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

René Padilla

doi:10.5014/ajot.2011.002618

Abstract

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 focuses on enabling people to do the activities, tasks, and roles they consider meaningful in their daily lives (American Occupational Therapy Association [AOTA], 2008). As the incidence and prevalence of Alzheimer’s disease (AD) and other dementias continue to grow, occupational therapy practitioners must find innovative, evidence-based ways to enable the occupations of people who find themselves losing their abilities to reach personal goals (Baum & Katz, 2010). Changes to how activities themselves are completed create a requirement or demand for the person to use his or her current abilities to succeed or develop them beyond the present levels (Mastos, Miller, Eliason, & Imms, 2007). Research evidence is needed to inform practice and justify the use of interventions designed to modify the activity demands of occupations for people with AD.

Background Literature

Activity demands are “the specific features of an activity that influence the type and amount of effort required to perform the activity” (AOTA, 2008, p. 634). Modifications of activity demands are expected to result in adaptation outcomes on the part of the client. In other words, as activity demands are modified, the client also modifies his or her approach toward the activity to complete it successfully (Bontje, Kinébanian, Josephsson, & Tamura, 2004). Activity demands may be modified by changing the context in which the activity normally takes place or by “enhancing some features to provide cues or reducing other features to reduce distractibility” (Dunn, McClain, Brown, & Youngstrom, 1998, p. 533). Modifications may include changing the materials used, varying the space in which the activity is carried out, and providing social interaction in the form of cues. Other modifications may include resequencing the steps of an activity, altering the position of the person completing the activity, or both (AOTA, 2008).

The effectiveness of occupational therapy intervention based on adaptation of activity demands has been studied in comparison with traditional biomechanical approaches. Greater functional gains were achieved by people who had experienced a stroke (Johnson & Schkade, 2001) and by deconditioned older adults admitted to a transitional unit after hospitalization (Spencer, Hersch, Eschenfelder, Fournet, & Murray-Gerzik, 1999). Interventions involved joint problem solving by therapist and participant, changes in tasks, modifications to the environment, and recruitment of family members for assistance. Adaptation was associated with a more efficient outcome and greater patient satisfaction. These findings were similar for female patients with hip fracture (Buddenberg & Schkade, 1998), people with lupus-related arthritis (Jack & Estes, 2010), and a considerable number of patients with orthopedic and neurological conditions (Burke, Bradley, Sinha, Wilgis, & Dubin, 2007; Meek et al., 2010).

Modification of activities by use of cues has been studied with several populations, most frequently with children with autism. Advance notice of an activity change in the form of combined verbal and photographic cues helped increase the appropriate number of transitions made in the daily routines of a young child with autism (Schmit, Alper, Raschke, & Ryndak, 2000). Disruptive behavior of children with autism decreased during intervention using Social Stories™ paired with single-word prompting (Crozier & Tincani, 2005). Simply removing verbal prompts from a system of least prompts (a sequence of a presumed prompt hierarchy that is ordered from least to most intrusive) evoked more efficient skill acquisition with fewer errors (West & Billingsley, 2005, p. 131). The cue of pointing increased mutual attention and symbolic play of a group of children with autism (Kasari, Freeman, & Paparella, 2006). Similarly, high-probability request sequencing (rapidly presenting two or three easy tasks with which a child has a history of compliance before presenting a difficult or low-probability task) reduced the need for more frequent verbal cues (Banda & Kubina, 2006). Learning was increased and classroom disruptions were decreased with unobtrusive vibrating pagers that discreetly alerted children with autism to attend to the teacher or the ongoing activity (Anson, Todd, & Cassaretto, 2008).

For people with dysphasia, the type of cueing, whether visual–gestural or auditory–verbal, appears to not be as significant as the order in which cues are presented. Regardless of cue type, the cue presented first is often the most effective (Drummond & Rentschler, 1981). Frequent prompts delivered unobtrusively to adults with severe intellectual disability through a small pocket device with an earpiece fostered a higher level of on-task behavior and correct task response (Lancioni, Dijkstra, O’Reilly, Groeneweg, & Van den Hof, 2000), and a combination of favorite songs and verbal prompts can add to fluency of performance and reduce time required in self-help tasks of people with multiple disabilities (Lancioni, O’Reilly, & Campodonico, 2002).

Instrumental activities of daily living, leisure, and social activities are most frequently reported as problematic by caregivers of people with mild to moderate dementia and targeted for treatment. The coping strategy caregivers use most commonly is verbal prompts to begin an activity (Cook, Fay, & Sherri, 2008). However, the use of cues or prompting with people with AD has received surprisingly little attention. Timed sequence analysis of self-care routines of nursing home residents with AD who had frequent episodes of agitation showed that abrupt and simple verbal prompts used by certified nurse assistants during personal care routines most frequently elicited agitation onset, whereas positive statements to the resident reduced it (Roth, Stevens, Burgio, & Burgio, 2002). Caregiver behaviors that occur significantly more often during the 5 s preceding an assault include calling the resident by his or her first name, confrontational communication, invalidation of the resident’s feelings, failure to prepare the resident for a task, disrespectful speech, any touch, absence of physical restraint, and hurried pace of bath (Somboontanont et al., 2004).

Adaptive equipment, sometimes also called assistive technology, includes any item, piece of equipment, or product system used to increase, maintain, or improve functional capabilities of people with disabilities (Mirza & Hammel, 2009). Such equipment may also include canes, walkers, and bath benches (Mann, Ottenbacher, Fraas, Tomita, & Granger, 1999). Environmental modifications or changes in the physical and social environment designed to increase functional independence and safety include the addition of ramps, lowering of cabinets, removal of throw rugs or physical barriers, installation of safety devices such as grab bars, and training for family members and caregivers in how to set up a work surface for easy access. The most common environmental modification needed by Medicare beneficiaries, many of whom have AD, is to the bathroom (Dudgeon et al., 2008). Studies have reported that adaptive equipment and environmental modifications are effective in encouraging the development of motor control, performance, and reaction time in children with cerebral palsy (Williams & Matesi, 1988). Such modifications may also slow the rate of decline of frail older people and reduce institutional and certain in-home personnel costs (Mann et al., 1999). Interventions based on principles of graded activity and environmental modification are effective for improving occupational participation of people with chronic fatigue syndrome (Cox, 2002) and for older adults with low vision (Ellexson, 2004).

Method for Conducting the Evidence-Based Review

This portion of the Alzheimer’s disease Evidence-Based Literature Review Project addressed the focused question “What is the evidence for the effect of interventions designed to modify the activity demands of the occupations of self-care, work, leisure, and social participation for people with AD?” Detailed information about the methodology for the entire AD Evidence-Based Literature Review Project can be found in Arbesman and Lieberman (2011; this issue). The initial review was completed in 2007 and updated first in 2008 and then in 2010 in preparation for this article.

Results

A total of 5,707 titles and abstracts were reviewed, and 131 articles were read in full. Ten studies (7 Level I and 3 Level III) were relevant to activities of daily living (ADLs) and leisure participation as stated in the focused question. No studies relevant to modification of activity demands of work or social participation of people with AD were located. Each article included in the review was abstracted using an evidence table format and later summarized and appraised in a Critically Appraised Topic. Supplemental Table 1, available online at www.ajot.ajotpress.net (navigate to this article, and click on “supplemental materials”), contains information about the objectives, design, intervention, outcomes, findings, and limitations of the studies. In the following sections, findings are organized according to the kinds of modifications of activity demands investigated in these studies: (1) matching of client skills and interests, (2) use of cues, and (3) compensatory and environmental strategies, including environmental modifications and adaptive equipment. Although these interventions overlap, the findings are summarized by the focus of the reported research.

Matching Client Skills and Interests

Evidence from 4 Level I studies (Dooley & Hinojosa, 2004; Gitlin et al., 2008; Kolanowski, Buettner, Costa, & Litaker, 2001; Spector et al., 2003) and 1 Level III study (Rogers et al., 1999) suggests that selecting or modifying activities that match the person’s highest level of retained skills can improve participation in ADLs and other occupations. Most of these studies had small samples and relied on subjective or observational outcome measures, which limit the generalizability of results. However, the consistency of results among the studies suggests that preliminary evidence exists that modifying activities to match them to the client’s skills and interests is a useful intervention strategy.

Gitlin et al. (2008; Level I, N = 40) provided a tailored activity program to people with AD after completing a semistructured clinical interview and the Pleasant Event Schedule with caregivers to identify previous and current activity interests. They also observed dyadic communication and home environmental features and assessed dementia patients using the Dementia Rating Scale and Allen’s observational craft-based assessments. Three activities per patient were then developed on the basis of assessments that identified cognitive capacities in areas of memory, language, conceptualization, attention, construction, and initiation and also evaluated cueing requirements, ability to follow directions and problem solve, and prior interests and roles (e.g., homemaker, carpenter). Caregivers were instructed in stress-reducing techniques (deep breathing) to establish a calm emotional tone. Caregivers were also instructed in strategies to simplify the setting of the activity (e.g., removing unnecessary objects, placing materials in the patient’s line of sight), simplify the activity itself (e.g., providing one part of a project at a time, extending time for completion of task), and enhance participation (e.g., drawing on the patient’s past interests, monitoring for frustration) and effective communication (e.g., using encouraging remarks; providing short, clear instructions). At the end of nine sessions over 4 mo, the main outcomes included a reduced number of problematic behaviors (shadowing, repetitive questioning, agitation). Caregivers reported a significant enhancement in the ability of patients with dementia to derive pleasure and engage in activities.

Similarly, Kolanowski et al. (2001; Level I, N = 10) tested the utility of theory-based activity selection for addressing behaviors such as screaming, wandering, and physical aggression that commonly occur with people who have dementia. The basis of the theory is that leisure behavior is continuous over time and that satisfaction with leisure is dependent on self-selection of activities. However, because people with dementia have difficulty with structuring their own activities and communicating their desire for specific activities, informant reports of premorbid personality must be used to identify engaging activities. Kolanowski et al. argued that dementia behaviors result from the interplay of stable background factors (such as neurological condition, cognitive and physical abilities, and premorbid personality) and more changeable proximal factors (such as physiological and psychological needs and qualities of the social and physical environment). The intervention targeted these later factors for manipulation. First, activities were matched to current cognitive and physical abilities so that they afforded the opportunity for participation. Then they were matched to premorbid interests and personality along a scale of extroversion and openness. Kolanowski et al. reported the intervention to be effective for increasing mean time spent on task, although it did not result in a significant difference in the degree of participation between intervention and control groups.

Spector et al. (2003; Level I, N = 209) tested an intervention program based on theoretical concepts of reality orientation and cognitive stimulation. This program included use of money, word games, famous face recognition, and present-day orientation accompanied by multisensory stimulation. A range of activities were adapted to match ability using cognitive stimulation therapy to emphasize use of information processing rather than factual knowledge. Cognitive stimulation therapy consisted of the use of a personalized orientation board with identifying information as well as reminders of the topic of the current session (money management, word games, present day, and faces). Spector et al. found that the intervention resulted in significant improvements in cognition and quality of life for people with dementia compared with control groups engaging in typical daily activities. The outcomes for functional ability, communication, anxiety, or depression were modest, and they found no differences in that regard between patients receiving cognitive stimulation therapy and usual care.

Dooley and Hinojosa (2004; Level I, N = 40) derived individualized occupational therapy recommendations for people with AD living in the community by using the Assessment of Instrumental Function. Specific recommendations included caregiver approaches (such as cueing to break down tasks, giving step-by-step instructions, structuring daily routines, and suggesting activities when the client is not occupied), environmental modifications (such as changes in the physical surroundings through use of visual cues, labeling drawers and cabinets), and community-based assistance (such as support groups, home-delivered meals). After a short orientation, caregivers implemented the recommendations, and the researchers conducted follow-up assessments. This short occupational therapy intervention resulted in significant improvements in quality of life, positive affect, and independence in self-care of the people with AD. In addition, caregivers had significantly lower feelings of burden.

Rogers et al. (1999; Level III, N = 40) implemented a skill elicitation (SE) program to ascertain the task skills retained by nursing home residents with probable or possible AD. The program consisted of an individualized three-category, five-level hierarchy of assists (actions initiated by the caregiver to further task completion) and task analysis. Assists were hierarchically arranged from least aid (nonphysical and nondirective) to most aid (physical support and help). Dressing, bathing, toileting, oral hygiene, and grooming were divided into chains of smaller discrete task skills. Assists were provided during these activities, beginning at the lowest level and increasing until the older adult was able to demonstrate the task skill. Once the assist level needed was identified, it—or a lower-level assist—was used to facilitate continued use of the skill during morning care. Other procedures involved positioning the older adult appropriately for task participation, modification of task methods or materials, and training in the use of adaptive equipment when necessary. Compared with participants receiving usual care, SE participants exhibited greater independence in performing dressing tasks, participated more in assisted dressing, and asked more appropriately for assistance with ADLs. The SE intervention was followed by a period of habit training, during which Rogers et al. expected that assist would be reduced because subtask skills were recovered. However, during this period skills were maintained, and the goal of achieving even greater gains was not accomplished. The researchers concluded that SE was effective in supporting skill retention.

Use of Cues

One Level I and 2 Level III studies were designed to test the effectiveness of verbal or visual cues, although most of the other reviewed studies included some discussion about this intervention. For example, Gitlin et al. (2008) evaluated participants’ cueing requirements to develop activity prescriptions that matched the older adults’ capabilities. The skill elicitation intervention tested by Rogers et al. (1999) relied on an assist hierarchy to identify older adults’ skill level in accomplishing self-care occupations. All levels included some form of verbal cues on a continuum from neutral statements to verbal requests to initiate, continue, or terminate an action; to step-by-step instructions; to gestural cues such as tapping the knee. In their program, Spector et al. (2003) used a reality orientation board that displayed both personal and orientation information to provide some form of continuity for older adults with AD. Dooley and Hinojosa (2004) developed individualized programs that included methods for caregivers to cue the person with AD to perform at the highest level possible. Examples include breaking down the task to give directions one step at a time, suggesting activities to the person when he or she is not occupied, and gently reminding the person to use visual cues and adaptive equipment. Such cues contributed to the overall effectiveness of the program, which also included environmental modifications and structured daily routines.

Coyne and Hoskins (1997; Level I, N = 24) specifically set out to determine the effect of directed verbal prompts and positive reinforcement on the level of eating independence of nursing home residents with dementia. They used standardized, directive phrases that matched subtasks of eating (such as “pick up the fork,” “put the food on the fork,” and “move the fork to your mouth”) and verbal praise (such as “good” or “that’s right”) for successful completion of the subtask. The experimental group demonstrated significantly improved performance after the treatment, although retention decreased, indicating that such cues afforded opportunities to maximize functioning.

In addition to developing individualized interventions that matched meaningful occupations with the client’s motor and process skill strengths and deficits, Chard, Liu, and Mulholland (2009; Level III, N = 5) tested the effectiveness of caregiver training to provide verbal cues and reinforcement with residents of an assisted living facility who had AD. Rather than action commands, caregivers were to use circumlocution (or talking around the problem) when participants had difficulty proceeding with a task. For example, if the participant asked a question such as “Where is the bread?” the caregiver was to facilitate progress by responding, “Where do you usually keep it?” or “Have you looked in the cupboard?” Verbal reinforcements were used to strengthen verbal cues by repeating the messages. Together with environmental modifications, cues were effective in helping all participants make significant gains in processing abilities, and some participants showed improvement in motor skills during ADLs and other occupations.

Finally, Cevasco and Grant (2003; Level III, N = 26) studied the effect of adding verbal and visual cues to exercise with music for clients with AD. They tested the effect of two methods of cueing (verbal cues at the beginning, followed by visual cues, and verbal cueing throughout the exercise). They also compared the effect of these methods of cueing on participation in exercise while the clients produced music with instruments or vocally. Cevasco and Grant concluded that continuous cueing elicited significantly more participation. They found little difference between continuous verbal cueing and initial verbal cueing followed by visual cues. They also reported that participation in exercise was greater during instrumental music than during vocal music. They concluded that perhaps clients in the later stages of AD are not capable of attending to multiple auditory stimuli or performing multiple tasks simultaneously.

Again, the results of these studies can only be considered preliminary because they all had small samples. The use of convenience (Cevasco & Grant, 2003) and nonrepresentative (Chard et al., 2009; Coyne & Hoskins, 1997) samples were additional methodological limitations that reduced the generalizability of these studies’ results.

Compensatory and Environmental Strategies

Several studies used compensatory or environmental modifications as part of the overall intervention, although only 3 Level I studies (Dooley & Hinojosa, 2004; Graff et al., 2006; Watson & Green, 2006) and 1 Level III study (Chard et al., 2009) specifically set out to evaluate their effectiveness. Some of the other studies included environmental modifications, training with any newly prescribed adaptive equipment (e.g., extended handles), or both if an individualized patient program required it (Kolanowski et al., 2001; Rogers et al., 1999; Spector et al., 2003).

Dooley and Hinojosa (2004; Level I, N = 40) incorporated environmental modifications into the caregiver strategies they used in their occupational therapy intervention with people with AD living in the community. This category was broad because such modifications were individualized to each participant. The most commonly recommended modifications were visual cues such as posting emergency telephone numbers or labeling drawers and cabinets. Other environmental modifications included bells and baby monitors at the front door of the home so the person with AD would not wander, adaptive devices such as pill reminder boxes, and so on. As noted earlier, the intervention resulted in significant improvements in quality of life, positive affect, and independence in self-care of the people with AD and lower feelings of caregiver burden.

Graff et al. (2006; Level I, N = 135) assessed the daily function of patients with dementia and caregiver burden before providing occupational therapy, including cognitive and behavioral intervention to train patients in the use of aids to compensate for cognitive decline and to train caregivers in coping behaviors and supervision. An occupational therapist evaluated the patient’s home and environment and observed the patient’s ability to perform daily activities and use of compensatory and environmental strategies. Compensatory strategies were described as the adaptation of ADLs to patients’ disabilities, and environmental strategies were described as adaptation of the patients’ environment to their cognitive disabilities. Graff et al. found the intervention to be effective in improving patients’ daily function and decreasing caregiver burden, and the effect was sustained at follow-up.

In a systematic review of research literature published between 1993 and 2003, Watson and Green (2006; Level I, N = 13) appraised 13 studies related to the effectiveness of interventions to promote oral intake of older people with dementia. Quiet music was the most common intervention used, but other environmental changes were also studied, such as changes from preplated to self-serve meal systems, feeding by multiple caregivers at meal time, change of meal setting, and changes in food texture and appearance. All interventions were reported to be effective in improving nutritional intake, although Watson and Green noted that none of the studies addressed confounding factors well.

As noted earlier, Chard et al. (2009; Level III, N = 5) found that statistically significant improvements in ADL ability resulted when individualized interventions were developed and meaningful occupations and cues were matched to the client’s motor and process skill strengths and deficits. Environmental modifications designed to ensure facilitation of performance rather than telling participants what to do or doing it for them supported greater independence in ADLs and were an integral part of these programs. Such modifications included placing labels on drawers and closets, setting up the workstation with items visible, removing distracting items from work spaces before tasks were initiated, and providing ADL equipment. Chard et al. concluded that an enabling approach (rather than providing direct assistance or caregiver intervention) was critical in maintaining participants’ engagement.

These studies used small and somewhat nonrepresentative samples, which limited the generalizability of results. The heterogeneity of interventions and difficulty in accounting for confounding factors such as comorbidities, use of medications, and participation in other therapies reduce the confidence with which the results can be applied to intervention with people with AD. The studies highlight the difficulty of carrying out research in this area. Randomized trials are difficult to carry out in a controlled manner in settings in which people with dementia are cared for, particularly in light of the need to individualize intervention. However, the interventions tested in these studies hold promise, and further testing is needed.

Discussion and Implications for Practice

Modification of activity demands has been a longstanding intervention in occupational therapy, and the evidence of its effectiveness in enabling people with AD to participate in self-care and leisure occupations is strong. None of the reviewed studies explicitly addressed work or social participation, and effectiveness of modification of activity demands for these occupations cannot be reasonably surmised. Collectively, the studies involved >742 participants between ages 64 and 99 (1 study did not report median age) with probable or confirmed AD and related dementias. About one-third (228) of the participants were men, and about 60% of the participants were living in the community; the remainder lived in nursing homes or extended living facilities. Of the latter, 17% were living in specialized Alzheimer units. Of the 7 Level I studies, only 1 was blinded (Spector et al., 2003), and sample sizes varied greatly (Ns = 5–201). Five of the studies (Chard et al., 2009; Dooley & Hinojosa, 2004; Gitlin et al., 2008; Graff et al., 2006; Rogers et al., 1999) relied on caregiver report of changes in the function of the person with dementia. Despite these limitations, the studies reported consistent positive effects from the interventions as assessed by a variety of outcome measures.

Results of these studies have four main implications for the practice of occupational therapy with this population:

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.

The lack of research on work and social participation of people with AD indicates that these areas need investigation. The nature of the individualized programs tested in most of the reviewed studies on ADLs and leisure may possibly have a similar effect in facilitating work and social participation. However, intervention strategies that are effective for engagement in these occupations need to be developed and studied, because qualitative studies have indicated that self-interventions by participants are inconsistently effective (Bontje et al., 2004; Gillot, Holder-Walls, Kurtz, & Varley, 2003; Parsons & Stanley, 2008). Application of the results of the studies included in this review may be similarly effective in addressing occupations of work and social participation. However, further occupational therapy research, using some of the strategies that have been found to be effective for modifying the activity demands of the occupations of self-care and leisure, is needed in these areas.

Acknowledgments

I acknowledge the contribution of Brittany Bennett, Tessa Cooper, Katie Horsager, Miranda Materi, Lisa Parr, Ana Smith, and Heather Valasek, who completed the initial database search and Critically Appraised Topic for this article while they were doctoral students in the occupational therapy program at Creighton University.

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*Studies included in the review.