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).

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.

Coping and Co-creation: One Attempt and One Route to Well-being. Part 2. Application to Identity and Social Well-being.

Background: This is the application part of a two-part paper that starts from the assumption that core cognition for promoting agent well-being is shared by all living beings. In Part 1, we derived a number of key terms of core cognition and two behavioral ontologies: coping and co-creation. Objective: Our first aim is to extend the conceptual framework and two behavioral ontologies, while explaining, from first principles, the observed basic structure in identity development. The second is to apply core cognition on a metatheoretical level to explain how the two theories about fostering well-being show the characteristic features of our two behavioral ontologies. Results: We demonstrate that the four different combinations of coping, co-creation, adequacy, and inadequacy explain from first principles the underlying structure of identity. Among other things, these accurately leads us to the defining features of authoritarianism. The notion of ontological security, as it is known in the literature, accurately describes the coping mode's restricted capacity for the creation and protection of well-being. Ontological security leads to a self-limiting form of well-being that has been described as "abnormal normality." In contrast, psychological safety provides the preconditions for high wellbeing and a safe environment, thus promoting the healthy development of coping and co-creation adequacy.

Coping and Co-creation: One Attempt and One Route to Well-Being. Part 1. Conceptual Framework.

Background: All life strives to be well, but not all life is well. This suggests that cognition aimed at improving and protecting well-being might share a common core across all life forms: core cognition. Objective: In this first of a two-part theoretical article, we systematically specify the evolutionary core cognition of well-being from the perspective of general living agents. In Part 2 we apply this to identity development and the theoretical approaches to well-being. This first part aims to identify the strategies and conditions for the creation and protection of generalized well-being and describes associated behavioral ontologies. Results: We defined a set of key terms that, together, specify core cognition. This set comprises quite naturally concepts like agency, behavior, need satisfaction, intelligence, authority, power, and wisdom, which are all derived from the defining properties of life. We derived coping and co-creation as two essentially different, but complementary, behavioral ontologies. Copingis for survival and targeted problem solving and aims to end the need for its activation. Co-creation is for thriving and problem prevention and aims to perpetuate its activation. Co-creation can explain the growth of the biosphere. While both strategies are essential, the successful interplay of their strengths leads to the dominance of one of them: co-creation. Absence of success leads to a dominance of coping: a coping-trap and a strong urge to curtail behavioral diversity. We summarize the key terms of core cognition and the ontologies in two tables with defined terms.

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.

Visual and auditory temporal integration in healthy younger and older adults.

As people age, they tend to integrate successive visual stimuli over longer intervals than younger adults. It may be expected that temporal integration is affected similarly in other modalities, possibly due to general, age-related cognitive slowing of the brain. However, the previous literature does not provide convincing evidence that this is the case in audition. One hypothesis is that the primacy of time in audition attenuates the degree to which temporal integration in that modality extends over time as a function of age. We sought to settle this issue by comparing visual and auditory temporal integration in younger and older adults directly, achieved by minimizing task differences between modalities. Participants were presented with a visual or an auditory rapid serial presentation task, at 40-100 ms/item. In both tasks, two subsequent targets were to be identified. Critically, these could be perceptually integrated and reported by the participants as such, providing a direct measure of temporal integration. In both tasks, older participants integrated more than younger adults, especially when stimuli were presented across longer time intervals. This difference was more pronounced in vision and only marginally significant in audition. We conclude that temporal integration increases with age in both modalities, but that this change might be slightly less pronounced in audition.

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.

Cognition from life: the two modes of cognition that underlie moral behavior.

We argue that the capacity to live life to the benefit of self and others originates in the defining properties of life. These lead to two modes of cognition; the coping mode that is preoccupied with the satisfaction of pressing needs and the co-creation mode that aims at the realization of a world where pressing needs occur less frequently. We have used the Rule of Conservative Changes - stating that new functions can only scaffold on evolutionary older, yet highly stable functions - to predict that the interplay of these two modes define a number of core functions in psychology associated with moral behavior. We explore this prediction with five examples reflecting different theoretical approaches to human cognition and action selection. We conclude the paper with the observation that science is currently dominated by the coping mode and that the benefits of the co-creation mode may be necessary to generate realistic prospects for a modern synthesis in the sciences of the mind.

Perceptual restoration of degraded speech is preserved with advancing age.

Cognitive skills, such as processing speed, memory functioning, and the ability to divide attention, are known to diminish with aging. The present study shows that, despite these changes, older adults can successfully compensate for degradations in speech perception. Critically, the older participants of this study were not pre-selected for high performance on cognitive tasks, but only screened for normal hearing. We measured the compensation for speech degradation using phonemic restoration, where intelligibility of degraded speech is enhanced using top-down repair mechanisms. Linguistic knowledge, Gestalt principles of perception, and expectations based on situational and linguistic context are used to effectively fill in the inaudible masked speech portions. A positive compensation effect was previously observed only with young normal hearing people, but not with older hearing-impaired populations, leaving the question whether the lack of compensation was due to aging or due to age-related hearing problems. Older participants in the present study showed poorer intelligibility of degraded speech than the younger group, as expected from previous reports of aging effects. However, in conditions that induce top-down restoration, a robust compensation was observed. Speech perception by the older group was enhanced, and the enhancement effect was similar to that observed with the younger group. This effect was even stronger with slowed-down speech, which gives more time for cognitive processing. Based on previous research, the likely explanations for these observations are that older adults can overcome age-related cognitive deterioration by relying on linguistic skills and vocabulary that they have accumulated over their lifetime. Alternatively, or simultaneously, they may use different cerebral activation patterns or exert more mental effort. This positive finding on top-down restoration skills by the older individuals suggests that new cognitive training methods can teach older adults to effectively use compensatory mechanisms to cope with the complex listening environments of everyday life.

Temporal integration of consecutive tones into synthetic vowels demonstrates perceptual assembly in audition.

Temporal integration is the perceptual process combining sensory stimulation over time into longer percepts that can span over 10 times the duration of a minimally detectable stimulus. Particularly in the auditory domain, such "long-term" temporal integration has been characterized as a relatively simple function that acts chiefly to bridge brief input gaps, and which places integrated stimuli on temporal coordinates while preserving their temporal order information. These properties are not observed in visual temporal integration, suggesting they might be modality specific. The present study challenges that view. Participants were presented with rapid series of successive tone stimuli, in which two separate, deviant target tones were to be identified. Critically, the target tone pair would be perceived as a single synthetic vowel if they were interpreted to be simultaneous. During the task, despite that the targets were always sequential and never actually overlapping, listeners frequently reported hearing just one sound, the synthetic vowel, rather than two successive tones. The results demonstrate that auditory temporal integration, like its visual counterpart, truly assembles a percept from sensory inputs across time, and does not just summate time-ordered (identical) inputs or fill gaps therein. This finding supports the idea that temporal integration is a universal function of the human perceptual system.

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.

Positioning soundscape research and management.

This paper is an outcome of a workshop that addressed the question how soundscape research can improve its impact on the local level. It addresses a number of topics by complementing existing approaches and practices with possible future approaches and practices. The paper starts with an analysis of the role of sound annoyance and suboptimal soundscapes on the lives of individuals and concludes that a good soundscape, or more generally a good sensescape, is at the same time pleasant as well as conducive for the adoption of healthy habits. To maintain or improve sensescape quality, urban planning needs improved design tools that allow for a more holistic optimization and an active role of the local stakeholders. Associated with this is a gradual development from government to governance in which optimization of the soundscape at a local (administrative or geographic) level is directly influenced by the users of spaces. The paper concludes that soundscape research can have a greater impact by helping urban planners design for health and pleasant experiences as well as developing tools for improved citizen involvement in local optimization.

How pleasant sounds promote and annoying sounds impede health: a cognitive approach.

This theoretical paper addresses the cognitive functions via which quiet and in general pleasurable sounds promote and annoying sounds impede health. The article comprises a literature analysis and an interpretation of how the bidirectional influence of appraising the environment and the feelings of the perceiver can be understood in terms of core affect and motivation. This conceptual basis allows the formulation of a detailed cognitive model describing how sonic content, related to indicators of safety and danger, either allows full freedom over mind-states or forces the activation of a vigilance function with associated arousal. The model leads to a number of detailed predictions that can be used to provide existing soundscape approaches with a solid cognitive science foundation that may lead to novel approaches to soundscape design. These will take into account that louder sounds typically contribute to distal situational awareness while subtle environmental sounds provide proximal situational awareness. The role of safety indicators, mediated by proximal situational awareness and subtle sounds, should become more important in future soundscape research.

Audiovisual perception of congruent and incongruent Dutch front vowels.

PURPOSE: Auditory perception of vowels in background noise is enhanced when combined with visually perceived speech features. The objective of this study was to investigate whether the influence of visual cues on vowel perception extends to incongruent vowels, in a manner similar to the McGurk effect observed with consonants. METHOD: Identification of Dutch front vowels /i, y, e, Y/ that share all features other than height and lip-rounding was measured for congruent and incongruent audiovisual conditions. The audio channel was systematically degraded by adding noise, increasing the reliance on visual cues. RESULTS: The height feature was more robustly carried over through the auditory channel and the lip-rounding feature through the visual channel. Hence, congruent audiovisual presentation enhanced identification, while incongruent presentation led to perceptual fusions and thus decreased identification. CONCLUSIONS: Visual cues influence the identification of congruent as well as incongruent audiovisual vowels. Incongruent visual information results in perceptual fusions, demonstrating that the McGurk effect can be instigated by long phonemes such as vowels. This result extends to the incongruent presentation of the visually less reliably perceived height. The findings stress the importance of audiovisual congruency in communication devices, such as cochlear implants and videoconferencing tools, where the auditory signal could be degraded.