Occupational Therapay interventions for Alzheimer's Disease

From UBC Wiki

Occupational Therapy Interventions

Alzheimer's disease (AD) has a profound impact on the individual diagnosed, his or her family, and all those involved in providing care [1]. Although the progression of cognitive and functional declines caused by AD are considered inevitable and irreversible [2], occupational therapy (OT) interventions have been shown to:

  • enhance the diagnosed individual's sense of usefulness, enjoyment and identity[3]
  • increase his or her functional independence [1]
  • decrease adverse behaviours [4]
  • lessen the burden of care felt by caregivers [1]

OT intervention goals:

  • adapt the physical environment to maximize function and improve quality of life
  • enhance the personal capacities of individuals with AD
  • change thinking about AD behaviours and caregiver roles
  • improve the supervision/coping skills of the caregivers [5]

The purpose of OT intervention goals are to maximize the independence and quality of life of both the individuals with AD as well as their caregivers.[6]


In order to be effective, occupational therapy interventions should be individualized, focusing on the person's specific needs, in their specific contexts, for the specific stage of their disease.[7] To accomplish this, occupational therapists (OTs) work as a part of a multidisciplinary team, using their skills to assess the functional abilities, occupational performance, and client and caregiver needs.[6]

Assessments

One of the first steps occupational therapists take when beginning therapy with individuals with AD is to assess their current level of function. Non-standardized assessments such as interviewing and observation of clients and their caregivers are essential tools for gathering information on clients’ functional abilities, coping strategies, care needs and interests.[8] However, OTs must take into consideration various factors that can impact assessment results. For example, OTs must pay close attention to non-verbal communication such as posture, facial expressions, reactions and tone of vocalisations, demonstrated by clients with dysphasia (swallowing difficulties).[8] Similarly, OTs must factor in the environment in which assessment takes place, as individuals with AD may use different cognitive strategies when interacting in familiar or unfamiliar environments.[8]

OTs also make use of many standardized assessments to gather information and assist with treatment planning for individuals with AD. Some common standardized assessments include:

  • Large Allen’s Cognitive Level Screen (LACLS): A cognitive screen used for treatment planning.[6]
  • Assessment of Motor and Process Skills (AMPS): A motor function assessment in which a client is observed performing an activity of their choosing.[6]
  • Canadian Occupational Performance Measure (COPM): A semi-structured interview used to assess changes in client self-perception of occupational performance.[7]
  • Pool Activity Level Instrument (PAL): A checklist about activity levels for caregivers to report.[6]
  • Braden Scale for Predicting Pressure Sore Risk (Braden Scale): A risk assessment for pressure sores.[9]

Occupational Therapy Interventions for Mild AD

Caregiver Education

In the early stages of AD, family caregivers tend to experience negative changes related to the increased burden of responsibility of caring for a family member with AD.[10][5] Occupational therapists will collaborate with the primary caregiver in order to identify specific areas of concern and tailor education to meet caregiver and client needs. Caregiver education is a continually evolving process, which is linked to both OT assessment and intervention.[5] Providing information regarding the course of AD is an important first step. The knowledge gained can help caregivers to accept the diagnosis, deal with feelings of guilt, set more realistic expectations on all those involved, respond more appropriately to the person with AD's needs, and recognize the need for assistance in the delivery of care.[5] Throughout the educational process, occupational therpasits will encourage the caregiver to choose activities that provide a sense of meaning for the individual with AD, with more emphasis placed on participation rather than outcome.[1]

OTs also provide education and support in a number of other areas, including:

  • Supervision,[10]
  • Communication[10]
  • Environmental adaptations[10]
  • Maintaining function[10]

Environmental Adaptation

In the home setting, OTs will work with caregivers to assess areas where most self-care tasks take place and make recommendations for adaptations to create a safe, functional environment.[11] For example, individuals with AD can compensate for forgetfulness by leaving notes throughout their homes and workplaces, using pill organizers to sort medications for the week, and placing large calendars in prominent areas to mark down appointments.[12] These environmental cues help to sustain independence for as long as possible, as well as provide individuals with an increased sense of well-being.[12]

Another important consideration is the risk of falls, which could lead to injury. To prevent falls, OTs provide recommendations to clients and their caregivers on how to make the home environment more safe. Some examples are:

  • making sure that potential obstacles are removed from home environment i.e. remove throw rugs and electrical cords and reduce clutter in home[12]
  • improve lighting in home i.e night lights and increased light in dark areas[12]

Occupational Therapy Interventions for Moderate AD

By middle stage AD, the disease has usually progressed to a point where individuals require round-the-clock care[2] and caregivers often find themselves having to make difficult decisions about the future care of their loved ones.[13] Middle stage AD is often when individuals begin to demonstrate increasingly challenging behaviours, which increases the likelihood of requiring placement in a full-time care facility.[2][12] During this stage, OT interventions begin to focus more on the areas of self-care, psychosocial behaviour,and safety.

Self-care

Individuals in middle stage AD will have difficulty with self-care tasks due to decreased attention and executive functioning.[14]

OTs assess a client's abilities, challenges, and safety concerns. OTs make recommendations for adaptive equipment and safety equipment, and advise caregivers on how to best adapt self-care activities to maximize the client's participation and well-being.[11]

Some OT interventions for self-care tasks are:

  • providing safety equipment for the bathroom (e.g. bath bench, grab bars, non-slip mat)[15]
  • teaching new techniques in dressing or bathing[15]


OTs may also educate caregivers regarding:

  • placing well-used items in visible locations (e.g. toothbrush, shoes)[16]
  • using simple instructions and visual cues[16]
  • using recorded instructions to help the client independently complete a task[17][18]

Behaviour

As individuals can demonstrate increasingly challenging social behaviours during middle stage AD, OTs will often focus on promoting healthy psychosocial functioning, especially when individuals are often unable to effectively communicate their feelings or concerns.[12] Normalizing activities is one type of intervention that can help maintain or improve positive behaviour by reinforcing occupational meaning and by relating activities to a role an individual with AD previously held.[12] For example, normalizing activities related to the role of “the mother” might include folding clothes or caring for plants, or related to the role of “the worker” might include sorting items or stuffing envelopes.[12]

Individuals in middle stage AD may also benefit from group activities facilitated by an OT.[19] Group goals often include reducing confusion, increasing control, and promoting positive interpersonal functioning through support groups or reminiscent therapy (i.e. looking through old photo albums, singing old songs, etc.).[20] However, OTs must keep in mind that if stimulation becomes overwhelming for individuals in group sessions, it can have lead to adverse behaviours.[12]

One very important aspect of managing behaviour is the establishment of routine. OTs encourage caregivers to establish a routine since consistent patterns of activities in familiar environments help the individual with AD to remain calm and use their implicit memory, which is the type of memory that remains intact the longest. [insert Gray reference here]

Safety

Safety is a major area of concern for OTs working with individuals in middle stage AD, both when the client lives at home or in a care facility.[2]

Being home alone becomes a safety issue if the client shows wandering behaviours. OTs might facilitate for this by:

  • suggesting adaptation of the home environment, such as wallpapering the door to match the walls in order to eliminate the cue of the exit[21]
  • providing an identification bracelet in case the client wanders off[16]

As individuals in middle stage AD decline in executive functioning and performance skills, they need increasing supervision and direction in completing everyday activities safely. When in a care facility, OTs can help by advocating for/providing caregiver training that focuses on the individual client's needs, verbal cues, and verbal reinforcement[22]

Individuals in middle stage AD typically experience an increased risk of falls.[23] OTs working in hospitals or care facilities can implement fall interventions for those with AD, including:

  • falls risk alert cards [23]
  • hip protectors[23]
  • exercise programs[23]
  • safety education programs[23]

Cognitive Intervention

OTs may use cognitive interventions to improve or maintain cognitive abilities in those in middle stage AD, as well as to compensate for lost cognitive functioning.[24][21]In the context of working with individuals with AD, cognitive interventions strive to maintain daily functioning by:

  • Cognitive Rehabilitation: To build on the strength of preserved aspects of memory and compensating for impaired aspect of memory.[24] Compensatory approaches would be used for those with AD (e.g. changing the context, establishing behavioural routines and habits, and learning compensatory strategies[21]
  • Cognitive Training: To maintain or improve specific cognitive functions such as memory, language, and attention through regular use and practice (e.g. word games) .[24]
  • Cognitive Stimulation: To encourage and enhance cognitive and social functioning through interaction with socially-stimulating environments (e.g. groups) and cognitively-stimulating activities (e.g. quizzes or mazes).[24]

Occupational Therapy Interventions for Severe AD

As individuals’ abilities continue to decline during late stage AD, OT intervention will focus on important areas of well-being, including contracture care, skin care, swallowing safety, and activity participation[25][26][27] and contracture care.[14]

Contractures

Prolonged immobility eventually causes joints to get stuck in fixed positions (contracted).[14] Once a joint is contracted the muscle and other soft tissue shorten in length. Contractures may not be treatable with exercise and stretching, although evidence suggests that some biomechanical interventions can help slow their progression, for example facilitating activities that incorporate movements and positions that make use of the person’s full range of motion.[14]

Skin Care

OT interventions include recommendations for frequent repositioning in bed or chairs as well as positioning adaptations to optimize pressure relief and reduce the risk for pressure ulcers.[28] Occupational therapists also address the surfaces that people are sitting and lying on, and recommend specialized cushions and mattresses that aid in the prevention or healing of pressure ulcers.[28] It is important to note that, while these cushions and mattresses decrease pressure ulcer risks, they also have the potential to decrease a person’s functional mobility in repositioning or transfering due to their yielding, cushy properties.[28]

Swallowing

People in the very late stages of AD eventually develop problems with eating and swallowing. [25][26][27] OTs contribute to the management of swallowing problems by:

  • Conducting swallowing assessments .[26]
  • Making recommendations for changing the textures and thicknesses of foods and liquids to make them easier and safer to swallow.[26]

Leisure

OTs work closely with caregivers to design sensory-based activities that can provide comfort, stimulation, joy and decrease isolation [19][11] by providing opportunities for interaction and awareness of the environment (even if they last only a few minutes).[19][11] Examples include batting a balloon, mimicking others’ actions, looking at brightly coloured stimuli, or rocking in a chair.[19]

==References==

  1. ↑ 1.0 1.1 1.2 1.3 Chard G, Liu L, Mulholland S. Verbal cueing andenvironmental modifications: strategies to improve engagement inoccupations in persons with Alzheimer disease. Phys Occup Ther Geriatr[Internet]. 2009 [cited 20011 Mar 12];27(3):197-211. Available fromCINAHL: www.cinahl.com/cgi-bin/refsvc?jid=307&accno=2010251600doi:10.1080/02703180802206280. Cite error: Invalid <ref> tag; name "Chard" defined multiple times with different content Cite error: Invalid <ref> tag; name "Chard" defined multiple times with different content Cite error: Invalid <ref> tag; name "Chard" defined multiple times with different content
  2. ↑ 2.0 2.1 2.2 2.3 Fraker J. Dementia. In: Atchison B, Dirette D,editors. Conditions in occupational therapy. Philadelphia: LippincottWilliams & Wilkins; 2007. p. 139-166. Cite error: Invalid <ref> tag; name "Fraker" defined multiple times with different content Cite error: Invalid <ref> tag; name "Fraker" defined multiple times with different content
  3. ↑ Egan M, Hobson S, Fearing VG. Dementia andoccupation: a review of the literature. Can J Occup Ther. 2006 Jun;73(3):132-40.
  4. ↑ Baum C. The contribution of occupation to function in persons with Alzheimer’s disease. J Occ Sci. 1995 Aug; 2(2):59-67.
  5. ↑ 5.0 5.1 5.2 5.3 Graff MJL, Vernooij-Dassen M, Zajec J, Olde-Rikkert M, Hoefnagels WHL, Dekker J. How can occupational therapy improve the daily performance and communication of an older patient with dementia and his primary caregiver? Dementia [Internet]. 2006 [cited 2011 Mar 10];5(4): 503-32. Availabe from PsychINFO: http://tinyurl.com/4nljwn2 doi:10.1177/1471301206069918.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Warren A. Dementia. In: McIntyre A, Atwal, A, editors. Occupational therapy and older people. Oxford: Blackwell Publishing Ltd; 2005. p. 70-72.
  7. ↑ 7.0 7.1 Canadian Association of Occupational Therapists. Enabling occupation: an occupational therapy perspective. Ottawa: CAOT Publications ACE; 2002.
  8. ↑ 8.0 8.1 8.2 Pool, J. Older people. In: Creek J, Lougher L, editors. Occupational therapy and mental health. 4th ed. New York: Churchill Livingstone Elsevier; 2008. p. 425-449.
  9. ↑ Ryan J. Teamwork keeps the pressure off: the role of the occupational therapist in the prevention of pressure ulcers. Home Healthc Nurse [Internet]. 2006 [cited 2011 Mar 21];24(2):97-103. Available from: http://journals.lww.com/homehealthcarenurseonline/Pages/default.aspx
  10. ↑ 10.0 10.1 10.2 10.3 10.4 Hogan VM, Lisy ED, Savannah RL, Henry L, KuoF, Fisher GS. Role change experienced by family caregivers of adultswith Alzheimer's disease: implications for occupational therapy. PhysOccup Ther Geriatr [Internet]. 2004 [cited 2011 Mar 16];22(1): 21-43.Availabe from PsychINFO: http://tinyurl.com/4mu7a9adoi:10.1300/J148v22n01_02
  11. ↑ 11.0 11.1 11.2 11.3 Cole MB, Tufano R. Applied theories in occupational therapy: a practical approach. Thorofare: Slack Inc; 2008.
  12. ↑ 12.0 12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 Carson VB, Smarr RR. Becoming an Alzheimer’s whisperer: responding to challenging behaviors. Home Healthc Nurse. 2007 Nov/Dec; 25(10):628-636.
  13. ↑ Lynn J, Lynch Schuster J, Wilkinson A, Noyes Simon L. Improving care for the end of life: a sourcebook for health care managers and clinicians. New York: Oxford University Press Inc; 2008.
  14. ↑ 14.0 14.1 14.2 14.3 Reisberg B, Franssen HE, Souren L, Kenowsky K, Jamil I, Anwar S, et al. Alzheimer’s disease. In: Flanagan RS, Zaretsky H , Moroz A, editors. Medical aspects of disability. 4th ed. New York: Springer Publishing; 2011. p.25-64.
  15. ↑ 15.0 15.1 Birge James A. Restoring the Role of Independent Person. In: Radomski MV, Latham CT, editors. Occupational therapy for physical dysfunction. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 774-816.
  16. ↑ 16.0 16.1 16.2 Goodman G, Bonder B. Preventing Occupational Dysfunction Secondary to Aging. In: Radomski MV, Latham CT, editors. Occupational therapy for physical dysfunction. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 974-999.
  17. ↑ Lancioni G., Pinto K, La Martire M, Tota A, Rigante V, Tatulli E, et al. Helping persons with mild or moderate Alzheimer’s disease recapture basic activities through the use of an instruction strategy. Disabil Rehabil. 2009; 31(3):211-219. doi:10.1080/09638280801906438.
  18. ↑ Witte Bewernitz M, Mann W, Dasler P, Belchior P. Feasibility of machine-based prompting to assist persons with dementia. Assis Technol. 2009; 21:196-207. doi:1080/10400430903246050.
  19. ↑ 19.0 19.1 19.2 19.3 Banzan-Salazar E. Alzheimer’s activities that stimulate the mind. New York: McGraw-Hill; 2005.
  20. ↑ Brody C. Working with Alzheimer’s disease residents of a nursing home. In: Brody C, Semel V, editors. Strategies for therapy with the elderly. 2nd ed. New York: Springer Publishing Company Inc; 2006. p. 93-111.
  21. ↑ 21.0 21.1 21.2 Radomski MV, Schold Davis E. Optimizing Cognitive Abilities. In: Radomski MV, Latham CT, editors. Occupational therapy for physical dysfunction. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 748-773.
  22. ↑ Chard G, Lui L, Mulholland S. Verbal cueing and environmental modifications: Strategies to improve engagement in occupations in persons with alzheimer disease. Physical & Occupational Therapy in Geriatrics. 2009; 27(3):197-211. doi: 10.1080/02703180802206280.
  23. ↑ 23.0 23.1 23.2 23.3 23.4 Haines TP, Bennell KL, Osborne RH, Hill KD. Effectiveness of targeted falls prevention programme in subacute hospital setting: randomised controlled trial. BMJ. 2004 Mar; 328(7441):676–79. doi:10.1136/bmj.328.7441.676.
  24. ↑ 24.0 24.1 24.2 24.3 Clare L, Woods R. Cognitive training and cognitive rehabilitation for people with early-stage Alzheimer’s disease: a review. Neuropsychol Rehabil. 2004; 14(4):385-401. doi:10.1080/09602010443000074.
  25. ↑ 25.0 25.1 Cichero J. Conditions commonly associated with dysphagia. In: Cichero J, Murdoch B, editors. Dysphagia: foundation, theory, and practice. West Sussex: John Wiley & Sons Ltd; 2006. p. 237-299.
  26. ↑ 26.0 26.1 26.2 26.3 Avery W. Dysphagia. In: Radomski MV, Latham CT, editors. Occupational therapy for physical dysfunction. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 1322-1339.
  27. ↑ 27.0 27.1 Kyung SM, Hee KH, Duk NL. Dysphagia in patients with dementia: Alzheimer versus vascular. Alzheimer Disease & Associated Disorders. 2009 Apr/Jun; 23(2):178-184. doi:10.1097/WAD.0b013e318192a539.
  28. ↑ 28.0 28.1 28.2 Toto PE. Success through teamwork in the home health setting: the role of occupational therapy. Home Health Care Manag Pract [Internet]. 2006 Dec [cited 2011 Mar 15];19(1):31-27. Available from SAGE Journals Online: http://hhc.sagepub.com.ezproxy.library.ubc.ca/content/19/1/31.
Retrieved from "https://wiki.ubc.ca/index.php?title=Occupational_Therapay_interventions_for_Alzheimer%27s_Disease&oldid=92590"