADRD non-pharmacological care options. Managing behavioral and psychiatric symptoms of dementia is crucial to enhancing quality of life for patients and decreasing caregiver burden.¹⁶ With current pharmacological intervention leaving patients at risk for adverse events, non-pharmacological sensory-based intervention holds great value if approached appropriately.⁴⁰

The call to action is urgent for applied research to develop the necessary data to aid in the development and implementation of an assessment that will identify specific sensory processing dysfunction in the ADRD population, bringing best practices to a higher level for lessening behavioral disturbances and decreasing caregiver burden in ADRD patients, which will be an ever-growing problem as the baby boomer generation ages.⁴¹ Few assessments exist and are available for use in clinical practice. Two sensory processing assessments, the Adults Sensory Profile^42,43 and the Sensory Modulation Program⁴⁴ are examples of assessments of sensory processing which can be used prior to intervention delivery in persons with dementia. However, the literature shows no evidence of formally assessing the sensory processing capacity of individuals with ADRD prior to implementation of an intervention. Currently the findings from the sensory intervention studies are mixed. A strong opportunity exists for appropriate assessment to improve care in this space.

Limitations

This review has a few limitations worth noting. Results of the systematic search were confined to the search terms, databases, and data extraction outlined in the original protocol. Additional articles may exist outside of the identified search terms and databases. However, investigators worked with a medical librarian, as well as content experts and an occupational therapy methodologist to create an extensive list of applicable terms for review. Challenges in identifying all relevant articles are in part due to varying terminology used in the field and indexing processes among various databases searched. Further, databases and additional sources were searched through October 2023. Other applicable articles may have been published since the search was complete. A brief search of literature was conducted prior to article preparation and no additional articles were identified. The search returned an exhaustive list of articles involved in this systematic review. Following standard guidelines for review, the findings are an accurate representation of the search outlined in the original protocol.

Conclusion

The illustrated void in sensory processing assessments in ADRD prior to providing intervention highlights the opportunity in the field to expand evidence for improved care. Numerous disciplines have the ability to contribute to this need. Occupational therapy, in particular, is a well-equipped field to fill this void in neurodegenerative conditions seen in geriatric settings due to the wealth of expertise in pediatric assessment and intervention.

Supplemental Material

sj-docx-1-alr-10.1177_25424823251388434 - Supplemental material for Sensory processing assessment in Alzheimer's disease and related dementias: Opportunities for improved care

Supplemental material, sj-docx-1-alr-10.1177_25424823251388434 for Sensory processing assessment in Alzheimer's disease and related dementias: Opportunities for improved care by Elizabeth K Rhodus, Lauren E Robinson, Celeste Roberts, Clarissa Benzarti, MaryEllen Thompson, Justin Barber, Katherine Snyder, Nancy Wolff, Carolyn Baum and Elizabeth G Hunter in Journal of Alzheimer's Disease Reports

Footnotes

Acknowledgements

Authors acknowledge and thank Dr Camille Skubik-Peplaski for her review of the project protocol, as well as two graduate assistants, Ashley Cummings, MS, OTR/L and Brandi Carey, MS, for their efforts in this work.

ORCID iD

Elizabeth K Rhodus

Author contribution(s)

Elizabeth K Rhodus: Conceptualization; Data curation; Formal analysis; Formal analysis; Investigation; Methodology; Project administration; Resources; Software; Supervision; Validation; Visualization; Writing – original draft; Writing – review & editing.

Lauren E Robinson: Conceptualization; Data curation; Investigation; Methodology; Resources; Validation; Writing – original draft; Writing – review & editing.

Celeste Roberts: Formal analysis; Writing – original draft.

Clarissa Benzarti: Formal analysis; Investigation; Methodology; Resources; Writing – original draft; Writing – review & editing.

MaryEllen Thompson: Formal analysis; Methodology; Writing – original draft.

Justin Barber: Formal analysis; Project administration; Validation; Writing – original draft; Writing – review & editing.

Katherine Snyder: Formal analysis; Writing – original draft.

Nancy Wolff: Methodology; Writing – original draft; Writing – review & editing.

Carolyn Baum: Conceptualization; Writing – original draft; Writing – review & editing.

Elizabeth G Hunter: Conceptualization; Data curation; Formal analysis; Methodology; Writing – original draft; Writing – review & editing.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The first author was funded by NIH/NIA T32 AG057461 and NIH/NIA K23-AG075262 during the described research.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The data supporting the findings of this study are available on request from the corresponding author.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

Please find the following supplemental material available below.

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