Course:RSOT513/2010W2/cognitive degenerative condition

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Alzheimer's Disease

Alzheimer’s disease (AD) is an age-related neurodegenerative disorder and the most frequent type of dementia found in the elderly. AD is initially characterized by deficits in memory and progresses through stages of functional decline that will eventually lead to death.[1] Throughout the progression of AD, occupational therapists work closely with individuals and their families or caregivers to enhance their quality of life and participation in meaningful occupations; in the context of occupational therapy, occupations include everything a person does.[2]

Etiology

While the exact causes of AD have yet to be identified, evidence has suggested that the etiology of AD is varied and complicated.[3] The strongest risk factor is old age, suggesting that AD is linked to the biological processes associated with aging.[4] There is also evidence that both genetics and environment can influence susceptibility to AD.[4]

There are many hypotheses around other risk factors for AD. Qui and Fratiglioni [4] note evidence supporting both vascular and psychosocial contributors to AD diagnosis, including factors such as high blood pressure during middle age, diabetes, stroke, low education, and depression. McDonald et al.[3] look into the co-factors theory on the etiology of AD, asserting that neurodegeneration and brain damage may result from a variety of factors interacting, including plaques and tangles, neurotransmitter changes, stress hormones, head trauma, circadian rhythms, seizures, estrogen, environmental factors, and glucose metabolism.[3]

Prevalence

  • Worldwide, it is estimated 26 million people have AD.[5]
  • At least 60% of all dementia cases are caused by Alzheimer’s disease.[6]
  • The prevalence of AD approximately doubles every five years after the age of 65 in developed countries, and every seven years in developing countries.[7]
  • Current evidence estimates that by 2050, the prevalence of AD will quadruple, and that by then, one in eighty-five people will have the illness.[5]
  • As the baby boomer generation ages, there will be an increase in AD prevalence.[5]
  • AD is also the leading cause of institutionalization and the fourth leading cause of death in the USA.[7]

Signs and Symptoms

Cognitve

The chief symptom of AD is an ongoing loss of memory, beginning with recent events and progressing to remote events.[8] This loss in memory inhibits learning because new information cannot be stored and is quickly forgotten. Generally, over time, the ability to respond to stimuli diminishes, due to the gradual decrease in executive functions, including initiating, planning, sequencing, and monitoring behavioural responses—all processes that play central roles in completing activities of daily living (ADL).[8] Several other areas of cognitive decline are associated with the progression of AD as well, including concentration, accurate sensation of time passing, and language.[9] Individuals with AD may have difficulty finding words, following complex conversations, and verbally identifying objects.[8] During onset, figurative expressions are not understood, while in later stages of AD, individuals will demonstrate poor category fluency (e.g. identifying whether something is a “fruit” or “animal”). Written communication is also affected, as individuals will exhibit circumlocution (indirect or “roundabout” expression) and paraphasias (inappropriate interruptions that render written text unintelligible).[8]

Psychosocial

The majority of individuals with AD develop behavioural disturbances over time, including agitation, hallucinations, delusions, sleep disturbances, depression, distractibility, and apathy.[8] Increasing disorientation to time, place, and person also becomes apparent, as well as paranoid thinking, resulting from memory loss and confusion. If unable to cope with these challenges, individuals may become aggressive or combative.[9] Depressive symptoms are particularly common among individuals with AD, affecting up to 80% of the population, while major depressive episodes occur in approximately 50% of the population.[8] Apathy is seen in approximately 70% of cases and often leads to social withdrawal.[8] [9] All these factors can be taxing on individuals with AD and their caregivers, and drastically increase the likelihood of institutionalization.[8]

Physical

Although AD is often characterized as a cognitive disease, physical symptoms also manifest as the disease progresses. Over time, individuals typically display an overall loss in gross motor function, coordination, balance, fine motor skills, and motor planning.[9] Gait disturbances also appear in later stages of AD.[9] A small percentage (5-10%) may also demonstrate muscle twitching or epileptic seizures).[8] In advanced stages, these changes in muscle activation can progress to Parkinsonism or muscle contractures, which may inhibit the ability to stand, walk, or engage in functional tasks.[9]


In addition to motor impairments, individuals may also demonstrate a loss in sensory processing, commonly leading to deficits in olfaction, stereognosis (object recognition using touch), and depth perception.[9][8] Simultaneously, the ability to filter incoming stimuli decreases, resulting in vulnerability to overstimulation.[9] Individuals will also experience deficits in visuospatial perception, causing them to easily lose their sense of direction, have difficulties using tools or utensils, or have difficulties copying simple drawings.[8]

Diagnosis

Core diagnostic criteria laid out by the Diagnostic and Statistical Manual of Mental Disorders(DSM-IV-TR) state that AD must include an early, significant, episodic memory impairment and some other cognitive impairment, both of which interfere with the individual’s social functioning or ADLs.[10] Core diagnostic criteria must also be accompanied by one of several supportive features, which include volume changes in certain structures of the brain, the presence of certain biomarkers in cerebrospinal fluid, the presence of certain patterns on functional neuroimaging, or a proven genetic component from the family.[10] Although many of these supportive features can be specifically tested for using modern imaging technology, it is important to note there is no single test available to confirm AD diagnosis.[10] There are also certain exclusion criteria for AD, including sudden onset of memory or cognitive dysfunction; early occurrence of gait dysfunction, seizures, or behavioural changes (though these may occur in later stages of AD); hemiparesis; or a diagnosis of severe depression, non-AD dementia, cerebrovascular disease, or toxic or metabolic abnormalities.[10]


Functional Implications

The average time from diagnosis to death is 8-12 years for individuals with AD.[7] Over this course of time, individuals progress through functional decline, which is often described by clinicians and researchers as taking place in three stages: mild, moderate, and severe. The purpose of this categorization is to describe the level of function an individual with AD would be expected to achieve, as well as to help families and health care providers anticipate their needs for care.[1][7] It is important to note the stages are provided only as guidelines for the progression of AD; each individual is unique, and will have varying characteristics, strengths, and care needs throughout their experience with AD.[1] From an occupational therapy perspective, the functional implications of occupation are often described within the three purposes of occupation: leisure,the activities people do for enjoyment; productivity, occupations done for social or economic contributions; and self-care, what people do to look after themselves [2].

Mild AD

Research conducted by Burgener and Dickerson-Putman concluded that the primary losses experienced by participants with AD pertained to meaningful employment and cognitively-demanding leisure pursuits.[11] Participants also described a sense of decreased independence associated with reduced ability to carry out instrumental activities of daily living (IADLs), such as managing their finances, grocery shopping, cooking, etc.[1] Due to the nature of symptom progression in AD, productivity and leisure activities are the first to be affected, as cognitive, psychosocial, and physical skills begin to decline.[1]

Productivity

As individuals with AD begin to experience symptoms of the early disease process (e.g. difficulties with anticipating results/consequences, multitasking, planning, reasoning, etc.)[12], so too do they begin to experience challenges with the daily tasks that require higher cognitive skills. For example, some common ways of how IADLs are affected include inability to balance a chequebook, follow a recipe, carry out meal preparation, or forgetting to pay bills.[1] Shopping and errand-running also become challenging, as individuals become overwhelmed with traveling or orienting themselves in new and different environments.[1] Also, driving to shopping centres and other destinations requires visuospatial skills, attention, executive functioning, and judgment that may become compromised during early stage AD, leading to further decreased ability to complete productive tasks.[13]


Employment in particular becomes a major area of concern for individuals in early stage AD, as work becomes a significant source of stress. Practical challenges in the areas of work modification and new learning can result in a sense of incompetence and a loss of identity in the office.[14] Deficits in memory and concentration often result in significant difficulties with reading and mental calculations, initiating and/or completing assigned tasks, maintaining commitments to meetings and appointments, and recalling names or other details.[1] Combined, these challenges can have a serious negative impact on job performance, resulting in early job retirement or termination.[7]


Often, one of the most difficult areas of productivity loss is that of caregiving. Individuals in the early stages of AD become unsafe caregivers for children and pets, as they are unable to maintain the attention and higher cognitive processing required to complete the complex tasks and responsibilities involved in caregiving.[1]

Leisure

Socially demanding leisure pursuits can become a source of anxiety or confusion for individuals with AD, as they begin to experience challenges with social demands, including remembering names, remembering current events and maintaining conversations.[7] As a coping mechanism, it is not unusual for individuals in early stage AD to avoid socially demanding situations to escape the anxiety they may cause.[1] [7]

Moderate AD

During middle stage AD, occupational performance becomes significantly impaired, as cognitive, psychosocial, and physical deficits continue to progress.[1] Individuals in this stage typically require increasing levels of assistance, especially for self-care needs, and are no longer able to live independently.[1]

Productivity/Leisure

Generally by middle stage AD, higher cognitive skills have declined to the point where previous productive and leisure occupations can no longer be fulfilled, and individuals require assistance with all IADLs and community outings.[15][16]

Self-care

Self-care becomes a major area of concern during middle stage AD, as individuals lose the functional abilities needed to complete their ADLs, such as dressing, toileting, bathing, and eating.[16] Dressing requires reasoning skills to choose appropriate clothing to wear for the day, and individuals are no longer able to cope with the decision-making process; as well, individuals become unable to logically sort out the arms and legs of their clothing.[1]


In middle stage AD, individuals begin to omit steps as they attempt to complete ADL tasks.[16][1] This can have a serious impact on daily functions, for example personal hygiene, if a person initiates toileting but forgets to use the toilet paper.[1] Alternatively, individuals may also repeat steps or perseverate on tasks. For example, an individual may not be able to finish bathing independently because she continues to wash the same area of her body repeatedly.[1]


From a physical perspective, visual skills begin to decline during middle stage AD, resulting in compromised depth perception, which can increase the risk of falls.[16] It also causes difficulties in grasping objects, and individuals with AD often knock objects over accidentally.[1] Functionally, these deficits usually lead to challenges with eating, as individuals with AD experience difficulties holding utensils or picking up cups.[1]


Lack of safety awareness also becomes a major barrier to a person’s ability to engage in independent self-care as the progressive deterioration of cognitive functions can lead to confusion and wandering.[1] If not supervised, individuals with AD can easily become disoriented or lost.[15] They may also no longer be able to distinguish between different items, which can result in serious consequences if things like cleaning products are mistaken for juice.[15]

Severe AD

By late stage AD, a person’s cognitive abilities deteriorate to a point where individuals will actively withdraw from stimuli and their attention span decreases from minutes to only seconds.[15] Psychosocial and physical functional abilities also decline to the point where individuals require total assistance with ADLs, and can no longer participate in any former IADLs or leisure activities.[1]

Self-care

Individuals in late stage AD are dependent on others for all ADLs, including dressing, bathing, toileting and eating[17][1] At this stage, individuals become incontinent of bowel and bladder and require assistance with their toileting needs.[7] Eating also becomes an area of significant concern as dysphagia develops, leading to a reduced ability to chew and swallow food.[18][19][20]

Physical deficits progress to the point where individuals are unable to ambulate or mobilize safely, resulting in the need for wheelchairs and assistance in transfers as well as mobilizing in bed.[1] Individuals are at risk for pressure ulcers which are caused by factors such as poor hygiene, excess moisture from incontinence, immobility, and poor positioning in bed or while seated.[17]

Occupational Therapy Interventions

Although the progression of AD is considered inevitable and irreversible, occupational therapy (OT) has been proven as an effective tool for enhancing occupational performance, which in turn, increases individuals’ sense of usefulness, enjoyment, and identity [21], and decreases adverse behaviour.[22] OT intervention aims to enhance the personal capacities of individuals with AD, change thinking about client behaviour and caregiver roles, improve the supervision/coping skills of the caregivers, and adapt the physical environment to maximize function and quality of life.[23] 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.[24]


In order to be effective, occupational therapy interventions should be individualized, focusing on clients’ specific needs, in their specific contexts, for the specific stage of their disease.[2] To accomplish this, occupational therapists (OTs) work as a part of a multidisciplinary team, utilizing their skills to assess functional abilities, occupational performance, and client and caregiver needs.[24]

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, interests, etc.[25] However, OTs must take into consideration various factors that can impact assessment results. For example, OTs must pay close attention to non-verbal communication demonstrated by clients with dysphasia, such as posture, facial expression, reactions, tone of vocalisations, etc.[25] 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.[25]

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

  • Large Allen’s Cognitive Level Screen (LACLS): A cognitive screen used for treatment planning.[24]
  • Assessment of Motor and Process Skills (AMPS): A motor function assessment in which a client is observed performing an activity of their choosing.[24]
  • Canadian Occupational Performance Measure (COPM): A semi-structured interview used to assess changes in client self-perception of occupational performance.[2]
  • Pool Activity Level Instrument (PAL): A checklist about activity levels for caregivers to report.[24]
  • Braden Scale for Predicting Pressure Sore Risk (Braden Scale): A risk assessment for pressure sores.[26]

Occupational Therapy Interventions for Mild AD

Caregiver Education

Client and caregiver education occurs as part of the collaborative OT process and is inextricably linked to assessment and intervention. Family caregivers tend to experience negative changes related to the increased burden of responsibility.[27][23] To help alleviate some of these difficulties, OTs can offer education on coping with the burden of care and challenging behaviours.[23] Providing information detailing the nature of AD is an important first step. It helps caregivers accept the diagnosis, deal with feelings of guilt, set realistic expectations, respond more appropriately to clients’ needs, and recognize the need for assistance in the delivery of care.[23] One area of emphasis with caregivers is the importance of choosing meaningful activities for individuals with AD and focusing on activity participation rather than just activity outcome.[28]

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

  • Supervision,[27]
  • Communication[27]
  • Environmental adaptations[27]
  • Maintaining function[27]

Cognitive Intervention

Cognitive interventions include a variety of strategies to improve or maintain cognitive functioning and compensate for lost cognitive functioning.[29] In the context of working with individuals with AD, cognitive interventions aim to maximize daily functioning through three different approaches:

  • Cognitive Training: Aims at maintaining or improving specific cognitive functions such as memory, language, and attention through the regular use and practice of those functions.[29]
  • Cognitive Stimulation: Aims at encouraging and enhancing cognitive and social functioning through interaction with socially-stimulating environments and cognitively-stimulating activities.[29]
  • Cognitive Rehabilitation: Aims at building on the strength of preserved aspects of memory and compensating for impaired aspect of memory.[29]

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.[15] 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.[16] These environmental cues help to sustain independence for as long as possible, as well as provide individuals with an increased sense of well-being.[16]

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[1] and caregivers often find themselves having to make difficult decisions about the future care of their loved ones.[30] Middle stage AD is often when individuals begin to demonstrate increasingly challenging behaviour, which increases the likelihood of requiring placement in a full-time care facility.[1][16] During this stage, OT intervention begins to focus more on 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.[7] After assessment of individuals’ abilities, challenges, and related safety concerns, OTs can make recommendations for adaptive/safety equipment and advise caregivers on how to best adapt self-care activities to maximize the individuals’ participation and well-being.[15] For example, in dressing, OTs may recommend simple dressing aids, trying new techniques, or the use of machine-recorded instructions to decrease the complexity of the activity.[31][32]

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.[16] Normalizing activities are one type of intervention that can help maintain or improve positive behaviour by reinforcing occupational meaning, by relating activities to a role an individual with AD previously held.[16] 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.[16]Individuals in middle stage AD may also benefit from group activities facilitated by an OT.[33] 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.).[34] However, OTs must keep in mind that if stimulation becomes overwhelming for individuals in group sessions, it can have lead to adverse behaviours.[16]

Safety

Addressing and preventing safety risks also becomes a major area of concern for OTs working with individuals in middle stage AD, especially as these individuals typically experience an increased risk of falls.[35] Interventions often include the introduction of falls risk alert cards, exercise and education programmes, and hip protectors.[35]

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 activity participation, skin integrity, swallowing safety [18][19][20]and contracture care.[7]

Contractures

Finally, individuals with late stage AD may experience contractures of their joints and muscles due to prolonged immobility.[7] While existing contractures may not be corrected by exercise and stretching, evidence suggests that some biomechanical interventions can help slow their progression.[7]

Skin Integrity

OTs also play a significant role in pressure ulcer prevention and management by recommending various strategies, such as increasing the frequency of bed or chair repositioning as well as the use of specialized cushions and mattresses.[17] It is important to note that, while specialized cushions and mattresses can decrease the risk of pressure ulcers, they also have the potential to decrease individuals’ mobility during repositioning or transfers due to their immersing properties.[17]

Swallowing

If individuals with late stage AD experience problems with eating or swallowing [18][19][20], OTs are often involved in their dysphagia care.[19] Interventions can include making recommendations on feeding plans (e.g. changing the textures and thicknesses of foods and liquids for easier swallowing) or rehabilitation of performance components that affect swallowing (e.g. cognition, postural control, and perception).[19]

Leisure

OTs work closely with caregivers to design sensory-based activities that can provide comfort, stimulation, and joy and decrease isolation [33][15] by providing opportunities for interaction and awareness of the environment (even if they last only a few minutes).[33][15] Examples include batting a balloon, mimicking others’ actions, looking at brightly coloured stimuli, or rocking in a chair.[33]

==References==

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21 1.22 1.23 Fraker J. Dementia. In: Atchison B, Dirette D, editors. Conditions in occupational therapy. Philadelphia: Lippincott Williams & Wilkins; 2007. p. 139-166.
  2. ↑ 2.0 2.1 2.2 2.3 Canadian Association of Occupational Therapists. Enabling occupation: an occupational therapy perspective. Ottawa: CAOT Publications ACE; 2002.
  3. ↑ 3.0 3.1 3.2 McDonald R, Craig L, Hong N. The etiology of age-related dementia is more complicated than we think. Behav Brain Res. 2010; 214: 3-11. doi:10.1016/j.bbr.2010.05.005.
  4. ↑ 4.0 4.1 4.2 Qui C, Fratiglioni L. Epidemiology of Alzheimer’s disease. In: Waldemar G, Burns A, editors. Alzheimer’s disease. New York: Oxford University Press; 2009. p. 17-26.
  5. ↑ 5.0 5.1 5.2 Brookmeyer R, Johnson E, Ziegler-Graham K, Arrighi HM. Forecasting the global burden of Alzheimer's disease. Alzheimer's and Dementia: JAD. 2007 July; 3(3):186–191. doi:10.1016/j.jalz.2007.04.381.
  6. ↑ Zahn R, Burns A. Dementia disorders: an overview. In: Waldemar G, Burns A, editors. Alzheimer’s disease. New York: Oxford University Press; 2009. p. 1-8.
  7. ↑ 7.00 7.01 7.02 7.03 7.04 7.05 7.06 7.07 7.08 7.09 7.10 7.11 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.
  8. ↑ 8.00 8.01 8.02 8.03 8.04 8.05 8.06 8.07 8.08 8.09 8.10 Lleo A, Blesa R. Clinical course of Alzheimer’s disease. In: Gunhild W, Austair B, editors. Alzheimer’s disease. New York: Oxford University Press; 2009. p. 9-17.
  9. ↑ 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 Reed KL. Quick reference to occupational therapy. 2nd ed. Gaithersburg: Aspen; 2000.
  10. ↑ 10.0 10.1 10.2 10.3 Dubois B, Feldman HF, Jacova C, DeKosky ST, Barberger-Gateau P, Cummings J, et al. Research criteria for the diagnosis of Alzheimer’s disease: revising the NINCDS-ADRDA criteria. Lancet [Internet]. 2007 Aug [cited 2011 Mar 23];6(8):734-46. doi:10.1016/S1474-4422(07)70178-3.
  11. ↑ Burgener SC, Dickerson-Putman J. Assessing patients in the early stages of irreversible dementia. J Ger Nur. 1999 Feb; 25(2):33-41
  12. ↑ Allen CK, Earhart CA, Blue T. Occupational therapy treatment goals for the physically and cognitively disabled. Bethesda: American Occupational Therapy Association; 1992.
  13. ↑ Frittelli C, Borghetti D, Iudice G, Bonanni E, Maestri M, Tognoni G, et al. Effects of Alzheimer's disease and mild cognitive impairment on driving ability: a controlled clinical study by simulated driving test. Int J Geriatr Psychiatry. 2009 July; 24:232–238. doi:10.1002/gps.2095.
  14. ↑ Ohman A, Nygard L, Borrell L. The vocational situation in cases of memory deficits or younger-onset dementia. Scan J Car Sci. 2001 Mar; 15(1):34-43. doi:10.1046/j.1471-6712.2001.1510034.x.
  15. ↑ 15.0 15.1 15.2 15.3 15.4 15.5 15.6 15.7 Cole MB, Tufano R. Applied theories in occupational therapy: a practical approach. Thorofare: Slack Inc; 2008.
  16. ↑ 16.00 16.01 16.02 16.03 16.04 16.05 16.06 16.07 16.08 16.09 16.10 Carson VB, Smarr RR. Becoming an Alzheimer’s whisperer: responding to challenging behaviors. Home Healthc Nurse. 2007 Nov/Dec; 25(10):628-636. Cite error: Invalid <ref> tag; name "Carson" defined multiple times with different content
  17. ↑ 17.0 17.1 17.2 17.3 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
  18. ↑ 18.0 18.1 18.2 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.
  19. ↑ 19.0 19.1 19.2 19.3 19.4 Avery W. Dysphagia. In: Radomski MV, Latham CT, editors. Occupational therapy for physical dysfunction. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2008. p. 1322-1339.
  20. ↑ 20.0 20.1 20.2 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.
  21. ↑ Egan M, Hobson S, Fearing VG. Dementia and occupation: a review of the literature. Can J Occup Ther. 2006 Jun; 73(3):132-40.
  22. ↑ Baum C. The contribution of occupation to function in persons with Alzheimer’s disease. J Occ Sci. 1995 Aug; 2(2):59-67.
  23. ↑ 23.0 23.1 23.2 23.3 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.
  24. ↑ 24.0 24.1 24.2 24.3 24.4 Warren A. Dementia. In: McIntyre A, Atwal, A, editors. Occupational therapy and older people. Oxford: Blackwell Publishing Ltd; 2005. p. 70-72.
  25. ↑ 25.0 25.1 25.2 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.
  26. ↑ 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
  27. ↑ 27.0 27.1 27.2 27.3 27.4 Hogan VM, Lisy ED, Savannah RL, Henry L, Kuo F, Fisher GS. Role change experienced by family caregivers of adults with Alzheimer's disease: implications for occupational therapy. Phys Occup Ther Geriatr [Internet]. 2004 [cited 2011 Mar 16];22(1): 21-43. Availabe from PsychINFO: http://tinyurl.com/4mu7a9a doi:10.1300/J148v22n01_02
  28. ↑ Chard G, Liu L, Mulholland S. Verbal cueing and environmental modifications: strategies to improve engagement in occupations in persons with Alzheimer disease. Phys Occup Ther Geriatr [Internet]. 2009 [cited 20011 Mar 12];27(3):197-211. Available from CINAHL: www.cinahl.com/cgi-bin/refsvc?jid=307&accno=2010251600 doi:10.1080/02703180802206280.
  29. ↑ 29.0 29.1 29.2 29.3 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.
  30. ↑ 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.
  31. ↑ 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.
  32. ↑ 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.
  33. ↑ 33.0 33.1 33.2 33.3 Banzan-Salazar E. Alzheimer’s activities that stimulate the mind. New York: McGraw-Hill; 2005.
  34. ↑ 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.
  35. ↑ 35.0 35.1 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.
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