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Research Article  |   July 2013
Update on Productive Aging Research in the American Journal of Occupational Therapy, 2012
Author Affiliations
  • Mariana D’Amico, EdD, OTR/L, BCP, CIMI, is Associate Professor, Department of Occupational Therapy, College of Allied Health Sciences and College of Graduate Studies, Georgia Regents University, 1120 15th Street, EC2330, Augusta, GA 30912-0700; mdamico@gru.edu
Article Information
Geriatrics/Productive Aging / Departments
Research Article   |   July 2013
Update on Productive Aging Research in the American Journal of Occupational Therapy, 2012
American Journal of Occupational Therapy, July/August 2013, Vol. 67, e77-e91. doi:10.5014/ajot.2013.008219
American Journal of Occupational Therapy, July/August 2013, Vol. 67, e77-e91. doi:10.5014/ajot.2013.008219
Abstract

This article describes a review of articles on productive aging published in the American Journal of Occupational Therapy (AJOT) during 2012 in light of the Centennial Vision charge of supporting practice through evidence. Seventeen AJOT articles published in 2012 specifically addressed productive aging. Of 6 Level I studies, 4 were systematic reviews that identified effective occupational therapy interventions for community-dwelling older adults; 1 randomized controlled trial examined the effectiveness of writing life reviews for residents of senior residences, and 1 meta-analysis investigated the effectiveness of fall-related efficacy and engagement in activity or occupation. Two Level II studies and 2 Level III studies produced support for the effectiveness of individual and group-based occupational therapy interventions. Of 7 descriptive studies addressing a variety of areas, 4 addressed the reliability and validity of assessments. In 2012, AJOT published more and higher quality studies addressing a variety of issues related to productive aging.

The Centennial Vision target date of 2017 is a mere few years away. This vision created a road map to the future of occupational therapy and will commemorate the American Occupational Therapy Association’s (AOTA’s) 100th anniversary. The vision statement projects a healing profession that “is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society’s occupational needs” (AOTA, 2007, p. 613). As we strive to fulfill the vision and follow the road map created, we continue to measure our progress along the way. To that end, the American Journal of Occupational Therapy (AJOT) annually assesses its success in accomplishing the goal of increased quantity and quality of the research studies it publishes. AOTA’s mission as stated in the Centennial Vision is to promote research that supports the effectiveness of occupational therapy services. Such research includes
  • Effectiveness studies supporting practice,

  • Instrument testing to establish reliability and validity for occupational therapy assessments,

  • Correlational and descriptive studies that demonstrate links between occupational engagement and health,

  • Studies that answer important questions about topics related to the direction of the profession’s growth, and

  • Basic research studies that provide information about disabilities and their impact on functional participation (Gutman, 2008).

Also contained in the Centennial Vision is a call to sustain existing practice areas while embracing new and emerging practice areas to meet society’s needs. Productive aging is one of the practice areas singled out for examination (AOTA, 2007; Baum, 2006). In this review, I evaluate the progress of AJOT articles related to productive aging published during 2012.
Method
Sharon Gutman, the editor of AJOT, screened all research articles published or accepted for publication in AJOT during 2012. She identified 17 articles related to productive aging practice, which represented approximately 20% of all research studies published. I read and reviewed the 17 articles on the basis of my broad experience in productive aging, occupational therapy, and evidence-based practice. I categorized the articles according to the AOTA Evidence-Based Literature Review Project Levels of Evidence Rating System (Lieberman & Scheer, 2002). This model standardizes and ranks the value of scientific evidence for biomedical practice using the following grading system (Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996):
  • Level I: Systematic reviews, meta-analyses, or randomized controlled trials (RCTs)

  • 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.

In addition, I evaluated the articles using criteria Gutman provided and summarized them in Table 1.
Table 1.
Summary of Evidence From 2012 Productive Aging Studies
Summary of Evidence From 2012 Productive Aging Studies×
Author/YearStudy ObjectivesLevel/Design/ParticipantsIntervention and Outcome MeasuresResultsStudy Limitations
Arbesman & Mosley (2012) To evaluate and synthesize the evidence for interventions to restore, modify, and maintain performance in the IADL of health management and maintenance
  • Level I
  • Systematic review
  • N = 28 studies; 24 Level I, 3 Level II, 1 Level III
  • Inclusion criteria: Studies focused on older adults living in the community and intervention within the scope of occupational therapy practice that had an activity- or occupation-based component
  • Interventions
  • Patient education, individual and group skills training, physical activity, phone support, cognitive–behavioral interventions, self-management programs, occupational therapy to incorporate lifestyle changes, activities, culturally specific programming, habit training, coaching, energy conservation, caregiver education
  • Outcome Measures
  • Physical and cognitive function, pain, disability, fatigue, activity level, quality of life, occupational performance, self-perception of performance, self-efficacy
  • Moderate to strong evidence was found that client-centered occupational therapy improved physical functioning and occupational performance related to health management.
  • Moderate evidence was found that group health education programs by educators and other health professionals improve health and function; that self-management programs result in decreased pain and disability; and that incorporating cognitive–behavioral principles into physical activity improves long-term participation in exercise.
  • Evidence for skill-specific training in isolation is limited, but skill-specific training was more effective when combined with health management programs.
Small sample sizes, high dropout rates, limited diversity among samples, incomplete data, much self-reported data, no replication studies
Chase, Mann, Wasek, & Arbesman (2012) To explore the impact of fall prevention programs and home modifications on falls and the performance of community-dwelling older adults
  • Level I
  • Systematic review
  • N = 33 studies; 31 Level I RCTs, 2 Level II
  • Inclusion criteria: Studies focused on older adults living in the community and intervention within the scope of occupational therapy practice that included a fall prevention or home modification intervention
  • Interventions
  • Detailed medical and occupational therapy assessment at home or hospital, recommendations for home modifications by an occupational therapist or other health professional or by a home visit or facility team, strength and balance training, vision assistance, home hazard removal, patient education, one-on-one training, group training, exercise, comprehensive functional assessments with recommendations for adaptive equipment and environmental modification; single sessions, multiple sessions, some follow-up assessment or sessions
  • Outcome Measures
  • Number of falls, ADL status, hospital admissions, length of hospital stay, self-report of functional level, fear of falling, self-efficacy, leg strength, quality of life, balance and gait, functional reach and balance, postural sway, reaction time, neuromuscular control, pain, health care costs, fall-related injuries, FIM scores, living situation, functional status
  • Strong evidence was found for using multifactorial programs that include home evaluations and home modifications, physical activity or exercise, education, vision and medication checks, and assistive technology to prevent falls.
  • Moderate support was found for programs that provided only physical activity or home modifications.
Possible contamination of groups, small sample sizes, self-report bias, some studies not blinded, inconsistent randomization of participants, samples with limited diversity, lack of clear description of intervention, difficulty separating benefits of occupational therapy–specific intervention from those resulting from other programs
Chippendale & Bear-Lehman (2012) To explore the effect of life review through writing on depressive symptoms in older adults residing in four senior residences
  • Level I
  • RCT
  • N = 45; 14 men, 31 = women; 34 White, 5 Black, 2 Hispanic, 4 Asian
  • Age range = 66–98 yr, mean = 84 yr
  • Inclusion criteria: Older adults ≥65 yr, able to speak and write English, negative screen for probable dementia on the Mini-Cog
  • Exclusion criteria: People with probable dementia
  • Intervention
  • The Share Your Life Story workshop protocol (Sierpina, 2002) consisted of 8 weekly 90-min sessions in which participants learned writing techniques, did writing exercises, and read their own written life stories. Participants were requested not to share their group experiences with other residents in an effort to prevent contamination of the wait-listed control group.
  • Outcome Measures
  • • Mini-Cog
  • • Geriatric Depression Scale (GDS)
  • • Demographics
  • • Self-rated health
  • • Independence in ADLs and IADLs
  • • Levels of leisure participation and social support
  • • Duke Social Support Index
  • • Social Support Appraisals Scale
  • Measures were done pre- and postintervention.
GDS scores improved after the 8-wk intervention; those who attended the most sessions had the most improvement. The occupation-based Share Your Life Story intervention protocol improved depressive symptoms in older adults who resided in senior residences.Possible bias because primary researcher conducted intervention and assessments, no follow-up measures after initial posttest
Classen et al. (2012a) To investigate the item- and person-level psychometrics and item hierarchy of the 68-item SDBM for three groups: older drivers, family caregivers, and driving evaluators
  • Level IV
  • Descriptive study
  • N = 80 older drivers aged 65–85 yr with valid driver’s license who were still driving and cognitively able to complete the SDBM and on-road driving test
  • N = 80 family members or caregivers aged 18–85 yr who were able to report observations about the older adult’s driving behavior
  • N = 2 professional driving rehabilitation specialist raters, one at each site
  • Exclusion criteria for older drivers: Missing limbs, severe psychiatric diagnosis, medical advice not to drive, uncontrolled seizures over past year, use of medication that impairs central nervous system functioning
  • Exclusion criteria for caregivers: Demonstration of a physical or mental condition that impaired ability to make an active contribution
  • Intervention
  • No intervention
  • Outcome Measures
  • • SDBM
  • • On-road driving assessment
Evidence was found that the SDBM is a unidimensional rating scale measuring safe and unsafe driving behaviors with good construct validity. Item analysis identified a hierarchy of items, high reliability of test items, and ability to stratify respondents from each group. Analysis also identified test items requiring further refinement.Limited diversity in convenience sample, which was highly educated, cognitively intact, and capable of high driving performance; small sample size
Classen et al. (2012b) To quantify the rater reliability and rater effects, using item response theory, of the 68-item SDBM for three rater groups: older drivers, family caregivers, and driving evaluators
  • Level IV
  • Descriptive instrument development
  • N = 80 older drivers aged 65–85 yr with valid driver’s license who were still driving and cognitively able to complete the SDBM and on-road driving test
  • N = 80 family members or caregivers aged 18–85 yr who were able to report observations about the older adult’s driving behavior
  • N = 2 professional driving rehabilitation specialist raters, one at each site
  • Exclusion criteria for older drivers: Missing limbs, severe psychiatric diagnosis, medical advice not to drive, uncontrolled seizures over past year, use of medication that impairs central nervous system functioning
  • Exclusion criteria for caregivers: Demonstration of a physical or mental condition that impaired ability to make an active contribution
  • Intervention
  • No intervention
  • Outcome Measures
  • • SDBM
  • • On-road driving assessment
  • ICCs among the ratings of the 3 rater groups were significant but weak. No significant correlations were found between the ratings of the older drivers and family caregiver groups or between the older driver and evaluator groups.
  • Driving specialists’ ratings were more severe than the ratings of the family caregivers or older drivers.
Limited diversity in convenience sample, small sample size, only 2 professionals used as raters
Deacy, Yuen, Barstow, Warren, & Vogtle (2012) To examine the preclinical curriculum content pertaining to low vision rehabilitation included in occupational therapy and occupational therapy assistant programs
  • Level IV
  • Descriptive study
  • N = 119 occupational therapy (n = 69) and occupational therapy assistant (n = 50) programs that responded to a survey of 10 closed-ended and 1 open-ended questions examining the type and extent of low vision rehabilitation (LVR) content offered in their programs
  • Intervention
  • No intervention
  • Outcome Measures
  • • Type of LVR content in program
  • • Extent of LVR content in program
  • 24 programs included a required course with primary emphasis on LVR.
  • 1 program offered an LVR required course in the postprofessional master’s-level curriculum.
  • 94 of the remaining 95 programs provided a range of 1–17 hr of LVR lecture and lab content in other required courses. Content varied across programs. 44 programs had faculty with advanced training or experience working in LVR.
  • More occupational therapy than occupational therapy assistant programs had faculty with advanced training or experience working in LVR. Some programs used specialists as adjunct faculty or guest speakers to cover LVR content or field trips to community resources.
Self-selected respondents, inability to generalize to nonrespondent programs or to assess effect on clinical opportunities and practice
Elliott et al. (2012) To examine the feasibility of conducting interdisciplinary fall risk screens at a community fall prevention event and to collect preliminary follow-up data on the balance confidence of and home or activity modifications made by adults screened at the event
  • Level III
  • One-group pretest–posttest pilot study
  • N = 11 community-dwelling adults ≥55 yr who participated in a fall prevention expo
  • Exclusion criterion: Cognitive inability to provide consent
  • Intervention
  • Multidisciplinary educational program presented in 4 hr at a fall prevention expo
  • Outcome Measures
  • • Activities-specific Balance Confidence (ABC) scale
  • • Falls Risk for Older People: Community Setting (FROP–Com)
  • Assessment was done before the expo and 4 mo post-expo.
  • 9 of 11 participants anticipated talking to their physician at baseline, and 5 had followed through at follow-up. 6 of 11 made environmental changes, and 7 of 11 made at least one activity change at follow-up.
  • It is feasible to provide interdisciplinary fall risk screens at an adult fall prevention event that can facilitate environmental and behavior changes to reduce fall risk.
Small convenience sample, inability to generalize to larger population, possible inaccuracy in self-reporting because of effect of time lapse on memory, no interrater reliability established for tools and raters
Haltiwanger (2012) To evaluate whether a structured peer-led group program with indirect supervision by an occupational therapy consultant improved diabetes-related adherence behaviors of Mexican-American older adults and to evaluate use of the Bridges Diabetes Support Group Manual (BDSGM)
  • Level III
  • One-group pretest–posttest pilot study
  • N = 8 at start (N = 5 at finish) peer mentors with Type 2 diabetes mellitus; mentors were Mexican-American; aged >60 yr; read and wrote English; followed guidelines for diet, glucose monitoring, and physical activity; and expressed a desire to help others
  • N = 16 at start (N = 11 at finish) mentees with Type 2 diabetes mellitus; mentees were Mexican-American; aged >60 yr; read and wrote English; and stated that their diabetes control was not as good as others expected it to be
  • Exclusion criterion: Spanish-only speaker
  • Intervention
  • The author modeled implementation of the BDSGM program, which she developed, for peer mentors over 8 weekly sessions of 1.5 hr. Peer mentors then implemented the program with two groups that met at times and days when the author was on site. After each session, the author provided peer mentors with education and supervision.
  • Outcome Measures
  • • HbA1c (glycosylated hemoglobin blood test) levels
  • • Diabetes Self-Efficacy Scale
  • • Adapted Illness Intrusiveness Scale
  • • Diabetes Attitude Scale
  • • Diabetes Empowerment Scale
  • • Author-modified version of the Transtheoretical Questionnaire
  • Data were collected 1 wk before intervention and at 2, 4, and 6 mo postintervention.
  • Changes in HbA1c levels were significant between pretest and 4-mo posttest. Responses on the Diabetes Self-Efficacy Scale and Diabetes Empowerment Scale improved significantly between pretest and all three posttests.
  • Peer mentors, with supervision from an occupational therapist, can run a structured, peer-led, culturally relevant support group program to encourage behavioral change in and provide support for older adults living with diabetes
Small sample, single culture, attrition of peer mentors and mentees, high level of ability to read and write English among sample
Hersch et al. (2012) To determine whether an occupation-based cultural heritage intervention facilitated older adults’ adaptation after relocation to a long-term care facility
  • Level II
  • Quasi-experimental two-group nonequivalent control with pre- and posttests
  • N = 29
  • Intervention group: N = 16; 69% African-American, 31% White; 19% >80 yr; 94% female
  • Control group: N = 13; 39% African-American, 62% White; 46% >80 yr; 69% female
  • Median age: 71–75 yr
  • Inclusion criteria: Age ≥55 yr, English speaking, relocated to site within 12 mo, able to participate in interviews, receiving licensed nursing care, scored ≤5 on the Short Portable Mental Status Questionnaire
  • Exclusion criteria: Residing in hospice or locked unit
  • Interventions
  • Both groups participated in identically structured and formatted groups 2×/wk for 4 wk. The intervention group engaged in activities with content specific to the cultural characteristics of the group. The control group engaged in typical facility activities. All groups were implemented by occupational therapy assistants trained in protocol administration.
  • Outcome Measures
  • • SF–12
  • • Duke Social Support and Stress Scale (DUSOCS)
  • • Sheltered Care Environment Scale (SCES)
  • • Yesterday Interview
  • • Quality of Life Index: Nursing Home Version
  • No significant differences were found between groups on baseline measures. Both groups’ SF–12 scores demonstrated frailty, with the intervention group showing a trend for lower physical health.
  • Quality of life (QOL) was significantly and positively correlated with the physical health and mental health scores on the SF–12, the SCES personal growth dimension, and the DUSOCS nonfamily support score. QOL was significantly and negatively correlated with DUSOCS family stress score and social stress score. Scores for the Overall QOL, Health and Function, and Psychological/Spiritual subscales improved for both groups.
  • No significant differences were found between groups pre- and postintervention in the Yesterday Interview regarding the amount of time spent in obligatory and discretionary activity.
Small sample size, frailty of sample, nonequivalent groups, variations in length of stay, unknown reasons for admission to long-term care facility
Hwang (2012) To explore the reliability (internal consistency, test–retest) of the Health Enhancement Lifestyle Profile Screener (HELP–Screener)
  • Level IV
  • Descriptive study
  • N = 90 for test–retest reliability
  • N = 483 for internal consistency
  • Inclusion criteria: Community-dwelling noninstitutionalized older adults aged ≥55 yr with adequate cognitive and English or Spanish capabilities to respond to a questionnaire
  • Intervention
  • Respondents completed the HELP–Screener, which consists of 15 yes–no items with a total score range of 0–15 and is available in English and Spanish. Respondents completed the screen by mail, responded individually or in a group via paper and pencil, or were administered it individually as a direct interview.
  • Outcome Measures
  • • Interrater reliability
  • • Internal consistency
Results showed ICCs of .75–1.00 and κ statistics of .76–.96, demonstrating good test–retest reliability. Cronbach’s α of .74 indicated an acceptable level of homogeneity within the 15-item scale and thus acceptable internal consistency.Limited population, self-report instrument
Katz, Averbuch, & Bar-Haim Erez (2012) To study the psychometric properties, internal consistency reliability, and construct validity of the Dynamic Lowenstein Occupational Therapy Cognitive Assessment–Geriatric Version (DLOTCA–G) To examine the contribution of mediation to performance on the DLOTCA–G subtests To examine which levels of mediation are most frequently required by older clients after stroke and by healthy older control participants
  • Level IV
  • Descriptive study
  • Intervention group: N = 61 clients with first stroke
  • Control group: N = 52 healthy participants
  • Inclusion criteria: Age >69 yr, score >24 on Mini-Mental State Examination
  • Exclusion criteria: Previous neurological or psychiatric illness, severe unilateral neglect and aphasia
  • Intervention
  • Evaluators administered the instrument using a four- or five-step mediation option in each subtest.
  • Outcome Measures
  • • Interrater reliability
  • • Mediation effect
  • Interrater reliability was good, at .90–.98.
  • Internal consistency and reliability were identified as high, with Cronbach’s αs of .68–.85 for all domains except Memory, which was low and requires further research.
  • The DLOTCA–G differentiated the cognitive performance of healthy control participants and patients with stroke both before and after mediation, supporting construct validity.
  • Both groups demonstrated changes after mediation.
Small sample size, limited patient population, limited cultural diversity
Leland, Elliott, O’Malley, & Murphy (2012) To summarize the occupational therapy literature related to fall prevention for community-dwelling older adults to elucidate occupational therapy’s involvement and suggest future opportunities
  • Level IV
  • Descriptive study, scoping literature review
  • N = 15 studies (6 from Australia; 12 RCTs)
  • Inclusion criteria: Description of occupational therapy–related intervention in 7 categories: environmental modification, exercise, medication management, managing postural hypotension, managing existing foot problems, recommending appropriate footwear, and behavioral modification
  • Exclusion criteria: Systematic reviews, meta-analyses, specialized patient populations, focus only on cost-effectiveness
  • Interventions
  • 7 environmental modification interventions, 3 exercise interventions, 4 multifactorial and 1 multicomponent interventions
  • Outcome Measures
  • • ADL indexes
  • • Physical functions of strength, walking, and balance
  • • Participation or engagement in activities and modifications of environment or behaviors
  • • Fall frequency
Occupational therapists are providing home modifications; home assessments; patient education; and ADL performance, exercise, and multidisciplinary programs, individually or in groups. They are not addressing the full scope of practice as outlined by the Occupational Therapy Practice Framework: Domain and Process (2nd ed.; AOTA, 2008) or the fall prevention guidelines of the AGS and BGS (2010) . Occupational therapists need to conduct further research on fall prevention and participate more consciously in managing medications, postural hypotension, foot problems and appropriate footwear, and behavioral modification as part of intervention.Inclusion only of intervention studies that involved occupational therapy practitioners, lack of consistency in intervention methods between studies, most studies documenting fall prevention outcomes related to occupational therapy conducted outside the United States
O’Brien, Bynon, Morarty, & Presnell (2012) To identify the impact of a functional conditioning program (FCP) on patient length of stay (LOS), discharge destination, departmental resource use, and functional status in older people admitted to acute care hospital setting as the result of trauma
  • Level II
  • Nonrandomized two-group control
  • Intervention group: N = 50 patients aged ≥65 yr who had been referred for the FCP
  • Control group: N = 105 patients aged ≥65 yr drawn from the hospital database who had been admitted to acute care hospital setting and referred for occupational therapy services
  • Exclusion criteria: Cognitive impairment identified by the Neurobehavioral Cognitive Status Examination or inability to communicate
  • Intervention
  • The FCP was delivered by an occupational therapist, a physical therapist, and an allied health assistant who specialized in care for older adults. They provided daily individual or group sessions of mobility practice, exercise, and activities chosen on the basis of patients’ premorbid self-care, leisure, or productivity activities.
  • Outcome Measures
  • • LOS
  • • Discharge destination
  • • Occupational therapy resource utilization patterns
Significant differences were found in LOS, initiation of therapy, referrals to occupational therapy services, and return to home. No difference in amount of service and hours of participation in occupational therapy between groups were found, but the intervention group was seen 1.5 days earlier.Possible lack of group equivalence, small sample, limited sample diversity
Orellano, Colón, & Arbesman (2012) To examine the effectiveness of occupation- or activity-based interventions in improving or maintaining IADL performance in community-dwelling older adults
  • Level I
  • Systematic review
  • N = 38 studies; 31 Level I, 3 Level II, 3 Level III, 1 Level IV
  • Inclusion criteria: Focus on older adults living in the community, intervention within the occupational therapy scope of practice, inclusion of an activity- or occupation-based component, evidence Level I–IV.
  • Exclusion criterion: Focus on driving (covered sufficiently in previous systematic reviews)
  • Intervention
  • Occupation-based, client-centered, and community-based care delivered by occupational therapists or a team of providers; multicomponent interventions; Lifestyle Redesign programs and occupational therapy interventions; functional activities interventions, including functional task exercise and simulated IADLs; performance skills interventions, including physical activity, strengthening, cognitive skills, and vision rehabilitation; home modification and assistive technology; patient education and adaptive devices
  • Outcome Measures
  • • Functional Status Questionnaire
  • • SF–36
  • • IADL Index
  • • Home Hazard Index
  • • Control-Oriented Strategy Index
  • • Task Modification and Timed Performance Scale
  • • Muscle strength
  • • Older Americans Resources and Services instrument
  • • FIM
  • • Craig Handicap Assessment and Reporting Technique
  • • Standardized timed measure of lower-extremity physical performance that included standing, balance, walking speed, and ability to rise from a chair
  • • 400-m timed walk
  • • Community Health Activities Model Program for Seniors Questionnaire
  • • Satisfaction with physical function
  • • Structured Assessment of Instrumental Living Skills
  • • Modified Baecke Questionnaire for Older Adults measuring household and leisure activity
  • • Walking
  • • State of Change Questionnaire
  • • Instrumental Activity Measure
  • • Self-ratings of difficulty in performance of daily activities
  • • Frenchay Activity Index
  • Strong evidence was found to support occupation-based, client-based, and multicomponent interventions for improving and maintaining IADL performance.
  • Moderate support was found for functional task exercise programs.
  • Limited evidence supported simulated IADL interventions to improve IADL performance.
  • Mixed evidence was found related to performance skills for physical activity and cognitive skills training.
  • Moderate support indicated that vision rehabilitation interventions improve IADL performance in older adults with low vision.
Self-report measures, IADL performance not comprehensively measured, limited ability to generalize findings, small samples, uncontrolled variables, attention bias, attrition
Painter et al. (2012) To explore the relationships among fear of falling, depression and anxiety, activity level, and activity restriction
  • Level IV
  • Descriptive study
  • N = 99 community-dwelling adults (84 from senior centers, 15 from an apartment complex) aged ≥55 yr who had not experienced a fall
  • Intervention
  • Occupational therapists met with participants for 2 hr to complete assessment surveys, invited participants to a 90-min fall prevention presentation, and provided incentive to participants on completion of surveys and presentation.
  • Outcome Measures
  • • Semistructured Fall Questionnaire
  • • Survey of Activities and Fear of Falling in the Elderly (SAFE), subsections A–F
  • • Geriatric Depression Scale–30 (GDS)
  • • Hamilton Anxiety Scale–IVR Version (HAMA)
  • More than one-third of study participants (38.4%) reported a fear of falling as measured by the SAFE B. Fear of falling correlated with depression (GDS), anxiety (HAMA), and activity level (SAFE A). Depression (GDS) was significantly correlated with anxiety (HAMA) and activity restriction (SAFE F). Conversely, activity level (SAFE A) was significantly negatively correlated with activity restriction, depression, anxiety, and fear of falling.
  • Occupational therapists should consider screening older adult clients for fear of falling, anxiety, and depression because these may lead to fall risk and activity restriction.
Small convenience sample, self-report measures
Schepens, Sen, Painter, & Murphy (2012) To examine the relationship between fall-related efficacy and scores on measures of activity and participation in community-dwelling older adults
  • Level I
  • Meta-analysis
  • N = 20 studies
  • Inclusion of both fall-related efficacy measures (e.g., Falls Efficacy Scale [FES] or Activities-specific Balance Confidence [ABC] Scale) and measure of activity and participation; participants >60 yr old not belonging to groups with specified diseases; provision of statistical information needed to perform a meta-analysis
  • Exclusion criteria: Case reports and qualitative studies, studies reporting only adjusted values
  • Intervention
  • Activity- and occupation-based interventions involving learning and applying knowledge, performance skills, general tasks and demands, communication, mobility, self-care, domestic life, participation in relationships and interpersonal interactions, major life areas, and community, social, and civic life
  • Outcome Measures
  • • FES
  • • ABC
  • • Measures of occupation and activity performance and participation
  • Fall-related efficacy is strongly related to measures of activity and performance in community-dwelling older adults. Higher fall-related efficacy in performing daily tasks without losing balance or falling is associated with higher levels of activity function and performance. Balance (ABC) showed a stronger relationship with activity than did fall-related efficacy (FES). No difference was found between occupation-based activities and performance skills for fall-related efficacy.
  • Occupational therapists may need to assess and intervene with both balance confidence and fall-related efficacy with older adults.
Capture of evidence about only one moment in time, lack of participation measures, wide variety of activity measures, inability to identify causal relationships, inability to differentiate between occupation-based activity and performance skills, inability to generalize because of smaller study samples
Stav, Hallenen, Lane, & Arbesman (2012) To appraise and synthesize the evidence for the relationship between occupational engagement and health and mortality outcomes for community-dwelling older adults
  • Level I
  • Systematic review
  • N = 98; 3 Level I, 95 Level II
  • Inclusion criteria: Community-dwelling older adults aged ≥60 yr, evidence related to occupational engagement and health and mortality outcomes.
  • Intervention
  • Physical activity including ADLs and IADLs, community activities, work or volunteering, social activity, participation in leisure activity
  • Outcome Measures
  • • Mortality
  • • Depression scales
  • • Well-being
  • • Katz ADL Scale
  • • Rosow–Breslau functional health scale
  • • Ryff’s Personal Growth Index
  • • Physical performance measures
  • • Cognitive performance measures
  • Strong evidence links participation in social activities and social networks to decreased cognitive and physical decline. Strong evidence was found linking physical activity to positive health outcomes. Physical inactivity was related to higher rates of mortality, higher prevalence of disease, and decreased levels of function.
  • Supportive evidence was found for the relationship between engagement in work or volunteering and positive physical, emotional, and mental health and sustained independence in ADLs and between participation in religious or spiritual activities and promotion of physical, emotional, mental, and social health. Sleeping 6–7.5 hr was associated with optimum health for older adults.
  • Dependence in IADLs, decreased community mobility, and leaving the house ≤4×/wk were associated with increased mortality and frailty and decreased ADL performance.
  • Caregivers with limited personal and social activities or who provided highly stressful caregiving were more likely to have poorer health.
Only 1 study conducted by an occupational therapist or specifically identified as an occupational therapy intervention, multiple definitions of constructs and variables, wide range of sample or population sizes, variety of cultural contexts (several studies conducted outside the United States)
Table Footer NoteNote. ADL = activity of daily living; AGS = American Geriatrics Society; AOTA = American Occupational Therapy Association; BGS = British Geriatrics Society; IADL = instrumental activity of daily living; ICC = intraclass correlation coefficient; RCT = randomized controlled trial; SDBM = Safe Driving Behavior Measure; SF–12 = 12-Item Short Form Health Survey; SF–36 = 36-Item Short Form Health Survey.
Note. ADL = activity of daily living; AGS = American Geriatrics Society; AOTA = American Occupational Therapy Association; BGS = British Geriatrics Society; IADL = instrumental activity of daily living; ICC = intraclass correlation coefficient; RCT = randomized controlled trial; SDBM = Safe Driving Behavior Measure; SF–12 = 12-Item Short Form Health Survey; SF–36 = 36-Item Short Form Health Survey.×
Table 1.
Summary of Evidence From 2012 Productive Aging Studies
Summary of Evidence From 2012 Productive Aging Studies×
Author/YearStudy ObjectivesLevel/Design/ParticipantsIntervention and Outcome MeasuresResultsStudy Limitations
Arbesman & Mosley (2012) To evaluate and synthesize the evidence for interventions to restore, modify, and maintain performance in the IADL of health management and maintenance
  • Level I
  • Systematic review
  • N = 28 studies; 24 Level I, 3 Level II, 1 Level III
  • Inclusion criteria: Studies focused on older adults living in the community and intervention within the scope of occupational therapy practice that had an activity- or occupation-based component
  • Interventions
  • Patient education, individual and group skills training, physical activity, phone support, cognitive–behavioral interventions, self-management programs, occupational therapy to incorporate lifestyle changes, activities, culturally specific programming, habit training, coaching, energy conservation, caregiver education
  • Outcome Measures
  • Physical and cognitive function, pain, disability, fatigue, activity level, quality of life, occupational performance, self-perception of performance, self-efficacy
  • Moderate to strong evidence was found that client-centered occupational therapy improved physical functioning and occupational performance related to health management.
  • Moderate evidence was found that group health education programs by educators and other health professionals improve health and function; that self-management programs result in decreased pain and disability; and that incorporating cognitive–behavioral principles into physical activity improves long-term participation in exercise.
  • Evidence for skill-specific training in isolation is limited, but skill-specific training was more effective when combined with health management programs.
Small sample sizes, high dropout rates, limited diversity among samples, incomplete data, much self-reported data, no replication studies
Chase, Mann, Wasek, & Arbesman (2012) To explore the impact of fall prevention programs and home modifications on falls and the performance of community-dwelling older adults
  • Level I
  • Systematic review
  • N = 33 studies; 31 Level I RCTs, 2 Level II
  • Inclusion criteria: Studies focused on older adults living in the community and intervention within the scope of occupational therapy practice that included a fall prevention or home modification intervention
  • Interventions
  • Detailed medical and occupational therapy assessment at home or hospital, recommendations for home modifications by an occupational therapist or other health professional or by a home visit or facility team, strength and balance training, vision assistance, home hazard removal, patient education, one-on-one training, group training, exercise, comprehensive functional assessments with recommendations for adaptive equipment and environmental modification; single sessions, multiple sessions, some follow-up assessment or sessions
  • Outcome Measures
  • Number of falls, ADL status, hospital admissions, length of hospital stay, self-report of functional level, fear of falling, self-efficacy, leg strength, quality of life, balance and gait, functional reach and balance, postural sway, reaction time, neuromuscular control, pain, health care costs, fall-related injuries, FIM scores, living situation, functional status
  • Strong evidence was found for using multifactorial programs that include home evaluations and home modifications, physical activity or exercise, education, vision and medication checks, and assistive technology to prevent falls.
  • Moderate support was found for programs that provided only physical activity or home modifications.
Possible contamination of groups, small sample sizes, self-report bias, some studies not blinded, inconsistent randomization of participants, samples with limited diversity, lack of clear description of intervention, difficulty separating benefits of occupational therapy–specific intervention from those resulting from other programs
Chippendale & Bear-Lehman (2012) To explore the effect of life review through writing on depressive symptoms in older adults residing in four senior residences
  • Level I
  • RCT
  • N = 45; 14 men, 31 = women; 34 White, 5 Black, 2 Hispanic, 4 Asian
  • Age range = 66–98 yr, mean = 84 yr
  • Inclusion criteria: Older adults ≥65 yr, able to speak and write English, negative screen for probable dementia on the Mini-Cog
  • Exclusion criteria: People with probable dementia
  • Intervention
  • The Share Your Life Story workshop protocol (Sierpina, 2002) consisted of 8 weekly 90-min sessions in which participants learned writing techniques, did writing exercises, and read their own written life stories. Participants were requested not to share their group experiences with other residents in an effort to prevent contamination of the wait-listed control group.
  • Outcome Measures
  • • Mini-Cog
  • • Geriatric Depression Scale (GDS)
  • • Demographics
  • • Self-rated health
  • • Independence in ADLs and IADLs
  • • Levels of leisure participation and social support
  • • Duke Social Support Index
  • • Social Support Appraisals Scale
  • Measures were done pre- and postintervention.
GDS scores improved after the 8-wk intervention; those who attended the most sessions had the most improvement. The occupation-based Share Your Life Story intervention protocol improved depressive symptoms in older adults who resided in senior residences.Possible bias because primary researcher conducted intervention and assessments, no follow-up measures after initial posttest
Classen et al. (2012a) To investigate the item- and person-level psychometrics and item hierarchy of the 68-item SDBM for three groups: older drivers, family caregivers, and driving evaluators
  • Level IV
  • Descriptive study
  • N = 80 older drivers aged 65–85 yr with valid driver’s license who were still driving and cognitively able to complete the SDBM and on-road driving test
  • N = 80 family members or caregivers aged 18–85 yr who were able to report observations about the older adult’s driving behavior
  • N = 2 professional driving rehabilitation specialist raters, one at each site
  • Exclusion criteria for older drivers: Missing limbs, severe psychiatric diagnosis, medical advice not to drive, uncontrolled seizures over past year, use of medication that impairs central nervous system functioning
  • Exclusion criteria for caregivers: Demonstration of a physical or mental condition that impaired ability to make an active contribution
  • Intervention
  • No intervention
  • Outcome Measures
  • • SDBM
  • • On-road driving assessment
Evidence was found that the SDBM is a unidimensional rating scale measuring safe and unsafe driving behaviors with good construct validity. Item analysis identified a hierarchy of items, high reliability of test items, and ability to stratify respondents from each group. Analysis also identified test items requiring further refinement.Limited diversity in convenience sample, which was highly educated, cognitively intact, and capable of high driving performance; small sample size
Classen et al. (2012b) To quantify the rater reliability and rater effects, using item response theory, of the 68-item SDBM for three rater groups: older drivers, family caregivers, and driving evaluators
  • Level IV
  • Descriptive instrument development
  • N = 80 older drivers aged 65–85 yr with valid driver’s license who were still driving and cognitively able to complete the SDBM and on-road driving test
  • N = 80 family members or caregivers aged 18–85 yr who were able to report observations about the older adult’s driving behavior
  • N = 2 professional driving rehabilitation specialist raters, one at each site
  • Exclusion criteria for older drivers: Missing limbs, severe psychiatric diagnosis, medical advice not to drive, uncontrolled seizures over past year, use of medication that impairs central nervous system functioning
  • Exclusion criteria for caregivers: Demonstration of a physical or mental condition that impaired ability to make an active contribution
  • Intervention
  • No intervention
  • Outcome Measures
  • • SDBM
  • • On-road driving assessment
  • ICCs among the ratings of the 3 rater groups were significant but weak. No significant correlations were found between the ratings of the older drivers and family caregiver groups or between the older driver and evaluator groups.
  • Driving specialists’ ratings were more severe than the ratings of the family caregivers or older drivers.
Limited diversity in convenience sample, small sample size, only 2 professionals used as raters
Deacy, Yuen, Barstow, Warren, & Vogtle (2012) To examine the preclinical curriculum content pertaining to low vision rehabilitation included in occupational therapy and occupational therapy assistant programs
  • Level IV
  • Descriptive study
  • N = 119 occupational therapy (n = 69) and occupational therapy assistant (n = 50) programs that responded to a survey of 10 closed-ended and 1 open-ended questions examining the type and extent of low vision rehabilitation (LVR) content offered in their programs
  • Intervention
  • No intervention
  • Outcome Measures
  • • Type of LVR content in program
  • • Extent of LVR content in program
  • 24 programs included a required course with primary emphasis on LVR.
  • 1 program offered an LVR required course in the postprofessional master’s-level curriculum.
  • 94 of the remaining 95 programs provided a range of 1–17 hr of LVR lecture and lab content in other required courses. Content varied across programs. 44 programs had faculty with advanced training or experience working in LVR.
  • More occupational therapy than occupational therapy assistant programs had faculty with advanced training or experience working in LVR. Some programs used specialists as adjunct faculty or guest speakers to cover LVR content or field trips to community resources.
Self-selected respondents, inability to generalize to nonrespondent programs or to assess effect on clinical opportunities and practice
Elliott et al. (2012) To examine the feasibility of conducting interdisciplinary fall risk screens at a community fall prevention event and to collect preliminary follow-up data on the balance confidence of and home or activity modifications made by adults screened at the event
  • Level III
  • One-group pretest–posttest pilot study
  • N = 11 community-dwelling adults ≥55 yr who participated in a fall prevention expo
  • Exclusion criterion: Cognitive inability to provide consent
  • Intervention
  • Multidisciplinary educational program presented in 4 hr at a fall prevention expo
  • Outcome Measures
  • • Activities-specific Balance Confidence (ABC) scale
  • • Falls Risk for Older People: Community Setting (FROP–Com)
  • Assessment was done before the expo and 4 mo post-expo.
  • 9 of 11 participants anticipated talking to their physician at baseline, and 5 had followed through at follow-up. 6 of 11 made environmental changes, and 7 of 11 made at least one activity change at follow-up.
  • It is feasible to provide interdisciplinary fall risk screens at an adult fall prevention event that can facilitate environmental and behavior changes to reduce fall risk.
Small convenience sample, inability to generalize to larger population, possible inaccuracy in self-reporting because of effect of time lapse on memory, no interrater reliability established for tools and raters
Haltiwanger (2012) To evaluate whether a structured peer-led group program with indirect supervision by an occupational therapy consultant improved diabetes-related adherence behaviors of Mexican-American older adults and to evaluate use of the Bridges Diabetes Support Group Manual (BDSGM)
  • Level III
  • One-group pretest–posttest pilot study
  • N = 8 at start (N = 5 at finish) peer mentors with Type 2 diabetes mellitus; mentors were Mexican-American; aged >60 yr; read and wrote English; followed guidelines for diet, glucose monitoring, and physical activity; and expressed a desire to help others
  • N = 16 at start (N = 11 at finish) mentees with Type 2 diabetes mellitus; mentees were Mexican-American; aged >60 yr; read and wrote English; and stated that their diabetes control was not as good as others expected it to be
  • Exclusion criterion: Spanish-only speaker
  • Intervention
  • The author modeled implementation of the BDSGM program, which she developed, for peer mentors over 8 weekly sessions of 1.5 hr. Peer mentors then implemented the program with two groups that met at times and days when the author was on site. After each session, the author provided peer mentors with education and supervision.
  • Outcome Measures
  • • HbA1c (glycosylated hemoglobin blood test) levels
  • • Diabetes Self-Efficacy Scale
  • • Adapted Illness Intrusiveness Scale
  • • Diabetes Attitude Scale
  • • Diabetes Empowerment Scale
  • • Author-modified version of the Transtheoretical Questionnaire
  • Data were collected 1 wk before intervention and at 2, 4, and 6 mo postintervention.
  • Changes in HbA1c levels were significant between pretest and 4-mo posttest. Responses on the Diabetes Self-Efficacy Scale and Diabetes Empowerment Scale improved significantly between pretest and all three posttests.
  • Peer mentors, with supervision from an occupational therapist, can run a structured, peer-led, culturally relevant support group program to encourage behavioral change in and provide support for older adults living with diabetes
Small sample, single culture, attrition of peer mentors and mentees, high level of ability to read and write English among sample
Hersch et al. (2012) To determine whether an occupation-based cultural heritage intervention facilitated older adults’ adaptation after relocation to a long-term care facility
  • Level II
  • Quasi-experimental two-group nonequivalent control with pre- and posttests
  • N = 29
  • Intervention group: N = 16; 69% African-American, 31% White; 19% >80 yr; 94% female
  • Control group: N = 13; 39% African-American, 62% White; 46% >80 yr; 69% female
  • Median age: 71–75 yr
  • Inclusion criteria: Age ≥55 yr, English speaking, relocated to site within 12 mo, able to participate in interviews, receiving licensed nursing care, scored ≤5 on the Short Portable Mental Status Questionnaire
  • Exclusion criteria: Residing in hospice or locked unit
  • Interventions
  • Both groups participated in identically structured and formatted groups 2×/wk for 4 wk. The intervention group engaged in activities with content specific to the cultural characteristics of the group. The control group engaged in typical facility activities. All groups were implemented by occupational therapy assistants trained in protocol administration.
  • Outcome Measures
  • • SF–12
  • • Duke Social Support and Stress Scale (DUSOCS)
  • • Sheltered Care Environment Scale (SCES)
  • • Yesterday Interview
  • • Quality of Life Index: Nursing Home Version
  • No significant differences were found between groups on baseline measures. Both groups’ SF–12 scores demonstrated frailty, with the intervention group showing a trend for lower physical health.
  • Quality of life (QOL) was significantly and positively correlated with the physical health and mental health scores on the SF–12, the SCES personal growth dimension, and the DUSOCS nonfamily support score. QOL was significantly and negatively correlated with DUSOCS family stress score and social stress score. Scores for the Overall QOL, Health and Function, and Psychological/Spiritual subscales improved for both groups.
  • No significant differences were found between groups pre- and postintervention in the Yesterday Interview regarding the amount of time spent in obligatory and discretionary activity.
Small sample size, frailty of sample, nonequivalent groups, variations in length of stay, unknown reasons for admission to long-term care facility
Hwang (2012) To explore the reliability (internal consistency, test–retest) of the Health Enhancement Lifestyle Profile Screener (HELP–Screener)
  • Level IV
  • Descriptive study
  • N = 90 for test–retest reliability
  • N = 483 for internal consistency
  • Inclusion criteria: Community-dwelling noninstitutionalized older adults aged ≥55 yr with adequate cognitive and English or Spanish capabilities to respond to a questionnaire
  • Intervention
  • Respondents completed the HELP–Screener, which consists of 15 yes–no items with a total score range of 0–15 and is available in English and Spanish. Respondents completed the screen by mail, responded individually or in a group via paper and pencil, or were administered it individually as a direct interview.
  • Outcome Measures
  • • Interrater reliability
  • • Internal consistency
Results showed ICCs of .75–1.00 and κ statistics of .76–.96, demonstrating good test–retest reliability. Cronbach’s α of .74 indicated an acceptable level of homogeneity within the 15-item scale and thus acceptable internal consistency.Limited population, self-report instrument
Katz, Averbuch, & Bar-Haim Erez (2012) To study the psychometric properties, internal consistency reliability, and construct validity of the Dynamic Lowenstein Occupational Therapy Cognitive Assessment–Geriatric Version (DLOTCA–G) To examine the contribution of mediation to performance on the DLOTCA–G subtests To examine which levels of mediation are most frequently required by older clients after stroke and by healthy older control participants
  • Level IV
  • Descriptive study
  • Intervention group: N = 61 clients with first stroke
  • Control group: N = 52 healthy participants
  • Inclusion criteria: Age >69 yr, score >24 on Mini-Mental State Examination
  • Exclusion criteria: Previous neurological or psychiatric illness, severe unilateral neglect and aphasia
  • Intervention
  • Evaluators administered the instrument using a four- or five-step mediation option in each subtest.
  • Outcome Measures
  • • Interrater reliability
  • • Mediation effect
  • Interrater reliability was good, at .90–.98.
  • Internal consistency and reliability were identified as high, with Cronbach’s αs of .68–.85 for all domains except Memory, which was low and requires further research.
  • The DLOTCA–G differentiated the cognitive performance of healthy control participants and patients with stroke both before and after mediation, supporting construct validity.
  • Both groups demonstrated changes after mediation.
Small sample size, limited patient population, limited cultural diversity
Leland, Elliott, O’Malley, & Murphy (2012) To summarize the occupational therapy literature related to fall prevention for community-dwelling older adults to elucidate occupational therapy’s involvement and suggest future opportunities
  • Level IV
  • Descriptive study, scoping literature review
  • N = 15 studies (6 from Australia; 12 RCTs)
  • Inclusion criteria: Description of occupational therapy–related intervention in 7 categories: environmental modification, exercise, medication management, managing postural hypotension, managing existing foot problems, recommending appropriate footwear, and behavioral modification
  • Exclusion criteria: Systematic reviews, meta-analyses, specialized patient populations, focus only on cost-effectiveness
  • Interventions
  • 7 environmental modification interventions, 3 exercise interventions, 4 multifactorial and 1 multicomponent interventions
  • Outcome Measures
  • • ADL indexes
  • • Physical functions of strength, walking, and balance
  • • Participation or engagement in activities and modifications of environment or behaviors
  • • Fall frequency
Occupational therapists are providing home modifications; home assessments; patient education; and ADL performance, exercise, and multidisciplinary programs, individually or in groups. They are not addressing the full scope of practice as outlined by the Occupational Therapy Practice Framework: Domain and Process (2nd ed.; AOTA, 2008) or the fall prevention guidelines of the AGS and BGS (2010) . Occupational therapists need to conduct further research on fall prevention and participate more consciously in managing medications, postural hypotension, foot problems and appropriate footwear, and behavioral modification as part of intervention.Inclusion only of intervention studies that involved occupational therapy practitioners, lack of consistency in intervention methods between studies, most studies documenting fall prevention outcomes related to occupational therapy conducted outside the United States
O’Brien, Bynon, Morarty, & Presnell (2012) To identify the impact of a functional conditioning program (FCP) on patient length of stay (LOS), discharge destination, departmental resource use, and functional status in older people admitted to acute care hospital setting as the result of trauma
  • Level II
  • Nonrandomized two-group control
  • Intervention group: N = 50 patients aged ≥65 yr who had been referred for the FCP
  • Control group: N = 105 patients aged ≥65 yr drawn from the hospital database who had been admitted to acute care hospital setting and referred for occupational therapy services
  • Exclusion criteria: Cognitive impairment identified by the Neurobehavioral Cognitive Status Examination or inability to communicate
  • Intervention
  • The FCP was delivered by an occupational therapist, a physical therapist, and an allied health assistant who specialized in care for older adults. They provided daily individual or group sessions of mobility practice, exercise, and activities chosen on the basis of patients’ premorbid self-care, leisure, or productivity activities.
  • Outcome Measures
  • • LOS
  • • Discharge destination
  • • Occupational therapy resource utilization patterns
Significant differences were found in LOS, initiation of therapy, referrals to occupational therapy services, and return to home. No difference in amount of service and hours of participation in occupational therapy between groups were found, but the intervention group was seen 1.5 days earlier.Possible lack of group equivalence, small sample, limited sample diversity
Orellano, Colón, & Arbesman (2012) To examine the effectiveness of occupation- or activity-based interventions in improving or maintaining IADL performance in community-dwelling older adults
  • Level I
  • Systematic review
  • N = 38 studies; 31 Level I, 3 Level II, 3 Level III, 1 Level IV
  • Inclusion criteria: Focus on older adults living in the community, intervention within the occupational therapy scope of practice, inclusion of an activity- or occupation-based component, evidence Level I–IV.
  • Exclusion criterion: Focus on driving (covered sufficiently in previous systematic reviews)
  • Intervention
  • Occupation-based, client-centered, and community-based care delivered by occupational therapists or a team of providers; multicomponent interventions; Lifestyle Redesign programs and occupational therapy interventions; functional activities interventions, including functional task exercise and simulated IADLs; performance skills interventions, including physical activity, strengthening, cognitive skills, and vision rehabilitation; home modification and assistive technology; patient education and adaptive devices
  • Outcome Measures
  • • Functional Status Questionnaire
  • • SF–36
  • • IADL Index
  • • Home Hazard Index
  • • Control-Oriented Strategy Index
  • • Task Modification and Timed Performance Scale
  • • Muscle strength
  • • Older Americans Resources and Services instrument
  • • FIM
  • • Craig Handicap Assessment and Reporting Technique
  • • Standardized timed measure of lower-extremity physical performance that included standing, balance, walking speed, and ability to rise from a chair
  • • 400-m timed walk
  • • Community Health Activities Model Program for Seniors Questionnaire
  • • Satisfaction with physical function
  • • Structured Assessment of Instrumental Living Skills
  • • Modified Baecke Questionnaire for Older Adults measuring household and leisure activity
  • • Walking
  • • State of Change Questionnaire
  • • Instrumental Activity Measure
  • • Self-ratings of difficulty in performance of daily activities
  • • Frenchay Activity Index
  • Strong evidence was found to support occupation-based, client-based, and multicomponent interventions for improving and maintaining IADL performance.
  • Moderate support was found for functional task exercise programs.
  • Limited evidence supported simulated IADL interventions to improve IADL performance.
  • Mixed evidence was found related to performance skills for physical activity and cognitive skills training.
  • Moderate support indicated that vision rehabilitation interventions improve IADL performance in older adults with low vision.
Self-report measures, IADL performance not comprehensively measured, limited ability to generalize findings, small samples, uncontrolled variables, attention bias, attrition
Painter et al. (2012) To explore the relationships among fear of falling, depression and anxiety, activity level, and activity restriction
  • Level IV
  • Descriptive study
  • N = 99 community-dwelling adults (84 from senior centers, 15 from an apartment complex) aged ≥55 yr who had not experienced a fall
  • Intervention
  • Occupational therapists met with participants for 2 hr to complete assessment surveys, invited participants to a 90-min fall prevention presentation, and provided incentive to participants on completion of surveys and presentation.
  • Outcome Measures
  • • Semistructured Fall Questionnaire
  • • Survey of Activities and Fear of Falling in the Elderly (SAFE), subsections A–F
  • • Geriatric Depression Scale–30 (GDS)
  • • Hamilton Anxiety Scale–IVR Version (HAMA)
  • More than one-third of study participants (38.4%) reported a fear of falling as measured by the SAFE B. Fear of falling correlated with depression (GDS), anxiety (HAMA), and activity level (SAFE A). Depression (GDS) was significantly correlated with anxiety (HAMA) and activity restriction (SAFE F). Conversely, activity level (SAFE A) was significantly negatively correlated with activity restriction, depression, anxiety, and fear of falling.
  • Occupational therapists should consider screening older adult clients for fear of falling, anxiety, and depression because these may lead to fall risk and activity restriction.
Small convenience sample, self-report measures
Schepens, Sen, Painter, & Murphy (2012) To examine the relationship between fall-related efficacy and scores on measures of activity and participation in community-dwelling older adults
  • Level I
  • Meta-analysis
  • N = 20 studies
  • Inclusion of both fall-related efficacy measures (e.g., Falls Efficacy Scale [FES] or Activities-specific Balance Confidence [ABC] Scale) and measure of activity and participation; participants >60 yr old not belonging to groups with specified diseases; provision of statistical information needed to perform a meta-analysis
  • Exclusion criteria: Case reports and qualitative studies, studies reporting only adjusted values
  • Intervention
  • Activity- and occupation-based interventions involving learning and applying knowledge, performance skills, general tasks and demands, communication, mobility, self-care, domestic life, participation in relationships and interpersonal interactions, major life areas, and community, social, and civic life
  • Outcome Measures
  • • FES
  • • ABC
  • • Measures of occupation and activity performance and participation
  • Fall-related efficacy is strongly related to measures of activity and performance in community-dwelling older adults. Higher fall-related efficacy in performing daily tasks without losing balance or falling is associated with higher levels of activity function and performance. Balance (ABC) showed a stronger relationship with activity than did fall-related efficacy (FES). No difference was found between occupation-based activities and performance skills for fall-related efficacy.
  • Occupational therapists may need to assess and intervene with both balance confidence and fall-related efficacy with older adults.
Capture of evidence about only one moment in time, lack of participation measures, wide variety of activity measures, inability to identify causal relationships, inability to differentiate between occupation-based activity and performance skills, inability to generalize because of smaller study samples
Stav, Hallenen, Lane, & Arbesman (2012) To appraise and synthesize the evidence for the relationship between occupational engagement and health and mortality outcomes for community-dwelling older adults
  • Level I
  • Systematic review
  • N = 98; 3 Level I, 95 Level II
  • Inclusion criteria: Community-dwelling older adults aged ≥60 yr, evidence related to occupational engagement and health and mortality outcomes.
  • Intervention
  • Physical activity including ADLs and IADLs, community activities, work or volunteering, social activity, participation in leisure activity
  • Outcome Measures
  • • Mortality
  • • Depression scales
  • • Well-being
  • • Katz ADL Scale
  • • Rosow–Breslau functional health scale
  • • Ryff’s Personal Growth Index
  • • Physical performance measures
  • • Cognitive performance measures
  • Strong evidence links participation in social activities and social networks to decreased cognitive and physical decline. Strong evidence was found linking physical activity to positive health outcomes. Physical inactivity was related to higher rates of mortality, higher prevalence of disease, and decreased levels of function.
  • Supportive evidence was found for the relationship between engagement in work or volunteering and positive physical, emotional, and mental health and sustained independence in ADLs and between participation in religious or spiritual activities and promotion of physical, emotional, mental, and social health. Sleeping 6–7.5 hr was associated with optimum health for older adults.
  • Dependence in IADLs, decreased community mobility, and leaving the house ≤4×/wk were associated with increased mortality and frailty and decreased ADL performance.
  • Caregivers with limited personal and social activities or who provided highly stressful caregiving were more likely to have poorer health.
Only 1 study conducted by an occupational therapist or specifically identified as an occupational therapy intervention, multiple definitions of constructs and variables, wide range of sample or population sizes, variety of cultural contexts (several studies conducted outside the United States)
Table Footer NoteNote. ADL = activity of daily living; AGS = American Geriatrics Society; AOTA = American Occupational Therapy Association; BGS = British Geriatrics Society; IADL = instrumental activity of daily living; ICC = intraclass correlation coefficient; RCT = randomized controlled trial; SDBM = Safe Driving Behavior Measure; SF–12 = 12-Item Short Form Health Survey; SF–36 = 36-Item Short Form Health Survey.
Note. ADL = activity of daily living; AGS = American Geriatrics Society; AOTA = American Occupational Therapy Association; BGS = British Geriatrics Society; IADL = instrumental activity of daily living; ICC = intraclass correlation coefficient; RCT = randomized controlled trial; SDBM = Safe Driving Behavior Measure; SF–12 = 12-Item Short Form Health Survey; SF–36 = 36-Item Short Form Health Survey.×
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Findings
Effectiveness Studies
Ten effectiveness studies related to productive aging were published in 2012. These studies included 4 systematic reviews, 1 RCT, 1 meta-analysis, 2 two-group nonrandomized controlled studies, and 2 pretest–posttest single-group studies.
Three systematic reviews found moderate to strong evidence for the effectiveness of occupation- and activity-based interventions. Arbesman and Mosley (2012)  and Orellano, Colón, and Arbesman (2012)  conducted systematic reviews that evaluated and synthesized the evidence for interventions commonly used in occupational therapy to restore, modify, and maintain performance of instrumental activities of daily living (IADLs) in community-dwelling older adults. Whereas Arbesman and Mosley focused specifically on performance in health management and maintenance, Orellano et al. focused specifically on occupation- and activity-based interventions for IADLs in general. Both studies found strong support for client-centered occupation-based interventions. Arbesman and Mosley found moderate evidence that self-management programs are effective; that educational programs for clients, caregivers, and health professionals improve health management in older adults; and that skill-specific training is more effective when combined with health management programs. Orellano et al. found moderate support for vision rehabilitation interventions to improve IADL performance, with mixed evidence noted for physical activity and cognitive performance skills training.
Stav, Hallenen, Lane, and Arbesman (2012)  found strong evidence that engagement by older adults in social activities and physical activity sustained occupational performance and decreased decline and that older community-dwelling adults who were not socially or physically active experienced greater mortality and decreased performance.
Two Level I studies (1 systematic review, 1 meta-analysis) and 1 Level III study focused on the effectiveness of interventions related to fall prevention. Chase, Mann, Wasek, and Arbesman (2012)  explored the impact of fall prevention programs and home modifications on falls and the occupational performance of community-dwelling older adults. They found strong evidence for the effectiveness of multifactorial programs that included home modifications, physical activity or exercise, education, vision and medication checks, and assistive technology. They also found moderate evidence for the effectiveness of programs that provided physical activity or home modifications.
Schepens, Sen, Painter, and Murphy (2012)  conducted a meta-analysis that examined the relationship between fall-related efficacy and measures of activity and participation in community-dwelling older adults. Participants who had higher fall-related efficacy had fewer falls and higher levels of activity function and performance, including performance of daily tasks.
Elliott et al. (2012)  conducted a Level III study that examined the feasibility of conducting interdisciplinary fall risk screens at a community-wide adult fall prevention event and investigated whether people who attended the event made home or activity modifications. They found that providing interdisciplinary fall risk screens at an adult fall prevention event can prompt older community-dwelling adults to modify their environments and behaviors to reduce fall risk.
Two studies explored culturally based occupational therapy interventions. Hersch et al. (2012)  conducted a Level II quasi-experimental study that looked at the effectiveness of providing culturally relevant, occupation-based intervention to facilitate the adaptation of older adults who had recently moved to a long-term care facility. Haltiwanger (2012)  conducted a one-group pretest–posttest pilot study that evaluated the effectiveness of a structured, culturally sensitive, peer-led group program with indirect occupational therapy supervision to improve diabetes self-management in Mexican-American older adults. Both studies concluded that providing culturally relevant occupational therapy improved participants’ quality of life and adherence to health maintenance and self-management.
Two studies examined specific occupational therapy interventions in limited contexts. O’Brien, Bynon, Morarty, and Presnell (2012)  conducted a two-group nonrandomized controlled study to determine the impact of a newly developed targeted occupational therapy intervention, a function conditioning program, on length of stay, discharge destination, resource use, and functional status of older adults admitted to an acute care hospital posttrauma. The researchers found significant differences in length of stay, initiation of therapy, and return to home rates. Also noted were increased occupational therapy referrals for participants in the functional conditioning program group compared with control group participants who received standard care.
Chippendale and Bear-Lehman (2012)  conducted an RCT to explore the effect of writing a life review on the depressive symptoms of older adults residing in senior residences. Residents who attended the most sessions of this occupation-based intervention, titled Share Your Life Story, demonstrated the most improvement in Geriatric Depression Scale scores.
Descriptive and Correlational Studies and Basic Research
Seven descriptive studies were published in 2012. Four addressed instrument development and testing. One explored the inclusion of low vision rehabilitation content in occupational therapy curricula. Another study explored the relationship between fear of falling and depression, anxiety, and activity participation. In addition, a scoping review was conducted to summarize the literature on occupational therapy’s involvement in fall prevention intervention.
Painter et al. (2012)  conducted basic research, a correlational study examining the relationship between fear of falling as measured by the Survey of Activities and Fear of Falling in the Elderly (SAFE) and scores from the Geriatric Depression Scale–30 and the Hamilton Anxiety Scale–IVR. Correlation analyses among these measures found relationships between fear of falling and depression, anxiety, and activity level; depression and anxiety; and activity restriction and depression for community-dwelling older adults.
Directions for the Profession’s Growth and Education
Deacy, Yuen, Barstow, Warren, and Vogtle (2012)  explored the curricula of occupational therapy and occupational therapy assistant programs in the United States for low vision rehabilitation content. Almost 40% of 314 programs responded to the survey. All of the programs that responded had some level of low vision rehabilitation content delivered in their curriculum. Only 25 programs included a required course with a primary focus on low vision rehabilitation. Content about low vision rehabilitation varied widely across curricula, even when specialists within the program or from the community provided the training.
Leland, Elliott, O’Malley, and Murphy (2012)  searched the literature for studies that were conducted by occupational therapists or that included occupational therapy intervention related to fall prevention. They identified 15 such studies, 6 from Australia and 9 from the global occupational therapy community; 12 were RCTs. The studies addressed occupational therapists providing home modifications, home assessments, patient education, activities of daily living performance interventions, exercise interventions, and multidisciplinary programs for individuals or groups. Leland et al.’s analysis indicated that occupational therapists are not providing the full scope of practice as outlined in the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2008). They advocated that occupational therapists consider facilitating medication management, managing postural hypotension, managing existing foot problems and recommending footwear, and recommending behavioral modifications as part of intervention. They concluded that occupational therapists need to conduct further research about fall prevention and to include interventions from the full scope of practice.
Instrument Development and Testing, Occupational Engagement, and Health
Three of the four studies related to instrument development focused on the psychometric properties of assessment tools in development. One study focused primarily on investigating the differences in perception of the assessment tool respondents based upon Toglia’s (2011)  Dynamic Interactional Model of Cognition.
Classen and colleagues (2012a, 2012b) conducted two studies examining the Safe Driving Behavior Measure (SDBM). One study quantified the rater reliability and rater effects using item response theory among three groups of raters—older drivers, family caregivers, and driving evaluators—and found that the evaluators were more severe in their rating of older drivers than family caregivers or the older drivers themselves (Classen et al., 2012b). The second study explored the item and person psychometrics of the SDBM using the same three groups for comparison (Classen et al., 2012a). The SDBM had good construct validity in measuring perceived safe and unsafe driving behaviors and good reliability in differentiating the scores of the test respondents; however, the authors noted the need for further refinement of some items. Both studies identified the need for further research.
Hwang (2012), who developed the Health Enhancement Lifestyle Profile (HELP; Hwang, 2010), conducted a psychometric study of the reliability of the HELP–Screener, a short form of the HELP. Test–retest reliability and construct reliability for a convenience sample of community-dwelling older adults who had not been institutionalized were in the acceptable to very good range.
Katz, Averbuch, and Bar-Haim Erez (2012)  compared clients with stroke with healthy control participants to examine the reliability and validity of the Dynamic Lowenstein Occupational Therapy Cognitive Assessment—Geriatric Version (DLOTCA–G). They found that interrater reliability and internal consistency were in the acceptable to good range but that the memory section requires further research and refinement. The dynamic aspect of the assessment involved the effect of mediation of learning using Toglia’s (2011)  Dynamic Interactional Model of Cognition, and both groups made gains after mediation.
Discussion
The AOTA collaboration developed for systematic reviews continues to provide the bulk of Level I effectiveness studies. Levels II and III effectiveness studies involving productive aging made a stronger showing in 2012 than in previous years (D’Amico, 2012; Murphy, 2010, 2011). The strong support these studies (even those not conducted by occupational therapists) provide for occupation-based and client-centered intervention to promote productive aging validates the foundational tenets of our profession. This validation enables other health care providers and society to recognize the value we provide to clients.
Research on productive aging published in AJOT in 2012 identifies opportunities for the occupational therapy profession:
  • Models demonstrating the importance and value of occupational therapy in promoting desirable patient and hospital outcomes demonstrate the efficacy of occupational therapy in improving health care outcomes (O’Brien et al., 2012).

  • Cultural relevance has been a cornerstone of occupational therapy since its inception, and studies supporting this aspect of occupational therapy remain important within the broader framework of health care (Haltiwanger, 2012; Hersch et al., 2012).

  • Community events such as health fairs provide a means to improve safety and health and assess potential changes that may result from community-based education (Painter et al., 2012).

  • The profession may need to consider standards related to curricula content about low vision rehabilitation (Deacy et al., 2012).

  • Falls prevention is a major area related to occupational performance that requires more attention within the context of practice and research (Chase et al., 2012; Elliott et al., 2012; Leland et al., 2012; Painter et al., 2012; Schepens et al., 2012). Existing research has predominantly been produced by occupational therapists in Australia and other parts of the world.

  • Although the areas of driving rehabilitation and assessment, falls prevention, and low vision rehabilitation have been around for many years, these topics have a continued and needed presence as the U.S. population ages and life expectancy around the world increases (Classen et al., 2012a, 2012b).

Studies addressing the validity and reliability of assessments developed by occupational therapists, including the SDBM (Classen et al., 2012a, 2012b), the HELP–Screener (Hwang, 2012), and the DLOTCA–G (Katz et al., 2012), increased in 2012. The continued refinement of assessments ensures the current potential and continued use of each tool. Assessments created by occupational therapists for occupational therapists are great, but assessments created by occupational therapists that have the potential to become standards in their specialties would be a tremendous boon to the profession, especially in the areas of driving, community living, and functional cognitive performance.
All studies demonstrated limitations, often related to small sample sizes, lack of replicability, limited diversity among samples, and lack of long-term follow-up. Although some studies supported the effectiveness of interventions within the scope of occupational therapy practice, many studies in the systematic reviews and scoping review revealed that few such studies are being conducted by occupational therapists.
Implications for Occupational Therapy Practice
This review has the following implications for occupational therapy practice:
  • Further evidence is available of the power of occupation-based and activity-based interventions in improving occupational performance.

  • Prevention services and programs provided in the community can improve health, well-being, and continued occupational performance and participation for older adults.

  • Community health fairs provide opportunities for practitioners, educators, and students to provide services and collect data.

  • Cultural relevance is an important element of client-centered interventions with older clients.

  • Fall prevention interventions should address exercise, home modifications, foot care and footwear, medication management, postural hypotension, and fear of falling.

  • Occupational therapy practitioners are encouraged to develop or identify programs and interventions that improve client performance and outcomes.

Conclusion
In 2012, AJOT articles related to productive aging practice increased 30% over previous years (2009–2011). The increased quality and quantity of such articles promise continued growth in the journal’s impact ratings. Although, as noted in several studies, much research remains to be done, this progress reflects “our unique and invaluable contributions to health care and societal needs, for which no other profession could ever substitute and [ensures] reimbursement streams to support the skillful and complex work we do every day” (Clark, 2011, p. 618).
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Table 1.
Summary of Evidence From 2012 Productive Aging Studies
Summary of Evidence From 2012 Productive Aging Studies×
Author/YearStudy ObjectivesLevel/Design/ParticipantsIntervention and Outcome MeasuresResultsStudy Limitations
Arbesman & Mosley (2012) To evaluate and synthesize the evidence for interventions to restore, modify, and maintain performance in the IADL of health management and maintenance
  • Level I
  • Systematic review
  • N = 28 studies; 24 Level I, 3 Level II, 1 Level III
  • Inclusion criteria: Studies focused on older adults living in the community and intervention within the scope of occupational therapy practice that had an activity- or occupation-based component
  • Interventions
  • Patient education, individual and group skills training, physical activity, phone support, cognitive–behavioral interventions, self-management programs, occupational therapy to incorporate lifestyle changes, activities, culturally specific programming, habit training, coaching, energy conservation, caregiver education
  • Outcome Measures
  • Physical and cognitive function, pain, disability, fatigue, activity level, quality of life, occupational performance, self-perception of performance, self-efficacy
  • Moderate to strong evidence was found that client-centered occupational therapy improved physical functioning and occupational performance related to health management.
  • Moderate evidence was found that group health education programs by educators and other health professionals improve health and function; that self-management programs result in decreased pain and disability; and that incorporating cognitive–behavioral principles into physical activity improves long-term participation in exercise.
  • Evidence for skill-specific training in isolation is limited, but skill-specific training was more effective when combined with health management programs.
Small sample sizes, high dropout rates, limited diversity among samples, incomplete data, much self-reported data, no replication studies
Chase, Mann, Wasek, & Arbesman (2012) To explore the impact of fall prevention programs and home modifications on falls and the performance of community-dwelling older adults
  • Level I
  • Systematic review
  • N = 33 studies; 31 Level I RCTs, 2 Level II
  • Inclusion criteria: Studies focused on older adults living in the community and intervention within the scope of occupational therapy practice that included a fall prevention or home modification intervention
  • Interventions
  • Detailed medical and occupational therapy assessment at home or hospital, recommendations for home modifications by an occupational therapist or other health professional or by a home visit or facility team, strength and balance training, vision assistance, home hazard removal, patient education, one-on-one training, group training, exercise, comprehensive functional assessments with recommendations for adaptive equipment and environmental modification; single sessions, multiple sessions, some follow-up assessment or sessions
  • Outcome Measures
  • Number of falls, ADL status, hospital admissions, length of hospital stay, self-report of functional level, fear of falling, self-efficacy, leg strength, quality of life, balance and gait, functional reach and balance, postural sway, reaction time, neuromuscular control, pain, health care costs, fall-related injuries, FIM scores, living situation, functional status
  • Strong evidence was found for using multifactorial programs that include home evaluations and home modifications, physical activity or exercise, education, vision and medication checks, and assistive technology to prevent falls.
  • Moderate support was found for programs that provided only physical activity or home modifications.
Possible contamination of groups, small sample sizes, self-report bias, some studies not blinded, inconsistent randomization of participants, samples with limited diversity, lack of clear description of intervention, difficulty separating benefits of occupational therapy–specific intervention from those resulting from other programs
Chippendale & Bear-Lehman (2012) To explore the effect of life review through writing on depressive symptoms in older adults residing in four senior residences
  • Level I
  • RCT
  • N = 45; 14 men, 31 = women; 34 White, 5 Black, 2 Hispanic, 4 Asian
  • Age range = 66–98 yr, mean = 84 yr
  • Inclusion criteria: Older adults ≥65 yr, able to speak and write English, negative screen for probable dementia on the Mini-Cog
  • Exclusion criteria: People with probable dementia
  • Intervention
  • The Share Your Life Story workshop protocol (Sierpina, 2002) consisted of 8 weekly 90-min sessions in which participants learned writing techniques, did writing exercises, and read their own written life stories. Participants were requested not to share their group experiences with other residents in an effort to prevent contamination of the wait-listed control group.
  • Outcome Measures
  • • Mini-Cog
  • • Geriatric Depression Scale (GDS)
  • • Demographics
  • • Self-rated health
  • • Independence in ADLs and IADLs
  • • Levels of leisure participation and social support
  • • Duke Social Support Index
  • • Social Support Appraisals Scale
  • Measures were done pre- and postintervention.
GDS scores improved after the 8-wk intervention; those who attended the most sessions had the most improvement. The occupation-based Share Your Life Story intervention protocol improved depressive symptoms in older adults who resided in senior residences.Possible bias because primary researcher conducted intervention and assessments, no follow-up measures after initial posttest
Classen et al. (2012a) To investigate the item- and person-level psychometrics and item hierarchy of the 68-item SDBM for three groups: older drivers, family caregivers, and driving evaluators
  • Level IV
  • Descriptive study
  • N = 80 older drivers aged 65–85 yr with valid driver’s license who were still driving and cognitively able to complete the SDBM and on-road driving test
  • N = 80 family members or caregivers aged 18–85 yr who were able to report observations about the older adult’s driving behavior
  • N = 2 professional driving rehabilitation specialist raters, one at each site
  • Exclusion criteria for older drivers: Missing limbs, severe psychiatric diagnosis, medical advice not to drive, uncontrolled seizures over past year, use of medication that impairs central nervous system functioning
  • Exclusion criteria for caregivers: Demonstration of a physical or mental condition that impaired ability to make an active contribution
  • Intervention
  • No intervention
  • Outcome Measures
  • • SDBM
  • • On-road driving assessment
Evidence was found that the SDBM is a unidimensional rating scale measuring safe and unsafe driving behaviors with good construct validity. Item analysis identified a hierarchy of items, high reliability of test items, and ability to stratify respondents from each group. Analysis also identified test items requiring further refinement.Limited diversity in convenience sample, which was highly educated, cognitively intact, and capable of high driving performance; small sample size
Classen et al. (2012b) To quantify the rater reliability and rater effects, using item response theory, of the 68-item SDBM for three rater groups: older drivers, family caregivers, and driving evaluators
  • Level IV
  • Descriptive instrument development
  • N = 80 older drivers aged 65–85 yr with valid driver’s license who were still driving and cognitively able to complete the SDBM and on-road driving test
  • N = 80 family members or caregivers aged 18–85 yr who were able to report observations about the older adult’s driving behavior
  • N = 2 professional driving rehabilitation specialist raters, one at each site
  • Exclusion criteria for older drivers: Missing limbs, severe psychiatric diagnosis, medical advice not to drive, uncontrolled seizures over past year, use of medication that impairs central nervous system functioning
  • Exclusion criteria for caregivers: Demonstration of a physical or mental condition that impaired ability to make an active contribution
  • Intervention
  • No intervention
  • Outcome Measures
  • • SDBM
  • • On-road driving assessment
  • ICCs among the ratings of the 3 rater groups were significant but weak. No significant correlations were found between the ratings of the older drivers and family caregiver groups or between the older driver and evaluator groups.
  • Driving specialists’ ratings were more severe than the ratings of the family caregivers or older drivers.
Limited diversity in convenience sample, small sample size, only 2 professionals used as raters
Deacy, Yuen, Barstow, Warren, & Vogtle (2012) To examine the preclinical curriculum content pertaining to low vision rehabilitation included in occupational therapy and occupational therapy assistant programs
  • Level IV
  • Descriptive study
  • N = 119 occupational therapy (n = 69) and occupational therapy assistant (n = 50) programs that responded to a survey of 10 closed-ended and 1 open-ended questions examining the type and extent of low vision rehabilitation (LVR) content offered in their programs
  • Intervention
  • No intervention
  • Outcome Measures
  • • Type of LVR content in program
  • • Extent of LVR content in program
  • 24 programs included a required course with primary emphasis on LVR.
  • 1 program offered an LVR required course in the postprofessional master’s-level curriculum.
  • 94 of the remaining 95 programs provided a range of 1–17 hr of LVR lecture and lab content in other required courses. Content varied across programs. 44 programs had faculty with advanced training or experience working in LVR.
  • More occupational therapy than occupational therapy assistant programs had faculty with advanced training or experience working in LVR. Some programs used specialists as adjunct faculty or guest speakers to cover LVR content or field trips to community resources.
Self-selected respondents, inability to generalize to nonrespondent programs or to assess effect on clinical opportunities and practice
Elliott et al. (2012) To examine the feasibility of conducting interdisciplinary fall risk screens at a community fall prevention event and to collect preliminary follow-up data on the balance confidence of and home or activity modifications made by adults screened at the event
  • Level III
  • One-group pretest–posttest pilot study
  • N = 11 community-dwelling adults ≥55 yr who participated in a fall prevention expo
  • Exclusion criterion: Cognitive inability to provide consent
  • Intervention
  • Multidisciplinary educational program presented in 4 hr at a fall prevention expo
  • Outcome Measures
  • • Activities-specific Balance Confidence (ABC) scale
  • • Falls Risk for Older People: Community Setting (FROP–Com)
  • Assessment was done before the expo and 4 mo post-expo.
  • 9 of 11 participants anticipated talking to their physician at baseline, and 5 had followed through at follow-up. 6 of 11 made environmental changes, and 7 of 11 made at least one activity change at follow-up.
  • It is feasible to provide interdisciplinary fall risk screens at an adult fall prevention event that can facilitate environmental and behavior changes to reduce fall risk.
Small convenience sample, inability to generalize to larger population, possible inaccuracy in self-reporting because of effect of time lapse on memory, no interrater reliability established for tools and raters
Haltiwanger (2012) To evaluate whether a structured peer-led group program with indirect supervision by an occupational therapy consultant improved diabetes-related adherence behaviors of Mexican-American older adults and to evaluate use of the Bridges Diabetes Support Group Manual (BDSGM)
  • Level III
  • One-group pretest–posttest pilot study
  • N = 8 at start (N = 5 at finish) peer mentors with Type 2 diabetes mellitus; mentors were Mexican-American; aged >60 yr; read and wrote English; followed guidelines for diet, glucose monitoring, and physical activity; and expressed a desire to help others
  • N = 16 at start (N = 11 at finish) mentees with Type 2 diabetes mellitus; mentees were Mexican-American; aged >60 yr; read and wrote English; and stated that their diabetes control was not as good as others expected it to be
  • Exclusion criterion: Spanish-only speaker
  • Intervention
  • The author modeled implementation of the BDSGM program, which she developed, for peer mentors over 8 weekly sessions of 1.5 hr. Peer mentors then implemented the program with two groups that met at times and days when the author was on site. After each session, the author provided peer mentors with education and supervision.
  • Outcome Measures
  • • HbA1c (glycosylated hemoglobin blood test) levels
  • • Diabetes Self-Efficacy Scale
  • • Adapted Illness Intrusiveness Scale
  • • Diabetes Attitude Scale
  • • Diabetes Empowerment Scale
  • • Author-modified version of the Transtheoretical Questionnaire
  • Data were collected 1 wk before intervention and at 2, 4, and 6 mo postintervention.
  • Changes in HbA1c levels were significant between pretest and 4-mo posttest. Responses on the Diabetes Self-Efficacy Scale and Diabetes Empowerment Scale improved significantly between pretest and all three posttests.
  • Peer mentors, with supervision from an occupational therapist, can run a structured, peer-led, culturally relevant support group program to encourage behavioral change in and provide support for older adults living with diabetes
Small sample, single culture, attrition of peer mentors and mentees, high level of ability to read and write English among sample
Hersch et al. (2012) To determine whether an occupation-based cultural heritage intervention facilitated older adults’ adaptation after relocation to a long-term care facility
  • Level II
  • Quasi-experimental two-group nonequivalent control with pre- and posttests
  • N = 29
  • Intervention group: N = 16; 69% African-American, 31% White; 19% >80 yr; 94% female
  • Control group: N = 13; 39% African-American, 62% White; 46% >80 yr; 69% female
  • Median age: 71–75 yr
  • Inclusion criteria: Age ≥55 yr, English speaking, relocated to site within 12 mo, able to participate in interviews, receiving licensed nursing care, scored ≤5 on the Short Portable Mental Status Questionnaire
  • Exclusion criteria: Residing in hospice or locked unit
  • Interventions
  • Both groups participated in identically structured and formatted groups 2×/wk for 4 wk. The intervention group engaged in activities with content specific to the cultural characteristics of the group. The control group engaged in typical facility activities. All groups were implemented by occupational therapy assistants trained in protocol administration.
  • Outcome Measures
  • • SF–12
  • • Duke Social Support and Stress Scale (DUSOCS)
  • • Sheltered Care Environment Scale (SCES)
  • • Yesterday Interview
  • • Quality of Life Index: Nursing Home Version
  • No significant differences were found between groups on baseline measures. Both groups’ SF–12 scores demonstrated frailty, with the intervention group showing a trend for lower physical health.
  • Quality of life (QOL) was significantly and positively correlated with the physical health and mental health scores on the SF–12, the SCES personal growth dimension, and the DUSOCS nonfamily support score. QOL was significantly and negatively correlated with DUSOCS family stress score and social stress score. Scores for the Overall QOL, Health and Function, and Psychological/Spiritual subscales improved for both groups.
  • No significant differences were found between groups pre- and postintervention in the Yesterday Interview regarding the amount of time spent in obligatory and discretionary activity.
Small sample size, frailty of sample, nonequivalent groups, variations in length of stay, unknown reasons for admission to long-term care facility
Hwang (2012) To explore the reliability (internal consistency, test–retest) of the Health Enhancement Lifestyle Profile Screener (HELP–Screener)
  • Level IV
  • Descriptive study
  • N = 90 for test–retest reliability
  • N = 483 for internal consistency
  • Inclusion criteria: Community-dwelling noninstitutionalized older adults aged ≥55 yr with adequate cognitive and English or Spanish capabilities to respond to a questionnaire
  • Intervention
  • Respondents completed the HELP–Screener, which consists of 15 yes–no items with a total score range of 0–15 and is available in English and Spanish. Respondents completed the screen by mail, responded individually or in a group via paper and pencil, or were administered it individually as a direct interview.
  • Outcome Measures
  • • Interrater reliability
  • • Internal consistency
Results showed ICCs of .75–1.00 and κ statistics of .76–.96, demonstrating good test–retest reliability. Cronbach’s α of .74 indicated an acceptable level of homogeneity within the 15-item scale and thus acceptable internal consistency.Limited population, self-report instrument
Katz, Averbuch, & Bar-Haim Erez (2012) To study the psychometric properties, internal consistency reliability, and construct validity of the Dynamic Lowenstein Occupational Therapy Cognitive Assessment–Geriatric Version (DLOTCA–G) To examine the contribution of mediation to performance on the DLOTCA–G subtests To examine which levels of mediation are most frequently required by older clients after stroke and by healthy older control participants
  • Level IV
  • Descriptive study
  • Intervention group: N = 61 clients with first stroke
  • Control group: N = 52 healthy participants
  • Inclusion criteria: Age >69 yr, score >24 on Mini-Mental State Examination
  • Exclusion criteria: Previous neurological or psychiatric illness, severe unilateral neglect and aphasia
  • Intervention
  • Evaluators administered the instrument using a four- or five-step mediation option in each subtest.
  • Outcome Measures
  • • Interrater reliability
  • • Mediation effect
  • Interrater reliability was good, at .90–.98.
  • Internal consistency and reliability were identified as high, with Cronbach’s αs of .68–.85 for all domains except Memory, which was low and requires further research.
  • The DLOTCA–G differentiated the cognitive performance of healthy control participants and patients with stroke both before and after mediation, supporting construct validity.
  • Both groups demonstrated changes after mediation.
Small sample size, limited patient population, limited cultural diversity
Leland, Elliott, O’Malley, & Murphy (2012) To summarize the occupational therapy literature related to fall prevention for community-dwelling older adults to elucidate occupational therapy’s involvement and suggest future opportunities
  • Level IV
  • Descriptive study, scoping literature review
  • N = 15 studies (6 from Australia; 12 RCTs)
  • Inclusion criteria: Description of occupational therapy–related intervention in 7 categories: environmental modification, exercise, medication management, managing postural hypotension, managing existing foot problems, recommending appropriate footwear, and behavioral modification
  • Exclusion criteria: Systematic reviews, meta-analyses, specialized patient populations, focus only on cost-effectiveness
  • Interventions
  • 7 environmental modification interventions, 3 exercise interventions, 4 multifactorial and 1 multicomponent interventions
  • Outcome Measures
  • • ADL indexes
  • • Physical functions of strength, walking, and balance
  • • Participation or engagement in activities and modifications of environment or behaviors
  • • Fall frequency
Occupational therapists are providing home modifications; home assessments; patient education; and ADL performance, exercise, and multidisciplinary programs, individually or in groups. They are not addressing the full scope of practice as outlined by the Occupational Therapy Practice Framework: Domain and Process (2nd ed.; AOTA, 2008) or the fall prevention guidelines of the AGS and BGS (2010) . Occupational therapists need to conduct further research on fall prevention and participate more consciously in managing medications, postural hypotension, foot problems and appropriate footwear, and behavioral modification as part of intervention.Inclusion only of intervention studies that involved occupational therapy practitioners, lack of consistency in intervention methods between studies, most studies documenting fall prevention outcomes related to occupational therapy conducted outside the United States
O’Brien, Bynon, Morarty, & Presnell (2012) To identify the impact of a functional conditioning program (FCP) on patient length of stay (LOS), discharge destination, departmental resource use, and functional status in older people admitted to acute care hospital setting as the result of trauma
  • Level II
  • Nonrandomized two-group control
  • Intervention group: N = 50 patients aged ≥65 yr who had been referred for the FCP
  • Control group: N = 105 patients aged ≥65 yr drawn from the hospital database who had been admitted to acute care hospital setting and referred for occupational therapy services
  • Exclusion criteria: Cognitive impairment identified by the Neurobehavioral Cognitive Status Examination or inability to communicate
  • Intervention
  • The FCP was delivered by an occupational therapist, a physical therapist, and an allied health assistant who specialized in care for older adults. They provided daily individual or group sessions of mobility practice, exercise, and activities chosen on the basis of patients’ premorbid self-care, leisure, or productivity activities.
  • Outcome Measures
  • • LOS
  • • Discharge destination
  • • Occupational therapy resource utilization patterns
Significant differences were found in LOS, initiation of therapy, referrals to occupational therapy services, and return to home. No difference in amount of service and hours of participation in occupational therapy between groups were found, but the intervention group was seen 1.5 days earlier.Possible lack of group equivalence, small sample, limited sample diversity
Orellano, Colón, & Arbesman (2012) To examine the effectiveness of occupation- or activity-based interventions in improving or maintaining IADL performance in community-dwelling older adults
  • Level I
  • Systematic review
  • N = 38 studies; 31 Level I, 3 Level II, 3 Level III, 1 Level IV
  • Inclusion criteria: Focus on older adults living in the community, intervention within the occupational therapy scope of practice, inclusion of an activity- or occupation-based component, evidence Level I–IV.
  • Exclusion criterion: Focus on driving (covered sufficiently in previous systematic reviews)
  • Intervention
  • Occupation-based, client-centered, and community-based care delivered by occupational therapists or a team of providers; multicomponent interventions; Lifestyle Redesign programs and occupational therapy interventions; functional activities interventions, including functional task exercise and simulated IADLs; performance skills interventions, including physical activity, strengthening, cognitive skills, and vision rehabilitation; home modification and assistive technology; patient education and adaptive devices
  • Outcome Measures
  • • Functional Status Questionnaire
  • • SF–36
  • • IADL Index
  • • Home Hazard Index
  • • Control-Oriented Strategy Index
  • • Task Modification and Timed Performance Scale
  • • Muscle strength
  • • Older Americans Resources and Services instrument
  • • FIM
  • • Craig Handicap Assessment and Reporting Technique
  • • Standardized timed measure of lower-extremity physical performance that included standing, balance, walking speed, and ability to rise from a chair
  • • 400-m timed walk
  • • Community Health Activities Model Program for Seniors Questionnaire
  • • Satisfaction with physical function
  • • Structured Assessment of Instrumental Living Skills
  • • Modified Baecke Questionnaire for Older Adults measuring household and leisure activity
  • • Walking
  • • State of Change Questionnaire
  • • Instrumental Activity Measure
  • • Self-ratings of difficulty in performance of daily activities
  • • Frenchay Activity Index
  • Strong evidence was found to support occupation-based, client-based, and multicomponent interventions for improving and maintaining IADL performance.
  • Moderate support was found for functional task exercise programs.
  • Limited evidence supported simulated IADL interventions to improve IADL performance.
  • Mixed evidence was found related to performance skills for physical activity and cognitive skills training.
  • Moderate support indicated that vision rehabilitation interventions improve IADL performance in older adults with low vision.
Self-report measures, IADL performance not comprehensively measured, limited ability to generalize findings, small samples, uncontrolled variables, attention bias, attrition
Painter et al. (2012) To explore the relationships among fear of falling, depression and anxiety, activity level, and activity restriction
  • Level IV
  • Descriptive study
  • N = 99 community-dwelling adults (84 from senior centers, 15 from an apartment complex) aged ≥55 yr who had not experienced a fall
  • Intervention
  • Occupational therapists met with participants for 2 hr to complete assessment surveys, invited participants to a 90-min fall prevention presentation, and provided incentive to participants on completion of surveys and presentation.
  • Outcome Measures
  • • Semistructured Fall Questionnaire
  • • Survey of Activities and Fear of Falling in the Elderly (SAFE), subsections A–F
  • • Geriatric Depression Scale–30 (GDS)
  • • Hamilton Anxiety Scale–IVR Version (HAMA)
  • More than one-third of study participants (38.4%) reported a fear of falling as measured by the SAFE B. Fear of falling correlated with depression (GDS), anxiety (HAMA), and activity level (SAFE A). Depression (GDS) was significantly correlated with anxiety (HAMA) and activity restriction (SAFE F). Conversely, activity level (SAFE A) was significantly negatively correlated with activity restriction, depression, anxiety, and fear of falling.
  • Occupational therapists should consider screening older adult clients for fear of falling, anxiety, and depression because these may lead to fall risk and activity restriction.
Small convenience sample, self-report measures
Schepens, Sen, Painter, & Murphy (2012) To examine the relationship between fall-related efficacy and scores on measures of activity and participation in community-dwelling older adults
  • Level I
  • Meta-analysis
  • N = 20 studies
  • Inclusion of both fall-related efficacy measures (e.g., Falls Efficacy Scale [FES] or Activities-specific Balance Confidence [ABC] Scale) and measure of activity and participation; participants >60 yr old not belonging to groups with specified diseases; provision of statistical information needed to perform a meta-analysis
  • Exclusion criteria: Case reports and qualitative studies, studies reporting only adjusted values
  • Intervention
  • Activity- and occupation-based interventions involving learning and applying knowledge, performance skills, general tasks and demands, communication, mobility, self-care, domestic life, participation in relationships and interpersonal interactions, major life areas, and community, social, and civic life
  • Outcome Measures
  • • FES
  • • ABC
  • • Measures of occupation and activity performance and participation
  • Fall-related efficacy is strongly related to measures of activity and performance in community-dwelling older adults. Higher fall-related efficacy in performing daily tasks without losing balance or falling is associated with higher levels of activity function and performance. Balance (ABC) showed a stronger relationship with activity than did fall-related efficacy (FES). No difference was found between occupation-based activities and performance skills for fall-related efficacy.
  • Occupational therapists may need to assess and intervene with both balance confidence and fall-related efficacy with older adults.
Capture of evidence about only one moment in time, lack of participation measures, wide variety of activity measures, inability to identify causal relationships, inability to differentiate between occupation-based activity and performance skills, inability to generalize because of smaller study samples
Stav, Hallenen, Lane, & Arbesman (2012) To appraise and synthesize the evidence for the relationship between occupational engagement and health and mortality outcomes for community-dwelling older adults
  • Level I
  • Systematic review
  • N = 98; 3 Level I, 95 Level II
  • Inclusion criteria: Community-dwelling older adults aged ≥60 yr, evidence related to occupational engagement and health and mortality outcomes.
  • Intervention
  • Physical activity including ADLs and IADLs, community activities, work or volunteering, social activity, participation in leisure activity
  • Outcome Measures
  • • Mortality
  • • Depression scales
  • • Well-being
  • • Katz ADL Scale
  • • Rosow–Breslau functional health scale
  • • Ryff’s Personal Growth Index
  • • Physical performance measures
  • • Cognitive performance measures
  • Strong evidence links participation in social activities and social networks to decreased cognitive and physical decline. Strong evidence was found linking physical activity to positive health outcomes. Physical inactivity was related to higher rates of mortality, higher prevalence of disease, and decreased levels of function.
  • Supportive evidence was found for the relationship between engagement in work or volunteering and positive physical, emotional, and mental health and sustained independence in ADLs and between participation in religious or spiritual activities and promotion of physical, emotional, mental, and social health. Sleeping 6–7.5 hr was associated with optimum health for older adults.
  • Dependence in IADLs, decreased community mobility, and leaving the house ≤4×/wk were associated with increased mortality and frailty and decreased ADL performance.
  • Caregivers with limited personal and social activities or who provided highly stressful caregiving were more likely to have poorer health.
Only 1 study conducted by an occupational therapist or specifically identified as an occupational therapy intervention, multiple definitions of constructs and variables, wide range of sample or population sizes, variety of cultural contexts (several studies conducted outside the United States)
Table Footer NoteNote. ADL = activity of daily living; AGS = American Geriatrics Society; AOTA = American Occupational Therapy Association; BGS = British Geriatrics Society; IADL = instrumental activity of daily living; ICC = intraclass correlation coefficient; RCT = randomized controlled trial; SDBM = Safe Driving Behavior Measure; SF–12 = 12-Item Short Form Health Survey; SF–36 = 36-Item Short Form Health Survey.
Note. ADL = activity of daily living; AGS = American Geriatrics Society; AOTA = American Occupational Therapy Association; BGS = British Geriatrics Society; IADL = instrumental activity of daily living; ICC = intraclass correlation coefficient; RCT = randomized controlled trial; SDBM = Safe Driving Behavior Measure; SF–12 = 12-Item Short Form Health Survey; SF–36 = 36-Item Short Form Health Survey.×
Table 1.
Summary of Evidence From 2012 Productive Aging Studies
Summary of Evidence From 2012 Productive Aging Studies×
Author/YearStudy ObjectivesLevel/Design/ParticipantsIntervention and Outcome MeasuresResultsStudy Limitations
Arbesman & Mosley (2012) To evaluate and synthesize the evidence for interventions to restore, modify, and maintain performance in the IADL of health management and maintenance
  • Level I
  • Systematic review
  • N = 28 studies; 24 Level I, 3 Level II, 1 Level III
  • Inclusion criteria: Studies focused on older adults living in the community and intervention within the scope of occupational therapy practice that had an activity- or occupation-based component
  • Interventions
  • Patient education, individual and group skills training, physical activity, phone support, cognitive–behavioral interventions, self-management programs, occupational therapy to incorporate lifestyle changes, activities, culturally specific programming, habit training, coaching, energy conservation, caregiver education
  • Outcome Measures
  • Physical and cognitive function, pain, disability, fatigue, activity level, quality of life, occupational performance, self-perception of performance, self-efficacy
  • Moderate to strong evidence was found that client-centered occupational therapy improved physical functioning and occupational performance related to health management.
  • Moderate evidence was found that group health education programs by educators and other health professionals improve health and function; that self-management programs result in decreased pain and disability; and that incorporating cognitive–behavioral principles into physical activity improves long-term participation in exercise.
  • Evidence for skill-specific training in isolation is limited, but skill-specific training was more effective when combined with health management programs.
Small sample sizes, high dropout rates, limited diversity among samples, incomplete data, much self-reported data, no replication studies
Chase, Mann, Wasek, & Arbesman (2012) To explore the impact of fall prevention programs and home modifications on falls and the performance of community-dwelling older adults
  • Level I
  • Systematic review
  • N = 33 studies; 31 Level I RCTs, 2 Level II
  • Inclusion criteria: Studies focused on older adults living in the community and intervention within the scope of occupational therapy practice that included a fall prevention or home modification intervention
  • Interventions
  • Detailed medical and occupational therapy assessment at home or hospital, recommendations for home modifications by an occupational therapist or other health professional or by a home visit or facility team, strength and balance training, vision assistance, home hazard removal, patient education, one-on-one training, group training, exercise, comprehensive functional assessments with recommendations for adaptive equipment and environmental modification; single sessions, multiple sessions, some follow-up assessment or sessions
  • Outcome Measures
  • Number of falls, ADL status, hospital admissions, length of hospital stay, self-report of functional level, fear of falling, self-efficacy, leg strength, quality of life, balance and gait, functional reach and balance, postural sway, reaction time, neuromuscular control, pain, health care costs, fall-related injuries, FIM scores, living situation, functional status
  • Strong evidence was found for using multifactorial programs that include home evaluations and home modifications, physical activity or exercise, education, vision and medication checks, and assistive technology to prevent falls.
  • Moderate support was found for programs that provided only physical activity or home modifications.
Possible contamination of groups, small sample sizes, self-report bias, some studies not blinded, inconsistent randomization of participants, samples with limited diversity, lack of clear description of intervention, difficulty separating benefits of occupational therapy–specific intervention from those resulting from other programs
Chippendale & Bear-Lehman (2012) To explore the effect of life review through writing on depressive symptoms in older adults residing in four senior residences
  • Level I
  • RCT
  • N = 45; 14 men, 31 = women; 34 White, 5 Black, 2 Hispanic, 4 Asian
  • Age range = 66–98 yr, mean = 84 yr
  • Inclusion criteria: Older adults ≥65 yr, able to speak and write English, negative screen for probable dementia on the Mini-Cog
  • Exclusion criteria: People with probable dementia
  • Intervention
  • The Share Your Life Story workshop protocol (Sierpina, 2002) consisted of 8 weekly 90-min sessions in which participants learned writing techniques, did writing exercises, and read their own written life stories. Participants were requested not to share their group experiences with other residents in an effort to prevent contamination of the wait-listed control group.
  • Outcome Measures
  • • Mini-Cog
  • • Geriatric Depression Scale (GDS)
  • • Demographics
  • • Self-rated health
  • • Independence in ADLs and IADLs
  • • Levels of leisure participation and social support
  • • Duke Social Support Index
  • • Social Support Appraisals Scale
  • Measures were done pre- and postintervention.
GDS scores improved after the 8-wk intervention; those who attended the most sessions had the most improvement. The occupation-based Share Your Life Story intervention protocol improved depressive symptoms in older adults who resided in senior residences.Possible bias because primary researcher conducted intervention and assessments, no follow-up measures after initial posttest
Classen et al. (2012a) To investigate the item- and person-level psychometrics and item hierarchy of the 68-item SDBM for three groups: older drivers, family caregivers, and driving evaluators
  • Level IV
  • Descriptive study
  • N = 80 older drivers aged 65–85 yr with valid driver’s license who were still driving and cognitively able to complete the SDBM and on-road driving test
  • N = 80 family members or caregivers aged 18–85 yr who were able to report observations about the older adult’s driving behavior
  • N = 2 professional driving rehabilitation specialist raters, one at each site
  • Exclusion criteria for older drivers: Missing limbs, severe psychiatric diagnosis, medical advice not to drive, uncontrolled seizures over past year, use of medication that impairs central nervous system functioning
  • Exclusion criteria for caregivers: Demonstration of a physical or mental condition that impaired ability to make an active contribution
  • Intervention
  • No intervention
  • Outcome Measures
  • • SDBM
  • • On-road driving assessment
Evidence was found that the SDBM is a unidimensional rating scale measuring safe and unsafe driving behaviors with good construct validity. Item analysis identified a hierarchy of items, high reliability of test items, and ability to stratify respondents from each group. Analysis also identified test items requiring further refinement.Limited diversity in convenience sample, which was highly educated, cognitively intact, and capable of high driving performance; small sample size
Classen et al. (2012b) To quantify the rater reliability and rater effects, using item response theory, of the 68-item SDBM for three rater groups: older drivers, family caregivers, and driving evaluators
  • Level IV
  • Descriptive instrument development
  • N = 80 older drivers aged 65–85 yr with valid driver’s license who were still driving and cognitively able to complete the SDBM and on-road driving test
  • N = 80 family members or caregivers aged 18–85 yr who were able to report observations about the older adult’s driving behavior
  • N = 2 professional driving rehabilitation specialist raters, one at each site
  • Exclusion criteria for older drivers: Missing limbs, severe psychiatric diagnosis, medical advice not to drive, uncontrolled seizures over past year, use of medication that impairs central nervous system functioning
  • Exclusion criteria for caregivers: Demonstration of a physical or mental condition that impaired ability to make an active contribution
  • Intervention
  • No intervention
  • Outcome Measures
  • • SDBM
  • • On-road driving assessment
  • ICCs among the ratings of the 3 rater groups were significant but weak. No significant correlations were found between the ratings of the older drivers and family caregiver groups or between the older driver and evaluator groups.
  • Driving specialists’ ratings were more severe than the ratings of the family caregivers or older drivers.
Limited diversity in convenience sample, small sample size, only 2 professionals used as raters
Deacy, Yuen, Barstow, Warren, & Vogtle (2012) To examine the preclinical curriculum content pertaining to low vision rehabilitation included in occupational therapy and occupational therapy assistant programs
  • Level IV
  • Descriptive study
  • N = 119 occupational therapy (n = 69) and occupational therapy assistant (n = 50) programs that responded to a survey of 10 closed-ended and 1 open-ended questions examining the type and extent of low vision rehabilitation (LVR) content offered in their programs
  • Intervention
  • No intervention
  • Outcome Measures
  • • Type of LVR content in program
  • • Extent of LVR content in program
  • 24 programs included a required course with primary emphasis on LVR.
  • 1 program offered an LVR required course in the postprofessional master’s-level curriculum.
  • 94 of the remaining 95 programs provided a range of 1–17 hr of LVR lecture and lab content in other required courses. Content varied across programs. 44 programs had faculty with advanced training or experience working in LVR.
  • More occupational therapy than occupational therapy assistant programs had faculty with advanced training or experience working in LVR. Some programs used specialists as adjunct faculty or guest speakers to cover LVR content or field trips to community resources.
Self-selected respondents, inability to generalize to nonrespondent programs or to assess effect on clinical opportunities and practice
Elliott et al. (2012) To examine the feasibility of conducting interdisciplinary fall risk screens at a community fall prevention event and to collect preliminary follow-up data on the balance confidence of and home or activity modifications made by adults screened at the event
  • Level III
  • One-group pretest–posttest pilot study
  • N = 11 community-dwelling adults ≥55 yr who participated in a fall prevention expo
  • Exclusion criterion: Cognitive inability to provide consent
  • Intervention
  • Multidisciplinary educational program presented in 4 hr at a fall prevention expo
  • Outcome Measures
  • • Activities-specific Balance Confidence (ABC) scale
  • • Falls Risk for Older People: Community Setting (FROP–Com)
  • Assessment was done before the expo and 4 mo post-expo.
  • 9 of 11 participants anticipated talking to their physician at baseline, and 5 had followed through at follow-up. 6 of 11 made environmental changes, and 7 of 11 made at least one activity change at follow-up.
  • It is feasible to provide interdisciplinary fall risk screens at an adult fall prevention event that can facilitate environmental and behavior changes to reduce fall risk.
Small convenience sample, inability to generalize to larger population, possible inaccuracy in self-reporting because of effect of time lapse on memory, no interrater reliability established for tools and raters
Haltiwanger (2012) To evaluate whether a structured peer-led group program with indirect supervision by an occupational therapy consultant improved diabetes-related adherence behaviors of Mexican-American older adults and to evaluate use of the Bridges Diabetes Support Group Manual (BDSGM)
  • Level III
  • One-group pretest–posttest pilot study
  • N = 8 at start (N = 5 at finish) peer mentors with Type 2 diabetes mellitus; mentors were Mexican-American; aged >60 yr; read and wrote English; followed guidelines for diet, glucose monitoring, and physical activity; and expressed a desire to help others
  • N = 16 at start (N = 11 at finish) mentees with Type 2 diabetes mellitus; mentees were Mexican-American; aged >60 yr; read and wrote English; and stated that their diabetes control was not as good as others expected it to be
  • Exclusion criterion: Spanish-only speaker
  • Intervention
  • The author modeled implementation of the BDSGM program, which she developed, for peer mentors over 8 weekly sessions of 1.5 hr. Peer mentors then implemented the program with two groups that met at times and days when the author was on site. After each session, the author provided peer mentors with education and supervision.
  • Outcome Measures
  • • HbA1c (glycosylated hemoglobin blood test) levels
  • • Diabetes Self-Efficacy Scale
  • • Adapted Illness Intrusiveness Scale
  • • Diabetes Attitude Scale
  • • Diabetes Empowerment Scale
  • • Author-modified version of the Transtheoretical Questionnaire
  • Data were collected 1 wk before intervention and at 2, 4, and 6 mo postintervention.
  • Changes in HbA1c levels were significant between pretest and 4-mo posttest. Responses on the Diabetes Self-Efficacy Scale and Diabetes Empowerment Scale improved significantly between pretest and all three posttests.
  • Peer mentors, with supervision from an occupational therapist, can run a structured, peer-led, culturally relevant support group program to encourage behavioral change in and provide support for older adults living with diabetes
Small sample, single culture, attrition of peer mentors and mentees, high level of ability to read and write English among sample
Hersch et al. (2012) To determine whether an occupation-based cultural heritage intervention facilitated older adults’ adaptation after relocation to a long-term care facility
  • Level II
  • Quasi-experimental two-group nonequivalent control with pre- and posttests
  • N = 29
  • Intervention group: N = 16; 69% African-American, 31% White; 19% >80 yr; 94% female
  • Control group: N = 13; 39% African-American, 62% White; 46% >80 yr; 69% female
  • Median age: 71–75 yr
  • Inclusion criteria: Age ≥55 yr, English speaking, relocated to site within 12 mo, able to participate in interviews, receiving licensed nursing care, scored ≤5 on the Short Portable Mental Status Questionnaire
  • Exclusion criteria: Residing in hospice or locked unit
  • Interventions
  • Both groups participated in identically structured and formatted groups 2×/wk for 4 wk. The intervention group engaged in activities with content specific to the cultural characteristics of the group. The control group engaged in typical facility activities. All groups were implemented by occupational therapy assistants trained in protocol administration.
  • Outcome Measures
  • • SF–12
  • • Duke Social Support and Stress Scale (DUSOCS)
  • • Sheltered Care Environment Scale (SCES)
  • • Yesterday Interview
  • • Quality of Life Index: Nursing Home Version
  • No significant differences were found between groups on baseline measures. Both groups’ SF–12 scores demonstrated frailty, with the intervention group showing a trend for lower physical health.
  • Quality of life (QOL) was significantly and positively correlated with the physical health and mental health scores on the SF–12, the SCES personal growth dimension, and the DUSOCS nonfamily support score. QOL was significantly and negatively correlated with DUSOCS family stress score and social stress score. Scores for the Overall QOL, Health and Function, and Psychological/Spiritual subscales improved for both groups.
  • No significant differences were found between groups pre- and postintervention in the Yesterday Interview regarding the amount of time spent in obligatory and discretionary activity.
Small sample size, frailty of sample, nonequivalent groups, variations in length of stay, unknown reasons for admission to long-term care facility
Hwang (2012) To explore the reliability (internal consistency, test–retest) of the Health Enhancement Lifestyle Profile Screener (HELP–Screener)
  • Level IV
  • Descriptive study
  • N = 90 for test–retest reliability
  • N = 483 for internal consistency
  • Inclusion criteria: Community-dwelling noninstitutionalized older adults aged ≥55 yr with adequate cognitive and English or Spanish capabilities to respond to a questionnaire
  • Intervention
  • Respondents completed the HELP–Screener, which consists of 15 yes–no items with a total score range of 0–15 and is available in English and Spanish. Respondents completed the screen by mail, responded individually or in a group via paper and pencil, or were administered it individually as a direct interview.
  • Outcome Measures
  • • Interrater reliability
  • • Internal consistency
Results showed ICCs of .75–1.00 and κ statistics of .76–.96, demonstrating good test–retest reliability. Cronbach’s α of .74 indicated an acceptable level of homogeneity within the 15-item scale and thus acceptable internal consistency.Limited population, self-report instrument
Katz, Averbuch, & Bar-Haim Erez (2012) To study the psychometric properties, internal consistency reliability, and construct validity of the Dynamic Lowenstein Occupational Therapy Cognitive Assessment–Geriatric Version (DLOTCA–G) To examine the contribution of mediation to performance on the DLOTCA–G subtests To examine which levels of mediation are most frequently required by older clients after stroke and by healthy older control participants
  • Level IV
  • Descriptive study
  • Intervention group: N = 61 clients with first stroke
  • Control group: N = 52 healthy participants
  • Inclusion criteria: Age >69 yr, score >24 on Mini-Mental State Examination
  • Exclusion criteria: Previous neurological or psychiatric illness, severe unilateral neglect and aphasia
  • Intervention
  • Evaluators administered the instrument using a four- or five-step mediation option in each subtest.
  • Outcome Measures
  • • Interrater reliability
  • • Mediation effect
  • Interrater reliability was good, at .90–.98.
  • Internal consistency and reliability were identified as high, with Cronbach’s αs of .68–.85 for all domains except Memory, which was low and requires further research.
  • The DLOTCA–G differentiated the cognitive performance of healthy control participants and patients with stroke both before and after mediation, supporting construct validity.
  • Both groups demonstrated changes after mediation.
Small sample size, limited patient population, limited cultural diversity
Leland, Elliott, O’Malley, & Murphy (2012) To summarize the occupational therapy literature related to fall prevention for community-dwelling older adults to elucidate occupational therapy’s involvement and suggest future opportunities
  • Level IV
  • Descriptive study, scoping literature review
  • N = 15 studies (6 from Australia; 12 RCTs)
  • Inclusion criteria: Description of occupational therapy–related intervention in 7 categories: environmental modification, exercise, medication management, managing postural hypotension, managing existing foot problems, recommending appropriate footwear, and behavioral modification
  • Exclusion criteria: Systematic reviews, meta-analyses, specialized patient populations, focus only on cost-effectiveness
  • Interventions
  • 7 environmental modification interventions, 3 exercise interventions, 4 multifactorial and 1 multicomponent interventions
  • Outcome Measures
  • • ADL indexes
  • • Physical functions of strength, walking, and balance
  • • Participation or engagement in activities and modifications of environment or behaviors
  • • Fall frequency
Occupational therapists are providing home modifications; home assessments; patient education; and ADL performance, exercise, and multidisciplinary programs, individually or in groups. They are not addressing the full scope of practice as outlined by the Occupational Therapy Practice Framework: Domain and Process (2nd ed.; AOTA, 2008) or the fall prevention guidelines of the AGS and BGS (2010) . Occupational therapists need to conduct further research on fall prevention and participate more consciously in managing medications, postural hypotension, foot problems and appropriate footwear, and behavioral modification as part of intervention.Inclusion only of intervention studies that involved occupational therapy practitioners, lack of consistency in intervention methods between studies, most studies documenting fall prevention outcomes related to occupational therapy conducted outside the United States
O’Brien, Bynon, Morarty, & Presnell (2012) To identify the impact of a functional conditioning program (FCP) on patient length of stay (LOS), discharge destination, departmental resource use, and functional status in older people admitted to acute care hospital setting as the result of trauma
  • Level II
  • Nonrandomized two-group control
  • Intervention group: N = 50 patients aged ≥65 yr who had been referred for the FCP
  • Control group: N = 105 patients aged ≥65 yr drawn from the hospital database who had been admitted to acute care hospital setting and referred for occupational therapy services
  • Exclusion criteria: Cognitive impairment identified by the Neurobehavioral Cognitive Status Examination or inability to communicate
  • Intervention
  • The FCP was delivered by an occupational therapist, a physical therapist, and an allied health assistant who specialized in care for older adults. They provided daily individual or group sessions of mobility practice, exercise, and activities chosen on the basis of patients’ premorbid self-care, leisure, or productivity activities.
  • Outcome Measures
  • • LOS
  • • Discharge destination
  • • Occupational therapy resource utilization patterns
Significant differences were found in LOS, initiation of therapy, referrals to occupational therapy services, and return to home. No difference in amount of service and hours of participation in occupational therapy between groups were found, but the intervention group was seen 1.5 days earlier.Possible lack of group equivalence, small sample, limited sample diversity
Orellano, Colón, & Arbesman (2012) To examine the effectiveness of occupation- or activity-based interventions in improving or maintaining IADL performance in community-dwelling older adults
  • Level I
  • Systematic review
  • N = 38 studies; 31 Level I, 3 Level II, 3 Level III, 1 Level IV
  • Inclusion criteria: Focus on older adults living in the community, intervention within the occupational therapy scope of practice, inclusion of an activity- or occupation-based component, evidence Level I–IV.
  • Exclusion criterion: Focus on driving (covered sufficiently in previous systematic reviews)
  • Intervention
  • Occupation-based, client-centered, and community-based care delivered by occupational therapists or a team of providers; multicomponent interventions; Lifestyle Redesign programs and occupational therapy interventions; functional activities interventions, including functional task exercise and simulated IADLs; performance skills interventions, including physical activity, strengthening, cognitive skills, and vision rehabilitation; home modification and assistive technology; patient education and adaptive devices
  • Outcome Measures
  • • Functional Status Questionnaire
  • • SF–36
  • • IADL Index
  • • Home Hazard Index
  • • Control-Oriented Strategy Index
  • • Task Modification and Timed Performance Scale
  • • Muscle strength
  • • Older Americans Resources and Services instrument
  • • FIM
  • • Craig Handicap Assessment and Reporting Technique
  • • Standardized timed measure of lower-extremity physical performance that included standing, balance, walking speed, and ability to rise from a chair
  • • 400-m timed walk
  • • Community Health Activities Model Program for Seniors Questionnaire
  • • Satisfaction with physical function
  • • Structured Assessment of Instrumental Living Skills
  • • Modified Baecke Questionnaire for Older Adults measuring household and leisure activity
  • • Walking
  • • State of Change Questionnaire
  • • Instrumental Activity Measure
  • • Self-ratings of difficulty in performance of daily activities
  • • Frenchay Activity Index
  • Strong evidence was found to support occupation-based, client-based, and multicomponent interventions for improving and maintaining IADL performance.
  • Moderate support was found for functional task exercise programs.
  • Limited evidence supported simulated IADL interventions to improve IADL performance.
  • Mixed evidence was found related to performance skills for physical activity and cognitive skills training.
  • Moderate support indicated that vision rehabilitation interventions improve IADL performance in older adults with low vision.
Self-report measures, IADL performance not comprehensively measured, limited ability to generalize findings, small samples, uncontrolled variables, attention bias, attrition
Painter et al. (2012) To explore the relationships among fear of falling, depression and anxiety, activity level, and activity restriction
  • Level IV
  • Descriptive study
  • N = 99 community-dwelling adults (84 from senior centers, 15 from an apartment complex) aged ≥55 yr who had not experienced a fall
  • Intervention
  • Occupational therapists met with participants for 2 hr to complete assessment surveys, invited participants to a 90-min fall prevention presentation, and provided incentive to participants on completion of surveys and presentation.
  • Outcome Measures
  • • Semistructured Fall Questionnaire
  • • Survey of Activities and Fear of Falling in the Elderly (SAFE), subsections A–F
  • • Geriatric Depression Scale–30 (GDS)
  • • Hamilton Anxiety Scale–IVR Version (HAMA)
  • More than one-third of study participants (38.4%) reported a fear of falling as measured by the SAFE B. Fear of falling correlated with depression (GDS), anxiety (HAMA), and activity level (SAFE A). Depression (GDS) was significantly correlated with anxiety (HAMA) and activity restriction (SAFE F). Conversely, activity level (SAFE A) was significantly negatively correlated with activity restriction, depression, anxiety, and fear of falling.
  • Occupational therapists should consider screening older adult clients for fear of falling, anxiety, and depression because these may lead to fall risk and activity restriction.
Small convenience sample, self-report measures
Schepens, Sen, Painter, & Murphy (2012) To examine the relationship between fall-related efficacy and scores on measures of activity and participation in community-dwelling older adults
  • Level I
  • Meta-analysis
  • N = 20 studies
  • Inclusion of both fall-related efficacy measures (e.g., Falls Efficacy Scale [FES] or Activities-specific Balance Confidence [ABC] Scale) and measure of activity and participation; participants >60 yr old not belonging to groups with specified diseases; provision of statistical information needed to perform a meta-analysis
  • Exclusion criteria: Case reports and qualitative studies, studies reporting only adjusted values
  • Intervention
  • Activity- and occupation-based interventions involving learning and applying knowledge, performance skills, general tasks and demands, communication, mobility, self-care, domestic life, participation in relationships and interpersonal interactions, major life areas, and community, social, and civic life
  • Outcome Measures
  • • FES
  • • ABC
  • • Measures of occupation and activity performance and participation
  • Fall-related efficacy is strongly related to measures of activity and performance in community-dwelling older adults. Higher fall-related efficacy in performing daily tasks without losing balance or falling is associated with higher levels of activity function and performance. Balance (ABC) showed a stronger relationship with activity than did fall-related efficacy (FES). No difference was found between occupation-based activities and performance skills for fall-related efficacy.
  • Occupational therapists may need to assess and intervene with both balance confidence and fall-related efficacy with older adults.
Capture of evidence about only one moment in time, lack of participation measures, wide variety of activity measures, inability to identify causal relationships, inability to differentiate between occupation-based activity and performance skills, inability to generalize because of smaller study samples
Stav, Hallenen, Lane, & Arbesman (2012) To appraise and synthesize the evidence for the relationship between occupational engagement and health and mortality outcomes for community-dwelling older adults
  • Level I
  • Systematic review
  • N = 98; 3 Level I, 95 Level II
  • Inclusion criteria: Community-dwelling older adults aged ≥60 yr, evidence related to occupational engagement and health and mortality outcomes.
  • Intervention
  • Physical activity including ADLs and IADLs, community activities, work or volunteering, social activity, participation in leisure activity
  • Outcome Measures
  • • Mortality
  • • Depression scales
  • • Well-being
  • • Katz ADL Scale
  • • Rosow–Breslau functional health scale
  • • Ryff’s Personal Growth Index
  • • Physical performance measures
  • • Cognitive performance measures
  • Strong evidence links participation in social activities and social networks to decreased cognitive and physical decline. Strong evidence was found linking physical activity to positive health outcomes. Physical inactivity was related to higher rates of mortality, higher prevalence of disease, and decreased levels of function.
  • Supportive evidence was found for the relationship between engagement in work or volunteering and positive physical, emotional, and mental health and sustained independence in ADLs and between participation in religious or spiritual activities and promotion of physical, emotional, mental, and social health. Sleeping 6–7.5 hr was associated with optimum health for older adults.
  • Dependence in IADLs, decreased community mobility, and leaving the house ≤4×/wk were associated with increased mortality and frailty and decreased ADL performance.
  • Caregivers with limited personal and social activities or who provided highly stressful caregiving were more likely to have poorer health.
Only 1 study conducted by an occupational therapist or specifically identified as an occupational therapy intervention, multiple definitions of constructs and variables, wide range of sample or population sizes, variety of cultural contexts (several studies conducted outside the United States)
Table Footer NoteNote. ADL = activity of daily living; AGS = American Geriatrics Society; AOTA = American Occupational Therapy Association; BGS = British Geriatrics Society; IADL = instrumental activity of daily living; ICC = intraclass correlation coefficient; RCT = randomized controlled trial; SDBM = Safe Driving Behavior Measure; SF–12 = 12-Item Short Form Health Survey; SF–36 = 36-Item Short Form Health Survey.
Note. ADL = activity of daily living; AGS = American Geriatrics Society; AOTA = American Occupational Therapy Association; BGS = British Geriatrics Society; IADL = instrumental activity of daily living; ICC = intraclass correlation coefficient; RCT = randomized controlled trial; SDBM = Safe Driving Behavior Measure; SF–12 = 12-Item Short Form Health Survey; SF–36 = 36-Item Short Form Health Survey.×
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