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Guideline Summary
Guideline Title
Occupational therapy practice guidelines for adults with Alzheimer's disease and related disorders.
Bibliographic Source(s)
Schaber P. Occupational therapy practice guidelines for adults with Alzheimer's disease and related disorders. Bethesda (MD): American Occupational Therapy Association, Inc.; 2010. 198 p. [279 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Alzheimer's disease and related disorders

Note: The term Alzheimer's disease and related disorders is used to include those brain diseases that may be presented concurrent with Alzheimer's or undistinguishable from Alzheimer's disease. In this guideline, Alzheimer's disease is the general term used; it may include other dementias such as Lewy bodies.

Guideline Category
Counseling
Evaluation
Management
Prevention
Rehabilitation
Clinical Specialty
Family Practice
Geriatrics
Internal Medicine
Neurology
Nursing
Physical Medicine and Rehabilitation
Preventive Medicine
Psychiatry
Psychology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Health Plans
Hospitals
Managed Care Organizations
Nurses
Occupational Therapists
Other
Physical Therapists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers
Utilization Management
Guideline Objective(s)
  • To provide an overview of the occupational therapy process for adults with Alzheimer's disease and related disorders
  • To define the occupational therapy domain and process and interventions that occur within the boundaries of acceptable practice
  • To help occupational therapists and occupational therapy assistants, as well as the individuals who manage, reimburse, or set policy regarding occupational therapy services, understand the contribution of occupational therapy in treating adults with Alzheimer's disease and related disorders
  • To serve as a reference for health care professionals, health care facility managers, education and health care regulators, third-party payers, and managed care organizations
Target Population

Adults with Alzheimer's disease and related disorders and their caregivers

Interventions and Practices Considered
  1. Referral for occupational services
  2. Evaluation
    • Developing the occupational profile
    • Analysis of occupational performance through observation and assessment
  3. Intervention process
    • Developing an intervention plan
    • Intervention implementation through creating, restoring, maintaining, modifying, and preventing deterioration of occupational performance
    • Intervention review
    • Developing interventions related to areas of occupation, performance skills and performance patterns, contexts and environments, activity demands, and client factors
  4. Discontinuation of service
  5. Documentation
Major Outcomes Considered
  • Performance skills
  • Performance patterns
  • Quality of life
  • Health
  • Client or caregiver satisfaction

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Seven focused questions were developed for the evidence-based literature review of occupational therapy interventions for adults with Alzheimer's disease. The questions were generated in conjunction with a group of content experts in Alzheimer's disease and evidence-based practice. They were developed and reviewed to provide needed information to update the previously published guidelines for the practice of occupational therapy for adults with Alzheimer's disease.

The following focused questions were included in the review:

  1. What is the evidence for the effect of interventions designed to establish, modify, and maintain activities of daily living (ADLs), instrumental activities of daily living (IADLs), leisure, and social participation on the quality of life, health and wellness, and client and caregiver satisfaction for persons with dementia? (Areas of Occupation)
  2. What is the evidence for the effect of interventions designed to modify and maintain perceptual abilities on the occupational performance of people with dementia? (Perception)
  3. What is the evidence for the effectiveness of interventions designed to establish, modify, or maintain routines on the occupational performance, quality of life, health and wellness, and client and caregiver satisfaction of people with Alzheimer's disease? (Routines)
  4. What is the effect of environmental-based interventions (e.g., Montessori and Snoezelen) on performance, affect, and behavior in both the home and institutions for people with Alzheimer's disease? (Environment)
  5. What is the effectiveness of interventions designed to modify the activity demands of the occupations of self-care, work, leisure, and social participation for people with Alzheimer's disease? (Activity Demands)
  6. What is the evidence for the effect of interventions to prevent falls in people with dementia? (Fall Prevention)
  7. What is the effectiveness of educational and supportive strategies for caregivers of people with dementia on the ability to maintain the participation in that role? (Caregiver Strategies)

Inclusion and exclusion criteria are critical to the systematic review process because they provide the structure for the quality, type, and years of publication of the literature incorporated into a review. The review of all seven questions was limited to the peer-review scientific literature published in English. The review also included consolidated information sources such as the Cochrane Collaboration. Except as described here, the literature included in the review was published since 1987, with the study populations including participants with dementia or their caregivers. The review excluded data from presentations, conference proceedings, non–peer-reviewed research literature, research reports, dissertations, and theses.

One team reviewed intervention questions focusing on areas of occupation, perception, and routines. These reviews included literature published between 1994 and 2005. The areas of occupation review included interventions that focused on at least one of the following: ADLs, IADLs, leisure, or social participation. Studies were considered for the review if they included at least one of the following outcome measures: quality of life, health, wellness, and client or caregiver satisfaction. Articles with study samples of people with AIDS-related dementia were excluded from the review. The perception review included studies that described and evaluated interventions that targeted perception, either improving or maintaining perception, or using remaining perceptual abilities. In addition, studies included in the perception review reported functional or occupational performance outcomes. The routines review included studies that described an intervention on the basis of the use of routine, described responses to the use of routine in the course of daily care, or described interactions during routines. Studies were excluded from the review if there was no report of data or systematic observations of the outcomes of the use of routines. For all three reviews, the following databases were searched: AgeLine, CINAHL, Medline, PsycInfo, EMBASE, and HealthSTAR. In addition, the Cochrane Library, OT Seeker, and Allied and Complementary Medicine were searched for the perception and routines questions. Bibliographies of selected studies in all three reviews were hand searched to locate additional potential articles. Team members developed the search strategies, and a research librarian with a specialty in rehabilitation science was consulted to finalize the search strategy. Table D2 in the original guideline document presents the search strategies for all three reviews. A team member conducted the searches, and review members discussed the search results to ensure that key articles or areas of research had not been overlooked and that articles met the inclusion criteria. Group consensus was used to resolve any uncertainties. For the review focusing on areas of occupation, 6,621 titles and abstracts were reviewed, and 291 articles were reviewed in full. Twenty-six articles fulfilled the inclusion and exclusion criteria for the review. A total of 3,766 titles and abstracts were reviewed from the perception search, and 111 of those articles were retrieved. Twenty-eight articles were included in the final review. For the review focusing on routines, 823 titles and abstracts were reviewed, and 24 articles were retrieved. Fourteen articles were included in the routines review.

The second team conducted the reviews on the environment, activity demands, fall prevention, and caregiver strategies. All reviews were completed in 2007 with the exception of the review on caregiver strategies, which was completed in 2008. Participants of the included studies were people with dementia, except for the falls and caregiver strategies, which focused on the caregivers. Interventions included in all reviews were specific to the question (e.g., interventions for activity demands related to self-care and other ADLs, IADLs, work, leisure, or social participation) and fit within the scope of practice of occupational therapy practitioners. This set of reviews included Level I, II, and III studies, except for the environment review, which included a Level IV study. For all reviews, the following databases were searched: Medline, OT Search, AgeLine, CINAHL, PsycInfo, Google Scholar, Academic Search Premiere, Science Direct, and Web of Science. In addition, the Cochrane Library was searched for the falls and caregiver strategies reviews. Search strategies were developed by the team leader, and a medical librarian, American Occupational Therapy Association (AOTA) staff, and a consultant to the AOTA Evidence-Based Practice Project reviewed them. Table D3 in the original guideline document presents the search strategies for the four questions reviewed by the second team. The team leader performed additional searching to update the reviews. A total of 17,000 abstracts were reviewed for the four-question search, and 127 articles were reviewed in depth. From those, 62 articles met the inclusion and exclusion criteria for final selection.

Number of Source Documents

129 articles

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence for Occupational Therapy Outcomes Research

Levels of Evidence Definitions
Level I Systematic reviews, meta-analyses, randomized controlled trials
Level II Two groups, nonrandomized studies (e.g., cohort, case-control)
Level III One group, nonrandomized (e.g., before and after, pretest and posttest)
Level IV Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)
Level V Case reports and expert opinion that include narrative literature reviews and consensus statements

Note: From "Evidence-based medicine: What it is and what it isn't," by D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, 71–72.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

The two teams working on each focused question reviewed the articles according to their quality (scientific rigor and lack of bias) and levels of evidence. Each article included in the review was then abstracted using an evidence table that provides a summary of the methods and findings of the article, an appraisal of the strengths and weaknesses of the study on the basis of the design, methodology, and implications for occupational therapy. Review authors also completed a Critically Appraised Topic (CAT), a summary and appraisal of the key findings, clinical bottom line, and implications for occupational therapy of the articles included in the review for each question. Review authors also completed Critically Appraised Papers for all articles included in the perception and routines reviews and the Level I, II, and III articles for the occupation review. American Occupational Therapy Association (AOTA) staff and the Evidence-Based Practice Project consultant reviewed the evidence tables and CATs to ensure quality control.

Limitations of selected studies incorporated in the review include small sample size, lack of power analysis, and limited detail regarding recruitment of participants. In several cases, the study group was heterogeneous and may not have been representative of the population with dementia. Depending on the level of evidence, there may have been a lack of randomization, lack of control group, and limited statistical reporting. In many cases, the studies included both a limited description of the outcome measure and explanation of the psychometric properties of the measures. In some cases, the outcome measures were subjective, and there was limited follow-up of the intervention. It is difficult to separate the effects of a single intervention that is part of a multimodal intervention. In addition, adverse effects of an intervention may not have been included, and some studies did not control for confounders in the analysis. Several of the qualitative studies were limited by the amount of information provided about the data collection and analytic procedures. Because several were published before 2001, the review author indicated that this may be a reflection of fewer demands related to trustworthiness and credibility as part of a general limited understanding of qualitative research in older literature.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

Not stated

Rating Scheme for the Strength of the Recommendations

Strength of Recommendations

A—Strongly recommend that occupational therapy practitioners routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and concludes that benefits substantially outweigh harm.

B—Recommend that occupational therapy practitioners routinely provide the intervention to eligible clients. At least fair evidence was found that the intervention improves important outcomes and concludes that benefits outweigh harm.

C—No recommendation is made for or against routine provision of the intervention by occupational therapy practitioners. At least fair evidence was found that the intervention can improve outcomes but concludes that the balance of the benefits and harm is too close to justify a general recommendation.

D—Recommend that occupational therapy practitioners do not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harm outweighs benefits.

I—Insufficient evidence to recommend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harm cannot be determined.

Note: Recommendation criteria are based on standard language developed by the Agency for Healthcare Research and Quality (2009).

Cost Analysis

The guideline developers reviewed published cost analyses.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

Content experts reviewed this guideline.

Recommendations

Major Recommendations

Referral

In the early stages of Alzheimer's disease, referral to occupational therapy is appropriate when an individual exhibits a decline or impairment in performance of functional activities because of problems with thinking, memory, or executive function. The individual may report general memory or communication difficulties to a health care provider, but often a family member is the one who raises concerns about occupational performance in instrumental activities of daily living (IADLs) and hazardous activities such as cooking on a stovetop, operating machinery, or getting lost when driving. These concerns are frequently echoed by adult children, employers, friends, and community members. In the early stages of the disease, a referral is indicated if cognitive limitations are barriers to participation in daily living skills, social activities, leisure interests, or work and volunteer activities. In the middle stages of the disease, additional indications for referrals may be to determine service needs such as home health assistance, memory care or day service programs, or caregiver respite support. In later stages of the disease, occupational therapy is referred to resolve barriers to performance in self-care or to manage challenging behaviors such as agitation, aggression, disruptive vocalizations, wandering, altered sleep–wake cycles, catastrophic reactions, or frustrations related to communication problems.

Referrals may be initiated by a client or a family member or may come from a physician (geriatrician, geropsychiatrist, neurologist, family practitioner), nurse (nurse practitioner, public health nurse), neuropsychologist, or social worker. The referral may indicate a specific purpose for the occupational therapy evaluation, such as cognitive performance testing for diagnostic information (for the physician, the presence of cognitive deficits that affect functional performance may discriminate mild cognitive impairment from dementia; a physician would use this information in diagnosing) or be a general order for an evaluation and intervention. For some clients, their first encounter with occupational therapy is in rehabilitation in a transitional or subacute care unit after a precipitating event, such as a fall or illness. A cognitive functional screening as part of an occupational therapy evaluation may serve as a referral for further cognitive assessment. Some specialty memory disorder clinics that use a team approach have a standing referral for clients that includes occupational therapy evaluation as an integral part of a comprehensive assessment for dementia.

Evaluation

The occupational therapy evaluation is conducted with the client, caregiver or family member, or health care proxy to facilitate an accurate exchange of information. Questions should be directed toward the client, allowing the client to take an active and central role in the interview process. Others present should be encouraged to provide additional information, if appropriate. Information is gathered through an occupational profile (interview), analysis of occupational performance (observation), and standardized and nonstandardized assessments. This section of the Guideline outlines areas for evaluation using the Occupational Therapy Practice Framework (see "Availability of Companion Documents" field) classification and justifies the rationale as it relates to characteristics of Alzheimer's disease.

The occupational therapist obtains client information through the occupational profile to determine barriers to occupational performance. If cognition is the primary concern limiting participation, a brief cognitive assessment using a screening tool such as the Large Allen Cognitive Lacing Screen is administered to determine whether a full cognitive functional assessment is warranted. Some standardized cognitive functional assessments such as the Cognitive Performance Test (CPT) or the Executive Function Test may require additional training to administer and interpret, reflecting a specialized area of practice.

An individual with cognitive deficits may exhibit a decline or impairment in performance of functional activities caused by comorbidities that affect motor and praxis, sensory-perceptual, emotional regulation, cognitive, communication, and social skills. One difficulty in assessment with comorbidities is delineating the source of the performance deficit. With clinical expertise, all factors that limit occupational performance are considered, along with thinking, memory, or executive function abilities. These factors need to be considered when selecting valid assessment tools. For instance, verbally based assessments may not be valid when auditory deficits are present, and perceptual tests lose validity when visual deficits are evident. Through skilled selection and administration of the assessment and interpretation of the results, the occupational therapy evaluation contributes to an individualized intervention plan.

Occupational Profile (Family/Caregiver Profile)

The occupational profile is a nonstandardized assessment to obtain background information about the client (see Table 3 in the original guideline document). It includes demographic information about the client, family members, living situation, employment or employment history, education, caregivers or people responsible for care, diagnoses including mental health diagnoses, resources, and reasons for the referral. Questions about leisure interests, strengths and limitations to participation in daily activities, and goals of intervention can be included (see Table 4 in the original guideline document for sample questions). The Canadian Occupational Performance Measure is an evidence-based, standardized tool used to identify occupational performance issues and to prioritize the selection of intervention goals with client and family input. Client and family goals are obtained to guide the family-centered intervention process.

The occupational profile includes the client and family member's description of the cognitive or memory impairments that may affect safety. Through the interview, the occupational therapist gains a sense of the client's self-awareness of disability. Self-awareness is important in making recommendations about supportive living situations and levels of assistance needed to remain safe in the home environment. Family members should be asked to describe their observation of the client's memory or thinking problems. The client's perception may differ from the family member's perception, especially in the middle to later stages of the disease, which will influence the strategies for intervention. Observation of the client provides an opportunity to screen for client factors that may guide the appropriate selection of assessments.

An occupational history provides information regarding participation in daily activities. "Describe a typical day" is a standard question. The client will identify activities he or she is able to perform or enjoys doing and may be considered the client strengths. Often these activities are habits or routines that are well rehearsed or rote, drawn from long-term or procedural memory. An occupational history includes information about those activities the client used to do but now finds challenging. An "interest checklist" can stimulate discussion about activities the client desires to continue and barriers to participation. Attention to the amount of time the person is engaged in activities is important because of the tendency to socially isolate or sleep for lengthy periods during the day or the propensity for occupational deprivation (obstructing occupational enjoyment because of disease) in the middle to later stages of the disease.

An important part of the occupational profile is to gain information about the physical environment, or living situation, and social environment, or available caregiver support. Key to effective management of the disease is providing environmental supports for safety and optimal functioning. Clients with dementia symptoms come to an evaluation from a variety of living situations with different levels of support—from living independently in a single family home to residing in a memory care facility with 24-hour supports in place. Promotion of security is targeted to prevent the six most common household injuries: falls and slips, burns, poisoning, cuts, electrocution, and drowning. A home safety assessment such as the Home Environmental Assessment Protocol or Safety Assessment of Function and the Environment for Rehabilitation can highlight necessary adaptations to the home to promote a safe environment and support caregiver supervisory responsibilities.

A significant factor in managing care throughout the course of the disease is the presence of a caregiver. A study on residential transition found the presence of potential caregivers had a statistically significant effect on the risk of transition from home to institutional placement. Aging in place, in which services and resources are added as needed to a person in his or her natural environment, requires the availability of adequate supports. Families with increased contact through geographic proximity, phone, mail, and e-mail have a greater propensity to provide informal family care and promote aging in place. Family members may live geographically close but be unable to provide the supervision or assistance needed for safety and proper care. With a spousal caregiver, some clients are able to live in the community into the middle and even later stages of the disease.

Analysis of Occupational Performance

In conjunction with the occupational profile, the occupational analysis includes observations or interviews to obtain information about areas of occupation, performance skills and patterns, contexts, activity demands, and client factors. Analysis includes administration and interpretation of select standardized and nonstandardized assessments in specific performance areas where more information is needed (see Table 5 in the original guideline document for assessments). With Alzheimer's disease, a key piece of the assessment process is a measure of cognitive functional abilities, or how the person draws from thinking and memory to organize and execute daily tasks.

The impact of cognition on performance skills and performance patterns must be considered in the selection and administration of standardized and nonstandardized assessments. Other client factors such as hearing acuity, visual perception, sensory processing, motor and praxis skills, or comorbidities such as chemical dependence, anxiety disorder, and depression need to be factored into the clinical reasoning process. The occupational therapist has the expertise to synthesize all evaluation results, including activity demands specific to the client, and to determine targeted outcomes of intervention. Because of the progressive nature of Alzheimer's disease, new learning is not the focus of the intervention; rather, caregiver education, environmental adaptations, and compensatory strategies in a family-centered care approach are recommended.

Cognitive functional assessments provide information about current capabilities and predictions about future performance in areas of occupation and needs for environmental supports. Although some cognitive assessments are verbally based or administered through client and family report, the most accurate are through direct observation of performance. The Kitchen Task Assessment is a standardized, observation-based assessment tool to measure six performance areas on a 3-point scale (0 = independent, 3 = totally incapable): initiation of task, organization, performance of steps, sequencing, judgment and safety, and completion of the task. The assessment is portable and easily administered in a home-based evaluation.

The CPT is a standardized, performance-based, seven-task assessment that measures global cognition. The score, an average of the seven subtests, has been used to predict performance of IADLs and activities of daily living (ADLs). The CPT was investigated for correlation on two measures of the Lawton, IADL (r = .64) and physical self-maintenance (r = .49). The score follows the Allen Cognitive Levels, which range from 6 = normal to 1 = severely impaired, reinterpreted for the Alzheimer's population (see Table 6 in the original guideline document). The CPT assessment also can be administered as a five-task assessment for home care evaluation.

The Executive Function Performance Test is an executive function test. It was developed for people with stroke and corresponding cognitive deficits to determine their capacity to live safely and independently and the level of support they needed. It uses daily living tasks (cooking, managing medications, using the phone, paying bills) to rate a person's executive function components: initiation, organization, sequencing, safety and judgment, and completion. It rates the level of cueing required to perform the task from minimum cueing (verbal guidance) to maximum cueing (doing for the person).

Other assessments of cognition are administered by many disciplines and are verbally based. The Mini-Mental Status Exam (MMSE) can be administered by occupational therapy practitioners and is the only short cognitive screening tool recommended by the American Academy of Neurology. For people presenting with relatively strong functional skills and mild cognitive impairment, a referral for neuropsychological testing is recommended. Neuropsychological testing, which measures dimensions of memory, attention, executive function, processing speed, recall, and learning, can distinguish normal aging from mild cognitive impairment or Alzheimer's disease.

Although cognition is the key area of assessment, other performance tasks can be assessed as part of a comprehensive evaluation with clients with Alzheimer's disease. The process scale of the Assessment of Motor and Process Skills (AMPS) has been used to determine people's potential to live independently in the community. The Performance Assessment of Self-Care Skills rates ADL and IADL performance in three areas: independence (amount of assist needed), safety, and adequacy. The scores can guide the occupational therapist in the selection of activities for intervention planning. The Routine Task Inventory is a rating of four areas: physical scale—ADLs, community scale—IADLs, communication scale, and work readiness scale. The score, obtained on the basis of observation or self- or caregiver report of assistance required, uses the Allen 6-point scale (6 = independent, 1 = total assistance).

Additional occupational therapy assessments may be included on the basis of client comorbidities or reported problems in target areas. With low endurance, a brief screening assessment, the 6-minute walk test, can be used to determine community mobility skills. People with dementia have a higher risk of falls; a history of falls within the past year is a strong predictor of future falls. A brief balance screen, the Functional Reach Test, can be used to determine risk for falls. Appropriate falls assessments like the AMPS or the Tinetti Assessment Tool can be administered, and prevention programs can be activated. For reported driving concerns, a formal driving evaluation by trained professionals that includes an on-road driving component can determine fitness to drive for people with mild Alzheimer's disease.

Areas of Occupation

The purpose of an occupational therapy evaluation is to design an intervention plan to create opportunities for participation, maintain occupational performance or modify activity demands, or prevent deterioration in performance capability. The area of occupation targeted depends on the cognitive ability of the client and stage of the disease. For instance, the focus of intervention in the early stage is work or employment, if applicable, and IADL participation, whereas the focus in the middle and later stages of the disease is ADL performance. Leisure, social participation, and rest/sleep are considered through the early to the later stages of the disease.

IADLs

Early signs of Alzheimer's disease include family concerns about the client's ability to drive, manage finances, self-administer medications, or make a meal. The concerns usually stem from an incident in which the client got lost while driving to a familiar location, left a stove on, had a rapid weight loss, experienced a medical crisis because of poor medication management, or had unpaid bills because of financial mismanagement. A cognitive assessment along with client and family report on IADL performance can indicate the area of occupation for skilled intervention. For each IADL, the therapist obtains information to determine the amount of monitoring, supervision, or assistance needed to ensure safe and optimal task completion. Table 7 in the original guideline document is a sample of the kind of information needed to make an informed recommendation and educational plan.

Driving is a complex IADL and poses ethical problems for people with Alzheimer's disease. The primary question is when to discontinue driving. Studies have found that drivers with even mild dementia are an increased safety risk. For some clients, an increasing tendency to get lost, more than technical driving skills, needs to be considered. For person with declining abilities, the challenge will be factoring in reports of getting lost, family reports of episodic confusion, and passenger apprehension about riding with the person or transporting their children. The comprehensive driving evaluation is one tool for understanding the interplay between cognitive challenges and onroad performance. However, experts in the field grapple with making this decision based on functional performance (onroad as the gold standard) or cognitive decline reported by families and measured by clinical tests. Additional information on driving and community mobility for people with Alzheimer's can be found in Appendix F of the original guideline document.

ADLs

An occupational therapy evaluation for the middle to later stages of the disease includes a cognitive assessment and ADL assessment. The focus of ADL assessment is on the cognitive capacity to plan, initiate, and complete the task in a safe, consistent (predictable), and efficient manner. The primary caregiver provides information about performance ability in dressing, bathing, grooming, and bowel/bladder control. In the middle stage, ability to complete the task may be present, but performance is inconsistent or inadequate. For example, a client may be able to don a sweater but may wear multilayer clothing inappropriately. In the later stages of the disease, ability to perform may be present, but behavioral concerns such as resistance or combativeness may impede task completion. This situation is especially true with bathing or showering activities. Information about sleep–rest cycles and bowel/bladder control is paramount in making informed decisions about residential settings. These two ADLs have the greatest effect on family decisions regarding home versus residential placement.

Leisure and Social Participation

A history of active engagement in physical leisure activities improves the physical and emotional health of people with Alzheimer's disease. With the disease, there is a gradual withdrawal from leisure activities because of an inability to perform or frustration caused by increased cognitive challenges. Activities that were formerly easy to do may now seem very difficult, which causes anxiety. The propensity for occupational deprivation exists when the activity demands are not altered to meet the changing abilities. There is a tendency to socially isolate, either because of language problems such as expressive or receptive aphasia or word-finding problems, or to hide the disease from former acquaintances. In the early stages of the disease, family members or friends need to encourage the person with Alzheimer's disease to keep him or her engaged and to creatively adapt leisure activities successfully. In the middle to later stages of the disease, specialized programs with adapted activities, such as adult day services, provide an outlet for appropriate activity stimulation. Gathering information about former leisure interests and social groups may lead to more effective intervention planning individually tailored to the client.

Performance Skills

Sensory and perceptual skills are progressively affected throughout the course of Alzheimer's disease. Although all sensory areas may be affected (visual, auditory, tactile, proprioceptive, vestibular, olfactory, and gustatory), the deficits are particular to the individual. One client may report visual perceptual disturbances, whereas another may report an aversion to certain foods or food textures. Astereognosis, in which a person is unable to identify an object by touch, is not uncommon. The degree and type of sensory impairment may be related to the area of the brain most involved. For this reason, the occupational therapy practitioner needs to be aware of individual skills on a case-by-case basis. Standardized visual–perceptual assessments may lack accuracy because of confounding factors such as verbal limitations and cognitive impairments.

Some clients with Alzheimer's disease have good motor skills in the early stages of the disease unless there are comorbidities that affect motor function. They are able to handle objects and complete tasks, especially those tasks that are overlearned and performed in a familiar environment. Motor skills begin to decline in the middle stages of the disease, specifically in the areas of motor planning, sequencing, and executing new movements. For example, a person may be able to insert a key into a lock but may not know the sequence of turn key, turn knob, push door to open. Cognitive deficits impede motor function. For instance, the person may not be able to problem solve the use of different knobs to open the door. In the middle to later stages of the disease, the risk of falls increases as apraxia, or the ability to motor plan, is affected. Falls may be caused by lack of judgment in the ability to descend a staircase, perceptual dysfunction, or failure to set the brakes on a wheelchair when transferring. Motor skills in the later stages of the disease are severely impaired, and the client may require a positioning evaluation for bed, wheelchair, or Geri-Chair.

Emotional regulation is defined as the "actions or behaviors a client uses to identify, manage, and express feelings while engaging in activities or interacting with others." Early diagnosis of Alzheimer's disease is generally accompanied with a sense of loss and grieving if the person has a self-awareness of memory loss. These emotional reactions range from mild depression to overt anger and aggression. Families may encounter increasing frustration as the person has difficulty verbalizing the experience of memory loss or expressing fears about the future. Emotional regulation is evaluated through direct observation or family/caregiver report of behaviors that may be manifesting underlying feelings of confusion. In the later stages of the disease, these behaviors may escalate to aggression or catastrophic reactions and may precipitate a residential change to a facility that is designed to manage challenging behaviors. After assessing emotional regulation, the practitioner can model or educate the caregiver in providing emotional support to the person as the disease progresses.

The primary impact in performance skills is with cognitive deficits. The evaluation includes the rate of progressive cognitive deficits based on client and caregiver report and specific components of cognition. Although the primary cognitive challenge is memory, clients lose executive function, including judgment, problem-solving ability, sequencing, organizing, prioritizing, planning, and initiating. For instance, in the middle stages of the disease, the client may be immobilized by the command "get ready for your appointment." By contrast, the caregiver may offer a coat, initiate donning, and the client will continue through completion. At each stage, cognitive deficits need to be reevaluated to determine the degree of adaptations or supports needed.

Communication and interaction skill deficits range widely among people with Alzheimer's disease. Although some people can hold a cohesive conversation into the middle stages of the disease, others lose the ability to interact early in the disease. This symptom may be manifested as receptive or expressive aphasia. Problems with word finding or recalling recent events impair the flow of conversation, and the individual may retreat from group discussions. The person may be embarrassed by the challenges and may attempt to hide the problem by withdrawing from social situations. Repeating questions or perseverating on a recent event or health problem can lead to annoyances for the primary caregiver. Evaluating communication and social interactions relies on client and caregiver report. The practitioner can gauge the client/caregiver interaction and counsel or model strategies. Effective communication requires patience on the part of the caregiver to reassure and respond multiple times with the same information.

Performance Patterns

Performance patterns are the habits, routines, rituals, and roles in daily activity. Habits become strengths that the person can draw from when he or she is no longer able to remember how to perform. Because habits are automatic, people may engage in an occupation beyond their cognitive ability to do so. A person into the middle and later stages of dementia can function optimally when he or she is able to draw from early learning in long-term memory and replicate skills that are well rehearsed. New learning is challenging with dementia. The person who is unable to learn a new routine may be able to carry out former routines successfully. People with cognitive impairment report that consistency in task demands and stability in their daily environment contributes to decreased stress and anxiety. Part of the evaluation process is to consider the person's former habits, routines, and rituals that were familiar and support occupational performance. The goal for family caregivers is to support habitual behavior and adapt routines for optimal functional performance.

Contexts and Environments

A primary focus of evaluation and intervention with a progressive, cognitive disorder is on the physical and social environment or the cultural, personal, temporal, and virtual contexts that affect occupational performance. These factors can be supports or barriers to engagement in occupation.

Physical Environment

Natural and built nonhuman environment is a key area of evaluation for occupational therapy that has the potential to affect interventions and management of the care of a person with Alzheimer's disease. Environments include the primary living space and places that the person frequents in day-to-day activities. Aging in place means that the environment can be adapted to provide the precautionary supports for safety and independence.

Social Environment

The social environment includes people in the client's life who are able to provide supports in daily living activities. Evaluating the social supports is accomplished through interview of the client and family members. It is important to know who is the primary caregiver and decision maker and the responsibilities that person is willing to accept. The social environment includes both paid (formal) and unpaid (informal) supports. Beyond family members, friends or neighbors also may be willing to provide assistance with weekly or daily tasks.

Cultural Context

Occupational therapy evaluations include information gathered through interview about cultural influences on customs, beliefs, activity patterns, behavior standards, and expectations to design a culturally sensitive intervention. Caregiving is considered a cultural activity, with caregiving outcomes and experiences differing for ethnic groups.

Personal Context

The personal context includes age, gender, educational level, socioeconomic level, marital status, and family composition and should be part of the information obtained in the occupational profile. Alzheimer's disease is an age-related disease in that the greater majority of people in the early to middle stages of the disease are in their later years. Younger onset (before age 65) poses a particular challenge because decisions regarding workforce involvement are emotional and affect self-worth.

Temporal Context

The temporal context refers to the "experience of time as shaped by engagement in occupations." Information about circadian rhythms (a measure of core body temperature and motor activity) is part of the initial interview in an occupational therapy evaluation because of the prevalence of "sundowner's syndrome" in people with Alzheimer's disease. Sundowners is a common term referring to increased motor activity or agitation in the late afternoon or early evening hours. Altered sleep–wake cycles occur in the middle stages of the disease. Altered sleep–wake cycles occur when daytime becomes confused with nighttime.

Virtual (Technology for Home Monitoring) Context

The virtual context, defined as a simulated environment that uses communication technologies in the absence of a human presence, can keep a person safe within his or her own home or in a residential facility. An interview can focus on information about behavioral issues related to wandering or exiting safe areas or potentially hazardous activities that require monitoring.

Activity Demands

Occupational therapy evaluation with people with Alzheimer's disease entails an exploration of the activity demands relative to the client's capabilities. This exploration frequently means interviewing the family members or primary caregivers in daily activity expectations and conducting an activity analysis. Activity analysis is breaking down the activity into components or steps of the process. The client may be competent to complete a task that is broken into step-by-step instructions or may be able to participate in portions of a task. The evaluation process should guide the practitioner in determining an educational plan for the caregiver. This plan may include the amount of assistance for each task, type of assistance, and safest method to approach the task.

Client Factors

Each client with Alzheimer's disease is a unique individual with a distinct set of underlying factors, both physical and motivational. The purpose of the evaluation is to determine what potential the client brings to the intervention process and to identify the barriers to optimal performance on the basis of physiological functions of body systems or personal values and beliefs. The assessments that correspond to specific body functions and are part of the domain of occupational practice can be used with this population with a caveat; if cognition alters the results of the assessment, another means of measuring that function needs to be selected. The individual may have visual deficits that impede unsupervised community mobility, but visual tests may require a cognitive–verbal response. The person with Alzheimer's may have apraxia that contributes to an unsafe environment but may not have the cognitive ability to learn to use a mobility support. A strong belief in self-determination may influence the desire to remain independent, but poor judgment because of cognitive decline may create an unsafe situation for living alone. In addition, evaluating the person's desire to pursue engagement in spiritual activities may influence recommendations in the intervention planning process. Spirituality is a component of quality of life and is connected to the dignity of each person regardless of cognitive awareness. For many areas of evaluation, the information is obtained through the clinical reasoning skills of a trained professional to identify which client factors justify intervention.

Intervention

Goals for Occupational Therapy Practice

For clients with Alzheimer's disease, the goal of occupational therapy intervention is to maximize the quality of life. According to the Occupational Therapy Practice Framework (see "Availability of Companion Documents" field), quality of life is defined as engagement in occupation related to health and participation measured by involvement in work or volunteer activities, leisure, and daily living skills. The emphasis on quality of life is for both the client and caregiver and may involve identifying appropriate supports and resources to ensure safety and well-being. The progressive nature of the disease means occupational therapy intervention occurs at intervals over time. The goals of stage-based intervention change based on the needs of the client at each stage of the disease (see Boxes 2–5 in the original guideline document for case studies in early, middle, and late stages of Alzheimer's disease). Intervention may entail therapeutic use of self by the occupational therapy practitioner to model a behavioral approach in working with a client, occupation-based therapeutic activities that have meaning for the client, consultation with the caregivers and other professionals working with the client regarding progress, family education about the disease progression, or advocacy for the client to receive community services. On a broader population-based scale, intervention may include developing programs for early to middle stages of the disease in community agencies; working on public policy for access to services; or administering services on an organizational, county, or state level.

With all interventions, the challenge is balancing client safety in performance with maximum independence. This balance may involve risk management—allowing greater independence per client choice at the risk of potential harm. The occupational therapy recommendation may be to encourage participation with strategies for safe performance or to limit participation because of the potential for injury and need to ensure safety. With that information, the client and family can make an informed decision with full knowledge of the risks and uncertainties.

Theory-Based Intervention

No single theoretical model guides occupational therapy intervention with people with Alzheimer's disease. Please refer to the original guideline document for a brief description of this model.

Family-Centered Care Model

A standard for occupational therapy intervention planning is to design interventions using a client-centered care model. This approach is a collaborative model with the therapist and client for selecting goals and developing a plan of care. For the client with Alzheimer's disease who is dependent on a family caregiver, intervention planning is frequently conducted using a family-centered care model. This model affects all steps of the evaluation and intervention planning process by including family caregivers in (1) obtaining information for the occupational history, (2) setting goals, and (3) exploring strengths and limitations. Another difference in a family-centered care model is that evidence for practice is drawn from occupational therapy and informed by social sciences research. Moreover, family members may be included in the intervention plan if they assist with self-care, productive activities, leisure pursuits, or social participation. Family-centered care is a collaboration with the therapist, client, and family member(s), and intervention is characterized by caregiver involvement through program implementation, education, and training. In the later stages of the disease, with a residential change to a memory care facility or long-term care institution, a team-centered care model is used to collaboratively select goals and develop a plan of care. At that point, the family becomes an integral part of the health care team.

Intervention Process

The occupational therapy process for intervention with people with Alzheimer's disease includes development of an intervention plan, implementation of the intervention plan, and intervention review. The plan, developed by an occupational therapist and corroborated with the client (family), reflects client and caregiver needs, occupational therapy evaluation, knowledge of theory, and evidence guiding best practice. Intervention implementation is carried out by the occupational therapy practitioner and includes actions taken and activities selected that affect client performance or family responses. Throughout the intervention implementation, the client and family response is monitored and recorded, and the intervention is modified on the basis of progress toward the goals. The implementation review is a review of the plan and includes a periodic measure of progress toward the targeted outcomes.

Occupational Therapy Practice Framework and Alzheimer's Disease

The Occupational Therapy Practice Framework (see "Availability of Companion Documents" field) provides a rubric for occupational therapy intervention approaches (see Table below). Interventions for people with Alzheimer's disease can be designed around creating, restoring, maintaining, modifying, or preventing deterioration of occupational performance.

Table: Occupational Therapy Intervention Approaches for People With Alzheimer's Disease and Family Caregivers, by Stage of Disease

  Stage of Disease
Intervention Approach Early Middle Late
Create or promote Create opportunities to enhance daily involvement in community activities Promote involvement through specialized memory loss programs Involve client in adapted activities designed for changing abilities
Establish or restore Restore functional independence using client and caregiver training and assistive technologies Provide training in daily living skills, establishing consistency in performance patterns Provide habituation training for communication systems and basic feeding, grooming, and dressing
Maintain Build on past skills and habits to maintain present function Develop functional maintenance programs for optimal engagement Maintain physical, social, and occupational engagement at the optimal level
Modify Adjust occupational demands, and increase environmental supports Simplify daily tasks, modify cues, break down sequence to ability level Guide with external supports to enhance participation in portions of the task
Prevent Provide prevention education in targeted areas (e.g., falls, geographic orientation, medication management, financial oversight, options for community mobility) Encourage activity engagement by initiating task and offering step-by-step guidance to minimize daytime sleep Stimulate activity in physical, social, and functional areas through sensory inputs

Discontinuation of Service

Discontinuation of occupational therapy intervention services occurs when clients meet their goals or appear to have reached their maximum potential in the targeted outcomes. With psychoeducational services or caregiver training programs, discontinuation of service occurs when the caregiver demonstrates an understanding of the program and can implement the functional maintenance program competently. Services also may be discontinued if the client refuses intervention or if the family, as legal guardian, requests an end to therapy. Measures of progress are taken at the time of discharge and documented in the appropriate medical or agency record. Outcomes may measure a change in occupational performance, such as greater effectiveness or efficiency, adaptations to compensate for cognitive declines, measures of health or wellness based on medical or family report, increased participation, prevention of excess disability or an absence of decline, or perceived improvement in quality of life of the client or caregiver. A follow-up may be scheduled to inquire about progress and maintenance of goals. With Alzheimer's disease, the follow-up may range from 6 months to 1 year because of the slow progression of the disease. Occupational therapy can reactivate when a referral is generated based on a change of condition or rapid decline in level of performance.

Documentation

An essential part of the evaluation and intervention process is documentation. This includes a documented evaluation report with a summary of occupational performance (see Box 1. Sample Evaluation Report in the original guideline document) intervention plan with measurable goals, progress notes with dates of service, and discontinuation summary with recommendations and/or referrals. Generally, for an occupational therapy intervention to be considered covered under the Medicare program, a service must be

  • Prescribed by a physician and furnished according to a written plan of care, established by the therapist and approved by the physician
  • Performed by a qualified occupational therapist or by an occupational therapy assistant under the supervision of an occupational therapist
  • Reasonable and necessary for the treatment of the person's illness or injury.

Although a mental health diagnosis does not preclude Medicare coverage of occupational therapy, the program does require that goals be related to the patient's condition, reasonable, and measurable. Therefore, it is very important that occupational therapy documentation reflect valid anticipated outcomes of treatment based on a supportable clinical assessment of the individual's condition.

Categorizing Intervention for People with Alzheimer's Disease

Interventions for people with Alzheimer's disease can be categorized in different ways, for instance, by stage of the disease (early, middle, or late stage), by setting (home, assisted living, memory care, institutional care), by caregiver availability (spousal/continuous, adult offspring/periodic, paid aide/scheduled), and by client capabilities (high risk vs. low risk factors). The problem in categorizing intervention approaches is that there is broad individual variation in multiple areas throughout the course of the disease. A general impression of client skills and capabilities can be gained through standardized testing at each stage of the disease; however, each client has a unique constellation of symptoms, degrees of motor and language involvement, behavioral issues, and caregiver availability. These differences require tailoring interventions or individualizing care.

Because there are many factors to be considered with each unique person with the disease, best practice for occupational therapy intervention is tailored to the individual and family/caregiver.

Intervention Areas of Occupation

Interventions in areas of occupation predominantly focus on caregiver education using environmental or compensatory strategies. An occupational therapy educational intervention should be tailored specifically to the person and family seeking services. The goal is maximum participation in areas of occupation at the desired level of the client, weighing risks for safety versus autonomy. Alzheimer's disease is predominantly found in populations ages 65 or older, although younger onset does appear with people in their 50s and early 60s. Therefore, the areas of occupation affected are those in which older adults are engaged, primarily work or volunteer, IADLs, ADLs, leisure, social participation, and sleep. In general, occupational performance goals in the early stage are directed toward participation in work or IADLs; in the middle stage, leisure, social participation, and ADLs; and in the later stages of the disease, social participation and basic ADLs (see table below).

Table: Occupational Therapy Intervention for Early, Middle, and Late Stages of Alzheimer's Disease

Stage of Disease Areas of Occupation Occupational Therapy Intervention
Early stage Work/volunteer
IADLs
Leisure
Social participation
Create opportunities to engage in work/volunteer tasks adapted to client capacity.
Modify environmental and activity demands to reduce frustration and provide caregiver education and training in modifications.
Maintain safe engagement in IADLs with appropriate supports and resources.
Establish primary and secondary social network with family and community.
Promote involvement in leisure activities of choice; adapt leisure activities to client capacity
Middle stage ADLs
Leisure
Social participation
Sleep
Maximize engagement in ADLs through compensatory and environmental adaptations
Train caregivers in tailored activity programs
Create opportunities for leisure skills identifying adequate supervision and concerns for safety
Pursue community-based programs designed for people with cognitive loss
Prevent sleep disturbances through active engagement in daytime activities
Late stage ADLs
Social participation
Sleep
Maintain client factors to participate in ADLs with caregiver support and training
Modify approach to social participation to meet the need for human contact
Prevent co-morbidities related to decreased movement during sleep/rest

Note: ADLs = activities of daily living; IADLs = instrumental activities of daily living.

Intervention Performance Skills and Performance Patterns

Performance skills, defined as motor, sensory–perceptual, cognitive, emotional, and social skills, are affected in people with Alzheimer's disease. The degree of impact follows the stage approach, with skills declining gradually and somewhat predictably over the course of the disease. Declining motor and praxis skills contribute to an increased risk of falls and the eventual need for mobility devices. Disturbing changes in perceptual skills result in getting lost in a familiar environment and the eventual nonrecognition of family members. Emotional regulation weakens as people become increasingly difficult to understand, precipitating behavioral agitation and, ultimately, catastrophic reactions. The ability to communicate declines and caregivers must find alternative methods to uncover the needs the client is attempting to resolve. Intervention with performance skills may involve prevention (e.g., a fall prevention program, validation therapy) or compensation (e.g., enrolling in a Safe Return or Comfort Zone program or feeding program). Behavioral management programs can provide the caregiver with strategies to divert negative emotional reactions and to guide the client in a positive direction.

Clients with short-term memory deficits draw from premorbid abilities and skills embedded in long-term or procedural memory. These splinter skills are remarkable and unique to each person, often related to past routines and habits. The objective of the occupational profile is to identify a person's unique skills and abilities, along with the areas of limitation. The strengths are then incorporated into the plan of intervention to guide recommendations for meaningful, individualized activities.

Performance patterns refer to the habits, routines, roles, and rituals that structure the daily life of an individual. With Alzheimer's disease, habits may disintegrate (both good and bad habits), routines and rituals are affected, and roles are redefined. Disruption in routines can lead to catastrophic reactions and caregiver stress. Interventions include habit training along with positive reinforcement and consistent reassurance. Interventions targeting performance patterns have focused on structuring daytime activity and routines of sleep and toileting.

Intervention Contexts and Environments

Contextual or environmental interventions include environmental modifications, caregiver education and training programs, and access to community resources. Many of the contextual interventions overlap because caregivers make the modifications as part of a larger, multi-strategic intervention plan. For instance, in a case of wandering or way finding, an environmental modification may be to install outside movement sensors and training the caregiver in approaches to guide the client away from and to secure restricted areas. The standard for occupational therapy intervention is to consider the context and environment along with the person and the task and the interaction among these dimensions.

Caregiver education and training is an integral part of occupational therapy intervention for people with Alzheimer's disease. Family interventions include home-based, outpatient, or institutional-based care protocols that can be applied during family visits. Caregiver education includes training staff and paid caregivers in managing daily cares for the client.

Intervention Activity Demands

Occupational therapy intervention includes modifying activity demands to meet client capabilities, interests, and personality style. This intervention includes altering the materials, approach to the task, method of completing the task, assistance provided, or expectations of the product or result. The goal of intervention is to increase the supports (external contextual factors) to mimic the rate of cognitive decline (internal client factors) for optimal successful participation (see Figure 4 in the original guideline document).

Verbal and nonverbal cues by a caregiver are considered an external support and one of the ways of altering activity demands. As the disease progresses, the amount of monitoring increases from periodic monitoring to occasional monitoring to frequent monitoring. Likewise, supervision increases over time. The task may initially require a single demonstration, progressing to multiple demonstrations. Cueing is modified from general instructions to specific instructions, abstract to concrete, multistep to single step. The caregiver initially assists with portions of a task to later assisting with the full task. In later stages of the disease, when the client is unable to physically participate, the client may observe the activity, gradually reducing observation time to accommodate attention span.

Task adaptations are another method of altering activity demands. The task can be adapted by reducing the number of task objects or simplifying the procedures, setting up the task, completing portions of the task before active client involvement, or controlling the environment. If the client can no longer participate in the task, client observation is a form of passive involvement.

Intervention Client Factors

Interventions related to client factors include those that motivate an individual to engage in occupational performance because they match a person's values, beliefs, and spirituality or personal quest for meaning. Interventions targeted toward client factors also include those that affect the physiological (i.e., cardiovascular, respiratory, endocrine) and anatomical structures (skeletal and circulatory). These interventions are designed to enhance the sensory (visual, auditory, tactile, vestibular) and motor systems (strength, balance, coordination) and cognition. Numerous attempts have been made to use interventions directed toward client factors to influence difficult behaviors, increase functional independence, and reduce caregiver burden. Although the intent is to alter client factors directly, many are environmental approaches designed to regulate or stimulate sensory input or compensate for declining abilities. Many of these interventions were previously discussed under environmental modifications with the evidence presented.

Multisensory interventions include programs like Snoezelen, which control sensory input for the individual to alter mood or behavior. Music or auditory regulation of the environment includes reducing extraneous noise like television, intercom systems, buzzers, and alarms. Visual environments such as colors, lighting, space designs, elimination of mirrors, or personnel cues have been used institutionally and incorporated into architectural planning of new environments for dementia care units. Programs like the Eden alternative, a nature-themed environment with plants, animals, and children, have been created with favorable results reported by those living in the facility. Tactile interventions include Healing Touch, a trained intervention to reduce agitation or distress. Rocking chairs or gliders that provide vestibular input are used to subdue clients during nighttime insomnias.

Cognitive interventions include reality orientation and reminiscence. These popular programs stimulate thinking and memory and bring temporary enjoyment from the engagement in group activity but have a limited long-term effect on cognitive abilities. Cognitive approaches early in the disease involve the use of memory aids, schedules, calendars, systems for compensating for memory loss, and habit training. Although the adage "use it or lose it" makes sense with aging people, cognitive exercises do little to counteract progressive cognitive decline in Alzheimer's disease. Even so, cognitive stimulation can be beneficial in that it reminds family members that the client should remain involved in daily conversation and thinking as long as frustration is minimized.

Mobility skill training has been used to improve ambulation and reduce falls. Interventions that target motor skills include aerobic and strength training exercise programs that are indirectly related to cognitive abilities but directly related to client well-being. As previously mentioned in the falls section, the goal of targeted physical activity is to maintain safe gait and balance skills further into the course of the disease when falls risk increases. Mobility skill training also promotes continued activity engagement and counteracts occupational deprivation.

Although many studies have focused on altering client factors through environmental modifications, most have minimal or limited effect as an intervention approach. The nature of the disease is that body functions and structures are gradually altering, creating barriers to occupational performance. To promote quality of life, interventions should incorporate the person's innate desire to achieve through selection of activities that motivate and challenge the person, accommodating the changing ability levels.

Recommendations

Table: Recommendations for Occupational Therapy Interventions for Clients With Alzheimer's Disease

  Recommended No Recommendation Not Recommended
Areas of Occupation
  • Client-centered occupational therapy identifying occupational performance issues and helping clients implement compensatory and environmental strategies for people with mild to moderate dementia (A)
  • Client-centered activities (e.g., leisure) tailored to the person with dementia (B)
  • Multi-faceted interventions (including removal of physical restraints, fall alarm, exercise, change in environment) to prevent falls (A for hospital and geriatric hospital settings, C for community and nursing home settings)
  • Physical training (gait, strengthening, balance, and flexibility) to prevent falls for older adults with cognitive impairments (B)
  • Regular therapeutic cooking group for residents (B)
  • Direct training that includes errorless learning, memory training, and ADL training (C)
  • At the early stages of the disease, assessment and training on the use of cognitive and physical assistive technology (C)
  • At later stages of the disease, adjusting food texture, and providing occupation-based and client-centered strategies to maintain weight and reduce wandering (C)
Reminiscence activities (I)  
Performance Skills
Perception
  • Attention-focusing group to improve visual matching and activities (B)
  • Music, body awareness, and mobility/functional training (B)
  • Use of live or recorded music (C)
  • Use of multisensory environments (C)
  • Snoezelen (I)
  • Sensory integration (I)
 
Fall Prevention
  • Multifaceted interventions (including removal of physical restraints, fall alarm, exercise, change in environment) to prevent falls (A for hospital and geriatric hospital settings, C for community and nursing home settings)
  • Physical training (gait, strengthening, balance, and flexibility) to prevent falls for older adults with cognitive impairments (B)
   
Routines
  • Sleep routines and sleep hygiene strategies to improve daytime activities and nighttime sleeping (A)
  • Prompted voiding strategies for toileting (B)
  • Timed voiding and habit retraining strategies for toileting (C)
  • General use of client-centered routines (C)
  • Skill elicitation and individualized behavioral interventions for habit training during ADL performance (C)
   
Context and Environment
Physical Environment
  • Intervention provided by occupational therapy practitioner that emphasizes the use of compensatory and environmental strategies that include cueing and step-by-step instructions (A)
  • Multifaceted interventions (including removal of physical restraints, fall alarm, exercise, change in environment) to prevent falls (A for hospital and geriatric hospital settings, C for community and nursing home settings)
  • Changes to the physical environment such as activity therapy, music, and natural environment simulations (B)
  • Use of Montessori materials that incorporate aesthetically pleasing materials from the environment (B)
  • Use of a schedule to balance high-arousal and low-arousal states (B)
  • Increased lighting at mealtime (C)
  • Changes to doors and exits (doors unlocked, concealment of knobs, portable visual barriers, and murals to disguise doorknobs) (C)
  • At the early stages of the disease, assessment and training on the use of cognitive and physical assistive technology (C)
  • Snoezelen (I)
  • Massage and aromatherapy (I)
  • Bright light therapy (I)
  • Enhancement of corridors and other changes in environmental design in residential facilities (I)
  • Units that emphasize the control of sensory stimulation, use of soothing music, and a decrease in traffic (I)
  • Signs and photographs outside residents' rooms to assist with way finding (I)
 
Person-Caregiver
  • Occupational therapy sessions that provide caregivers with education, problem solving, technical skills (task simplification, communication), and simple home modifications (A)
  • Caregiver interventions combining counseling and support groups (A)
  • Caregiver interventions that combine education, case management, client involvement, stress management, and training (A)
  • Interventions taking place in the client's home (B)
  • Customized activity-based interventions in conjunction with instructions to caregivers (B)
  • Participation in a support group (B)
  • Technology-mediated support groups (B)
  • Day care for people with Alzheimer's disease (C)
Respite care (I)
  • Interventions focusing only on the behavior of the person with dementia (D)
  • Interventions focusing only on knowledge of dementia (D)
Activity Demands
  • Intervention provided by occupational therapy practitioner that emphasizes the use of compensatory and environmental strategies that include cueing and step-by-step instructions (A)
  • Interventions during feeding that include consistent verbal prompts from carer, reinforcement for eating, use of music during dining, and changes in meal presentation (A)
  • Skill elicitation and individualized behavioral interventions for habit training during ADL performance (C)
  • Activity selection on the basis of personal style of client (C)
  • Cognitive stimulation therapy with adapted daily tasks matched to ability level (C)
   

Note: Recommendation criteria are based on standard language developed by the Agency for Healthcare Research and Quality (2009). Suggested recommendations are based on the available evidence and content experts' opinions. ADL = activities of daily living.

Definitions

Strength of Recommendations

A—Strongly recommend that occupational therapy practitioners routinely provide the intervention to eligible clients. Good evidence was found that the intervention improves important outcomes and concludes that benefits substantially outweigh harm.

B—Recommend that occupational therapy practitioners routinely provide the intervention to eligible clients. At least fair evidence was found that the intervention improves important outcomes and concludes that benefits outweigh harm.

C—No recommendation is made for or against routine provision of the intervention by occupational therapy practitioners. At least fair evidence was found that the intervention can improve outcomes but concludes that the balance of the benefits and harm is too close to justify a general recommendation.

D—Recommend that occupational therapy practitioners do not provide the intervention to eligible clients. At least fair evidence was found that the intervention is ineffective or that harm outweighs benefits.

I—Insufficient evidence to recommend for or against routinely providing the intervention. Evidence that the intervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harm cannot be determined.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The evidence-based literature review includes Level I randomized controlled trials; Level II studies, in which assignment to a treatment or a control group is not randomized (cohort study); Level III studies, which do not have a control group; Level IV studies, which are single-case experimental design, sometimes reported over several participants; and Level V studies, which are case reports and expert opinion that include narrative literature reviews and consensus statements. In addition, qualitative studies were included in two of the focused question reviews. The inclusion of the qualitative literature provides additional information in areas of limited research. The table below provides a breakdown of the number of studies included in the complete review by level of evidence.

Table. Number and Levels of Evidence for Articles Included in Each Review Question

Number of Articles Included in Review
Review Question Level I Level II Level III Level IV Level V Qualitative Total in Each Review
Areas of Occupation 7 1 11 7 0 0 26
Perception 10 4 8 5 0 1 28
Routines 7 0 1 0 1 5 14
Environmental Interventions 13 6 2 1 0 0 21
Activity Demands 6 0 1 0 0 0 7
Falls 3 0 2 0 0 0 5
Caregiver Interventions 23 1 4 0 0 0 28
Total for Each Level 69 12 29 13 1 6  

Total in All Reviews

129

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Assist occupational therapists and occupational therapy assistants in communicating about their services to external audiences
  • Assist other health care practitioners, case managers, families and caregivers, and health care facility managers in determining whether referral for occupational therapy services would be appropriate
  • Help third-party payers determine the medical necessity for occupational therapy
  • Aid health and education planning teams in determining the need for occupational therapy
  • Assist legislators, third-party payers, and administrators in understanding the professional education, training, and skills of occupational therapists and occupational therapy assistants
  • Assist program developers, administrators, legislators, and third-party payers in understanding the scope of occupational therapy services
  • Support program evaluators and policy analysts in this practice area in determining outcome measures for analyzing the effectiveness of occupational therapy intervention
  • Assist policy, education, and health care benefit analysts in understanding the appropriateness of occupational therapy services for adults with Alzheimer's disease
  • Help policymakers, legislators, and organizations understand the contribution occupational therapy can make in program development and health care reform for people with Alzheimer's disease
  • Support occupational therapy educators in designing appropriate curricula that incorporate the role of occupational therapy in Alzheimer's disease
Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • This guideline does not discuss all possible methods of care, and although it does recommend some specific methods of care, the occupational therapist makes the ultimate judgment regarding the appropriateness of a given intervention in light of a specific client's circumstances, needs, and available evidence to support intervention.
  • This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold or distributed with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service. If legal advice or other expert assistance is required, the services of a competent professional person should be sought.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Schaber P. Occupational therapy practice guidelines for adults with Alzheimer's disease and related disorders. Bethesda (MD): American Occupational Therapy Association, Inc.; 2010. 198 p. [279 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010
Guideline Developer(s)
American Occupational Therapy Association, Inc. - Professional Association
Source(s) of Funding

American Occupational Therapy Association, Inc.

Guideline Committee

Not stated

Composition of Group That Authored the Guideline

Author: Patricia Schaber, PhD, OTR/L, Assistant Professor, Program in Occupational Therapy, Center for Allied Health Programs, University of Minnesota, Minneapolis, Member, Academy of Excellence in the Scholarship of Teaching and Learning, Academic Health Center, University of Minnesota, Research Consultant, University of Minnesota Medical Center–Fairview Memory Clinic

Issue Editor: Marian Arbesman, PhD, OTR/L, President, ArbesIdeas, Inc., Consultant, AOTA Evidence-Based Practice Project, Clinical Assistant Professor, Department of Rehabilitation Science, State University of New York at Buffalo

Series Editor: Deborah Lieberman, MHSA, OTR/L, FAOTA, Program Director, Evidence-Based Practice, Staff Liaison to the Commission on Practice, American Occupational Therapy Association, Bethesda, MD

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Not available at this time.

Print copies: Available for purchase from The American Occupational Therapy Association (AOTA), Inc., 4720 Montgomery Lane, Bethesda, MD 20814, Phone:1-877-404-AOTA (2682), TDD: 800-377-8555, Fax: 301-652-7711. This guideline can also be ordered online at the AOTA Web site External Web Site Policy.

Availability of Companion Documents

The following is available:

In addition, a sample Client and Family/Caregiver Report form is available in the original guideline document.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on November 19, 2010.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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