René Padilla; Effectiveness of Interventions Designed to Modify the Activity Demands of the Occupations of Self-Care and Leisure for People With Alzheimer’s Disease and Related Dementias. Am J Occup Ther 2011;65(5):523-531. doi: 10.5014/ajot.2011.002618.
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A systematic review of evidence for the effectiveness of modification of activity demands in the care of people with Alzheimer’s disease (AD) was conducted as part of the American Occupational Therapy Association’s Evidence-Based Literature Review Project. The review included 10 articles addressing occupations of self-care and leisure. No reports related to work and social participation were located. Results suggest that evidence for this intervention’s effectiveness is strong. Four practice principles were derived from this appraisal: (1) Occupational therapy programs should be individualized to elicit the person’s highest level of retained skill and interest, (2) cues used while assisting people with AD to complete tasks should be short and provide clear direction, (3) compensatory strategies in the form of environmental modifications and simple adaptive equipment should be specifically implemented on the basis of the unique needs of the person, and (4) caregiver training and involvement are essential in implementing individualized programs.
Occupational therapy programs should be individualized to elicit the person’s highest level of retained skill and interest in occupations. This individualization involves matching activities to current cognitive and physical abilities rather than attempting to significantly challenge gains in function or independence. Eliciting remaining abilities assists people with AD to maintain independence longer and even to regain some lost function. Activities that are well matched to the person’s abilities provide the amount of social stimulation and novelty preferred and thereby capture the person’s interest. Drawing on the person’s premorbid personality traits and past interests while supporting self-selection of activities maintains the engagement of people with AD in meaningful activities for longer periods of time, thus reducing dementia-related behaviors such as wandering, screaming, and physical aggression.
Cues used while assisting people with AD to complete tasks should be short and provide clear direction. Cues provided by practitioners and caregivers during activities are one of the most important ways to modify activity demands. Essentially, cues should match the person’s level of cognitive function. Thus, cues may range from neutral statements (e.g., “It is the beginning of the day”) to directive statements (e.g., “Please get dressed now” or “Put this sock on your left foot”) and, when needed, may be accompanied by gestures (e.g., pointing at an item or demonstrating a movement) or physical prompts (e.g., touching the person’s left foot while stating, “Put this sock on your left foot”). Verbal cues should frequently be accompanied by reinforcements (e.g., “That’s right,” “Good,” or “You are doing well!”) on completion of subtasks. Activities for more impaired people should be broken down into segments, and verbal cues should accordingly be provided one step at a time. Cues should encourage the person with higher function to use information processing rather than factual knowledge (e.g., rather than telling a person to obtain meal preparation items one by one, use cues such as “You now have the bread. What do you like to put in a sandwich?”). Reality orientation cues in the form of signs, visibly located calendars, and so forth may be useful in helping the person maintain a sense of the present without reinforcing dependence or frequently confronting confusion. Finally, suggesting leisure activities to the person when he or she is not occupied and assisting in initiating these activities to maintain a high level of activity that continually invites the person to use his or her remaining abilities may be necessary.
Compensatory strategies in the form of environmental modifications and simple adaptive equipment should be specifically implemented on the basis of the unique needs of the person with AD. Visual cues such as directional signs and drawer or cupboard labels are the most effective strategies. In addition, creating an organized work space in which materials needed for an activity are visible may help the person complete tasks more independently. Likewise, removing clutter from rooms and work surfaces will reduce distractions and support development of habits to maintain function. Adaptive equipment should facilitate completion of tasks but not modify them so dramatically that they cause confusion. For example, extended handles, grab bars, and so on serve as safety cues, whereas attempts to begin using a buttonhook may undermine the person’s ability to dress independently because he or she cannot rely on past automatic actions.
Caregiver training and involvement are essential in implementing individualized programs to maintain retained skills. When caregivers are trained in how to break down tasks and provide appropriate cues, not only are people with AD able to participate more interdependently in activities and meaningful occupations, but they also experience greater quality of life and satisfaction. In addition, caregiver training results in lower caregiver burden because the person with AD is more able to participate in activities, and dyadic interactions are more positive, successful, and meaningful. Moreover, because individualized programs are designed to elicit the highest level of retained skill, it is possible for caregivers to implement the program and reduce costly ongoing professional intervention.
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