A randomized, controlled trial of a home environmental intervention: effect on efficacy and upset in caregivers and on daily function of persons with dementia

City governments and aging in place: community design, transportation and housing innovation adoption

PURPOSE OF THE STUDY

To examine the characteristics associated with city government adoption of community design, housing, and transportation innovations that could benefit older adults.

DESIGN AND METHODS

A mixed-methods study with quantitative data collected via online surveys from 62 city planners combined with qualitative data collected via telephone interviews with a subsample of 18 survey respondents.

RESULTS

Results indicate that advocacy is an effective strategy to encourage city government adoption of these innovations. Percent of the population with a disability was positively associated, whereas percent of the population aged 65 and older was not associated or negatively associated, with innovation adoption in the regression models. Qualitative interviews suggest that younger individuals with disabilities are more active in local advocacy efforts.

IMPLICATIONS

Results suggest that successful advocacy strategies for local government adoption include facilitating the involvement of older residents, targeting key decision makers within government, emphasizing the financial benefits to the city, and focusing on cities whose aging residents are vulnerable to disease and disability.

A multicentre RCT on community occupational therapy in Alzheimer's disease: 10 sessions are not better than one consultation

OBJECTIVE

To compare the benefits and harms of a Dutch 10-session Community Occupational Therapy programme for patients with Alzheimer's disease with the impact of a one session consultation at home in German routine healthcare.

DESIGN

A seven-centre, parallel group, active controlled randomised controlled trial. Patients and carers were not masked. Assessors were fully blind for treatment allocation for one of two primary-outcome measurements.

SETTING

Patients' homes.

PARTICIPANTS

Patients with mild to moderate Alzheimer's disease (Mini-Mental State Examination 14-24), living in the community with primary carer available and without severe depression or behavioural symptoms, were eligible.

INTERVENTIONS

Experimental 10 home visits within 5 weeks by an occupational therapist, educating patients in the performance of simplified daily activities and in the use of aids to compensate for cognitive decline; and educating carers in coping with behaviour of the patient and in giving supervision to the patient. Control one home visit including individual counselling of patient and carer and explanation of a leaflet on coping with dementia in daily life.

OUTCOME MEASURES

The primary outcome was the patient's daily functioning measured with the Interview of Deterioration in Daily activities in Dementia and the Perceive, Recall, Plan and Perform System of Task Analysis. Assessments were at baseline, 6, 16 and 26 weeks, with a postal assessment at 52 weeks.

RESULTS

141 patients were 1:1 randomised to the experimental (N=71) and control group (N=70). Data for 54 and 50 participants were analysed. Patients' daily functioning did not differ significantly between the experimental and control group at week 6, 16, 26 or 52 and remained stable over 26 weeks in both groups. No adverse events were associated with the interventions.

CONCLUSIONS

In German healthcare, a Dutch 10-session community occupational therapy was not better than a one-session consultation for the daily functioning of patients with Alzheimer's disease. Further research on the transfer of complex psychosocial is needed. International Clinical Trials Registry Platform DRKS00000053; Funded by the German Federal Ministry of Health.

Do patients diagnosed with Alzheimer's disease benefit from a psycho-educational programme for family caregivers? A randomised controlled study

OBJECTIVE

The Aide dans la Maladie d'Alzheimer (AIDMA) study was conducted to determine whether a psycho-educational programme (PEP) for primary caregivers in addition to standard anti-dementia drugs for patients improves caregivers' psychological condition and patients' activities of daily life.

METHOD

Multicentre randomised controlled intervention trial. One hundred and sixty-seven dyads 'patient-caregiver' were recruited from 15 French memory clinics and randomised in two parallel groups. The intervention group was offered the PEP in 12 group sessions for 3 months. The control group had usual care. Patients in both groups with mild to moderate Alzheimer's disease (AD) were diagnosed and treated with pharmacotherapy. Patients' primary efficacy variable was functional status assessed with the Disability Assessment Scale for Dementia (DAD) scale. Alzheimer Disease Assessment Scale (ADAS-Cog) and Neuropsychiatric Inventory (NPI) were secondary criteria. Caregivers' first outcome measure was depressive symptoms assessed with the Montgomery and Asberg Depression Rating Scale (MADRS) scale. Zarit scale, Sense of Competence Questionnaire (SCQ) and Visual Analogue Scales (VAS) were secondary criteria. Assessment was done at baseline, 3 months (M3, end of intervention) and 6 months (M6).

RESULTS

Patients' stabilisation was observed in both groups. In caregivers, significant improvement in disease understanding at M3 (p = 0.007) and M6 (p = 0.0001) and in ability to cope with care-recipients' disease at M6 (0.02) was evidenced.

CONCLUSION

The PEP had no additional impact on patients but carers developed more effective disease understanding and ability of coping. Results support the idea that the PEP although improving caregivers' condition is not sufficient to improve patients' activities in daily life which requires additional individually tailored interventions provided by professionals.

Environmental barriers and supports to the health, function, and participation of people with developmental and intellectual disabilities: report from the State of the Science in Aging with Developmental Disabilities Conference

BACKGROUND

This article summarizes the proceedings of the Environmental Barriers and Supports to Health, Function and Participation Work Group that was part of the "State of the Science in Aging with Developmental Disabilities: Charting Lifespan Trajectories and Supportive Environments for Healthy Living" symposium. The aim was to provide a research and policy agenda targeting the assessment and evaluation of environmental factors influencing the health, function, and participation of people with developmental and intellectual disabilities (I/DD).

METHODS

Key environmental areas addressed were (1) the built environment including homes and communities; (2) assistive and information technology design and use; (3) social environment factors and interventions; and (4) environmental access and participation policies, legislation, and system change implications.

RESULTS

The group identified gaps in knowledge and priorities for future research, including (1) multivariate analyses of attributes of the built environment; (2) large-scale intervention trials of assistive and information technology use with people with cognitive disabilities; (3) development and testing of social, peer-mentoring, and self-management interventions as applied to people with I/DD; (4) incorporation of environmental health research methodologies, such as GIS mapping into I/DD research; (5) participatory action approaches that actively include people with I/DD in the research process; and (6) rigorous examination of the impact of legislative and policy initiatives related to least restrictive community living and participation with people with I/DD.

CONCLUSION

Future research and policy initiatives should focus on examining how the environment (build, technological, social, and system level) influence community living and participation of people with intellectual disabilities.

Alive and well: the state of behavioral gerontology in 2011

In this paper, the authors present a brief personal account of the senior author's 30 years of exploration in behavioral gerontology. The main thesis of the paper is that behavioral methods and interventions have found a home both in mainstream gerontology and at the National Institutes of Health (NIH). There are three sections: (a) a personal vignette discussing the problems inherent in using operant terminology in a nonoperant world; (b) a discussion, with examples from NIH sources, of the Institutes' views on behavior change; and (c) using Burgio and Burgio (1986) as a reference point, the authors show evidence of progress and vitality of behavioral gerontology in 2011.

Survey of current pre-discharge home visiting practices of occupational therapists

BACKGROUND/AIM

Discharge planning frequently involves occupational therapy pre-discharge home visiting as one component of intervention. Pre-discharge home visits aim to maximise a person's functional performance within the context of their home and community environment, bridging the transition between hospital and home. The aim of this study was to describe the pre-discharge home visiting practices of occupational therapy departments.

METHODS

This descriptive study used a postal survey which was sent to occupational therapists in 215 public and privately funded hospitals in New South Wales, Australia. The survey enquired about the number of pre-discharge home visits completed per month, who went on visits and time spent on visits. Descriptive statistics were used in analyses.

RESULTS

Surveys were returned by occupational therapists from 53 departments, representing a response rate of 25%. Respondents estimated that they conducted approximately 13 pre-discharge home visits per month (range: 1-60). Visits were estimated to take an average of 1 hour and 20 minutes (excluding travel time). Approximately one-quarter of respondents felt that there was pressure to reduce the number of pre-discharge home visits conducted. Using their local hospital records, nine hospital departments estimated that the number of home visits completed per month had reduced by 50% compared with the number of home visits five years previously.

DISCUSSION

Findings suggest a wide variation in current pre-discharge home visiting practice. There is a need for well-designed clinical trials that investigate the effectiveness of these costly and time-consuming visits on functional performance.

Association of the spatial layout of the home and ADL abilities among older adults with dementia

We investigated the relationship between architectural space syntax measures describing the spatial layout of a home and activities of daily living (ADL) among people with dementia. We visited the homes of 82 participants in a dementia care comparative effectiveness clinical trial and measured the space syntax variables intelligibility and convexity along with several clinical variables, including ADLs. In regression models, we estimated the cross-sectional association between space syntax measures and ADLs. Higher convexity was associated with worse performance of basic but not instrumental ADLs (adjusted β =19.2, P = .02). Intelligibility was not associated with ADLs. These results imply that enclosed rooms with a clearly legible meaning and function might be better memorized and associated with the spatial layout of the home resulting in better basic ADL performance. These results warrant further research on space syntax measures in the home environment of people with dementia, including longitudinal study, which we are pursuing.

In-Home Occupational Performance Evaluation (I-HOPE)

OBJECTIVE

We describe the development and preliminary psychometric properties of an assessment to quantify the magnitude of an environmental barrier's influence on occupational performance.

METHOD

The assessment was developed and then piloted on a group of 77 older adults before and after an occupational therapy intervention focused on environmental barrier removal. Refinements were made to the assessment before it was evaluated for interrater reliability in a sample of 10 older adults using 2 raters.

RESULTS

The In-Home Occupational Performance Evaluation (I-HOPE) is a performance-based measure that evaluates 44 activities in the home. The 4 subscales of Activity Participation, Client's Rating of Performance, Client's Satisfaction With Performance, and Severity of Environmental Barriers are sensitive to change in the environment. The subscales' internal consistency from .77 to .85, and intraclass correlation coefficients ranged from .99 to 1.0.

CONCLUSION

This preliminary study suggests that the I-HOPE is a psychometrically sound instrument that can be used to examine person-environment fit in the home.

Effectiveness of an intervention in groups of family caregivers of dependent patients for their application in primary health centers. Study protocol

Background

Although Primary Health Care (PHC) Teams are used to deal with prevention and treatment of sanitary problems in adults with chronic diseases, they usually have a lack of experience in development of psychotherapeutic interventions. However, these interventions are the ones that achieve better results to reduce symptomatology and improve emotional state of caregivers.

The study aims to evaluate the effectiveness of an intervention of psychotherapy in improving the mental health and Quality of life of caregivers. This intervention is based on theoretical approaches to care adjusted to cognitive theory, in order to be applied in primary health care centres.

Methods/Design

This is multicentre clinical trials study, randomized in two parallel groups, carry out in two PHC, Study population: 150 caregivers will be included by consecutive sampling and they will be randomized the half to experimental group and the other half to control group. They provide mostly all the assistance to care-dependent familiars receiving attention in PHC Centers.

Measurements: Each caregiver will be evaluated on a personal interview. The caregivers' assessment protocol: 1) Assessment of different socio-demographic related to care, and caregiver's personal situation. 2)Care-dependent individuals will also be assessed by Barthel Index and Pfeiffer Questionnaire (SPMSQ). 3)Change in caregivers will be the principal measure: family function (Family APGAR Questionnaire), burden short questionnaire (Short Zarit Burden Interview), quality of life (Ruiz & Baca: 1993 Questionnaire), the Duke-UNK Functional Social Support Questionnaire, the General Health Questionnaire-12, and changes in Dysfunctional Thoughts about caring. 4) Intervention implementation measures will also be assessed.

Intervention: A psychotherapeutic intervention will be 8 sessions of 90 minutes in groups. This intervention has been initially developed for family caregivers of patients with dementia.

Discussion

Psychotherapeutic interventions have been proved to obtain better results to reduce symptomatology and improve emotional state of caregivers. Moreover, this intervention has been proved to be effective in a different setting other than PHC, and was developed by professionals of Mental Health. If we found that this intervention is effective in PHC and with our professionals, it would be an important instrument to offer to caregivers of care-dependent patients.

Trial Registration

ClinicalTrials.gov Identifier NCT01177696

Translation of a dementia caregiver intervention for delivery in homecare as a reimbursable Medicare service: outcomes and lessons learned

PURPOSE

families of dementia patients receiving skilled homecare do not receive supportive services. We evaluated whether a proven intervention, Environmental Skill-building Program (ESP), which reduces caregiver burden and enhances skills managing patient functioning, can be integrated into homecare practices of occupational therapists (OTs) and reimbursed through Medicare Part B.

DESIGN AND METHODS

a 2-year translational project with a homecare practice was conducted. Five translational activities included refining ESP, site preparation, therapist training, establishing referral mechanisms, and evaluating outcomes using Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM).

RESULTS

of 30 OTs approached for participation, 23 (77%) agreed, 22 (96%) completed training, and 21 (95.5%) used ESP and intended to continue use. Of 69 eligible caregivers, 41 (59%) agreed to participate averaging 4.7 sessions. Of 20 returned caregiver surveys, enhancements were reported in all targeted areas of knowledge and skills. Fidelity monitoring revealed inconsistency in therapists use of problem solving, yet caregiver enactment of ESP strategies was high. ESP sessions integrated within patient-directed therapy were reimbursed by Medicare Part B.

IMPLICATIONS

RE-AIM indicators suggest moderate translational success. As ESP was reimbursed through Medicare B, its delivery may be sustainable and meet the needs of family caregivers of dementia patients receiving therapies at home.

An individualized dyadic problem-solving education intervention for patients and family caregivers during allogeneic hematopoietic stem cell transplantation: a feasibility study

BACKGROUND

Allogeneic hematopoietic stem cell transplantation (HSCT) generates multiple problems that vary in complexity and create significant distress for both patients and their caregivers. Interventions that address patient and family caregiver distress during allogeneic hematopoietic stem cell transplantation (HSCT) have not been tested.

OBJECTIVE

To evaluate the feasibility of conducting an individualized dyadic problem-solving education (PSE) intervention during HSCT and estimate a preliminary effect size on problem-solving skills and distress.

METHODS

The PSE intervention consisted of 4 sessions of the Prepared Family Caregiver PSE model. Data were collected with an interventionist log, subject interviews and standardized questionnaires.

RESULTS

Of the 34 adult dyads screened, 24 were ineligible primarily because of being non-English-speaking (n = 11) and inconsistent caregivers (n = 10). Ten dyads (n = 20) were enrolled, and 8 dyads (n = 16) completed the intervention. Of the 31 sessions, 29 were completed (94%). Worsening patient condition was the primary reason for sessions to be incomplete. Patients attended 90% of the sessions; caregivers attended 74%. Reasons for missed sessions included patient symptom distress and limited caregiver availability. Dyads reported being very satisfied (mean, 4.8 [SD, 1.8]; range, 1-5), stating "an opportunity to talk" and "creative thinking" were most beneficial.

CONCLUSION

Results suggest that dyads can participate in PSE during HSCT and view it as beneficial. Participants identified the active process of solving problems as helpful.

IMPLICATIONS FOR PRACTICE

Targeted interventions that promote effective, meaningful behaviors are needed to guide patients and caregivers through HSCT. Future research recommendations include testing a version of PSE with fewer sessions, including spousal and nonspousal caregivers and those who are non-English speaking.

Reviews: developing culturally sensitive dementia caregiver interventions: are we there yet?

Despite evidence of ethnic differences in family caregivers' experiences, the extent to which caregiver interventions are culturally tailored to address these differences is unknown. A systematic review of literature published from 1980 to 2009 identified: differences in caregiving experiences of African American, Latino, and Chinese American caregivers; psychosocial support interventions in these groups; and cultural tailoring of interventions. Ethnic differences in caregiving occurred at multiple levels (intrapersonal, interpersonal, environmental) and in multiple domains (psychosocial health, life satisfaction, caregiving appraisals, spirituality, coping, self-efficacy, physical functioning, social support, filial responsibility, familism, views toward elders, use of formal services and health care). Only 18 of 47 intervention articles reported outcomes by caregiver ethnicity. Only 11 reported cultural tailoring; 8 were from the Resources for Enhancing Alzheimer's Caregiver Health (REACH) initiative. Cultural tailoring addressed familism, language, literacy, protecting elders, and logistical barriers. Results suggest that more caregiver intervention studies evaluating systematically the benefits of cultural tailoring are needed.

Environmental interventions and the design of homes for older adults with dementia: an overview

In Western societies, the vast majority of people with dementia live at home and wish to remain doing so for as long as possible. Aging in place can be facilitated through a variety of environmental interventions, including home modifications. This article provides an overview of existing design principles and design goals, and environmental interventions implemented at home, based on literature study and additional focus group sessions. There is a multitude of design principles, design goals, and environmental interventions available to assist with activities of daily living and functions, although few systematic studies have been conducted on the efficacy of these goals and interventions. The own home seems to be a largely ignored territory in research and government policies, which implies that many problems concerning aging in place and environmental interventions for dementia are not adequately dealt with.

Differential features of burden between spouse and adult-child caregivers of patients with Alzheimer's disease: an exploratory comparative design

BACKGROUND

Research into burden among spouse and adult-child caregivers of patients with Alzheimer's disease has generated contradictory results as regards the group which suffers the greatest burden and the factors underlying any differences.

OBJECTIVES

The aim of the present study was to identify and compare the factors associated with caregiver burden among spouse and adult-child caregivers.

DESIGN

Cross-sectional analytic study.

SETTINGS

All clinical subjects had been referred on an out-patient basis to the Memory and Dementia Assessment Unit of the Santa Caterina Hospital in Girona (Spain).

PARTICIPANTS

Data were collected from 251 patients and their caregivers, 112 with spouse and 139 with adult-child caregivers.

METHODS

The association between caregiver burden and the socio-demographic and clinical variables of both patients and caregivers was analysed, the results being compared for spouse vs. adult-child caregivers. Burden was analysed using a multivariate linear regression including all the variables for the two groups of caregivers.

RESULTS

The results show greater burden among adult-child caregivers (p<.05), who experience more feelings of guilt (p<.001). In both groups the behavioural and psychological symptoms of patients were correlated with burden (p<.001). Living with the patient has a notable influence on burden among adult children (p<.001). Husbands, wives, daughters and sons, in this order, showed increasing levels of burden (p<.05) and progressively worse mental health (p<.01). However, the correlations between burden and mental health were strongest in daughters (p<.001).

CONCLUSION

The differences in burden between spouse and adult-child caregivers were not associated with age, physical health or clinical factors of the patients. Overall burden was greater among adult-child caregivers, especially those who lived with the patient and who had other family duties. Feelings of guilt were associated with not living with the patient, and there was a strong correlation between burden and mental health. These results support the hypothesis that spouses regard caregiving as part of their marital duties, whereas for adult children such tasks imply an important change in their lifestyle.

Stress process model for individuals with dementia

PURPOSE

Individuals with dementia (IWDs) face particular challenges in managing and coping with their illness. The experience of dementia may be affected by the etiology, stage, and severity of symptoms, preexisting and related chronic conditions, and available informal and formal supportive services. Although several studies have examined particular features of IWD's illness experience, few draw upon a conceptual model that outlines the global illness experience and the resulting stressors that commence with symptom onset, proliferate over time, and continue through the later stages of cognitive loss. Building on the work of Pearlin and colleagues (1990, Caregiving and the stress process: An overview of concepts and their measures. The Gerontologist, 30, 583-594), this article proposes a stress process model (SPM) for IWDs that conceptualizes and examines the illness experience of IWDs.

IMPLICATIONS

The proposed SPM for IWDs serves as a guide to (a) consider and understand the short- and long-term complexities of the illness experience for IWDs, (b) investigate specific hypotheses by outlining key stressors in the illness experience and by positing relationships among stressors and outcomes, and (c) help inform the development of interventions to prevent or reduce the negative stressors and enhance the positive experiences of living with a dementing illness.

Burnout among care staff for older adults with dementia

People working in the helping professions have been found to be vulnerable to the development of burnout and research has suggested a relationship between dementia care and burnout. Literature suggests that the development of burnout may be linked to a number of factors, including lack of reciprocity, low self-efficacy and organizational factors. The study explored burnout in staff for older people with dementia and examined the roles of reciprocity, self-efficacy and organizational factors and aimed to identify which of these variables was the greatest predictor of burnout. Sixty—one members of staff in continuing care homes for people with dementia completed self-report questionnaires. Self-efficacy was found to be the greatest predictor of burnout. Findings from the study also emphasized the connections of reciprocity, occupational commitment, demographic factors and self-efficacy with burnout. The clinical implications of the study, methodological considerations and recommendations for future research are discussed.

Client-centred home modifications improve daily activity performance of older adults

BACKGROUND

Remaining at home is a high priority for many older adults, but the capacity to "age in place" often is threatened by environmental barriers.

PURPOSE

To describe a client-centred occupational therapy home modification intervention program and examine the impact of the intervention on daily activity performance over time.

METHODS

Using a competence-environmental press framework, a client-centred home modification program for older adults was implemented. In this quasiexperimental, single group prospective study, participants'subjective ratings of daily activity performance were evaluated before and after the intervention (baseline/post/post).

FINDINGS

After home modification, participants'perception of their daily activity performance at home improved significantly and was maintained 2 years post-modification.

IMPLICATIONS

Home modification may benefit older adults attempting to age in place.

Persons with mild and moderate Alzheimer's disease use verbal-instruction technology to manage daily activities: effects on performance and mood

OBJECTIVE

To extend the evaluation of verbal-instruction technology for helping persons with mild and moderate Alzheimer's disease recapture daily activities and improve their mood.

METHODS

Two studies targeted two activities (i.e. snack preparation/sharing and shaving) with six and three new participants, respectively. Intervention effects on activity performance were assessed through non-concurrent multiple baseline designs across participants. The impact of intervention (activity) on mood was assessed by recording indices of happiness or indices of unhappiness during activity and non-activity trials.

RESULTS

The use of a technology providing verbal instructions helped all participants perform the target activities. Performance was largely accurate with seven of the participants. Eight of the participants also showed mood improvement (i.e. increases in indices of happiness or decreases in indices of happiness) during activity.

CONCLUSION

These results suggest that the approach reported may be a useful strategy for helping persons with Alzheimer's disease enhance their activity and mood.

Performance of activities of daily living in a sample of applicants for home modification services

Home modification services are provided to support persons with functional limitations to live independently at home. It is not well known what causes individuals to apply for home modifications, or in what kind of life situation this need appears. The aim of this study was to examine the relationship between performance of activities of daily living, housing and living situation, and the home modification applied for in a sample of home modification applicants. Further, the aim was to examine differences in performance of activities of daily living between subgroups with different social support. A total of 102 participants were included in the study. Data on performance of activities of daily living was collected through interviews in the participants' homes, using structured instruments. The participants reported high levels of independence in activities of daily living, and were using assistive devices to a large extent. However, the applicants clearly experienced difficulties in performing activities related to the applied home modification. The study indicates that the main reason for applying for Home Modification Grants was perceived difficulties in performance of activities of daily living. This stresses the importance of including other aspects besides independence when trying to understand persons' activity performance and planning for occupational therapy interventions.

Challenges in the development of strategies for housing adaptation evaluations

Founded on recent empirical experiences and results from a Housing Adaptation Project accomplished in a Swedish municipality, this paper aims to elucidate and problematize challenges inherent in the process of developing research-based strategies for housing adaptation (HA) evaluations feasible for municipality contexts. In this paper, theory and conceptual definitions of client-level outcomes related to Swedish HA legislation - i.e. accessibility, usability, and activity - are presented. In order to lay the ground for the presentation and discussion on challenges, the Housing Adaptation Project is described with regard to design sampling and data collection, client-level outcomes and assessment instruments used, as well as longitudinal results. The challenges faced during the project were related to the assessment of outcomes, the logistic flow of the data-collection process, client availability for follow-up assessments as well as interpretation of changes in accessibility. Some challenges were due to the organizational HA framework in the municipalities, while others were related to the methodology used for outcomes assessment. Based on our experiences with this project, a set of evaluation recommendations for practice and research is provided.

The bath environment, the bathing task, and the older adult: A review and future directions for bathing disability research

PURPOSE

To review existing research studies to identify optimal intervention strategies for remediation and prevention of bathing disability and future directions for bathing disability research.

METHOD

Bathing disability, defined as problems in the interaction between the person and the environment during bathing performance, is examined through a comprehensive, narrative literature review.

RESULTS

Most studies focus on the relationship between the person and the environment (such as assistive device use and environmental hazards) while fewer studies focus on analysis of the bathing task or the interaction of the person, environment, and bathing task. Of intervention studies, most do not focus solely on remediation of bathing disability and outcomes vary widely.

CONCLUSIONS

In order to help remediate and prevent bathing disability, it will be necessary to better understand and measure the person-environment-occupation interaction involved in bathing as it relates to specific groups of older adults.

Persons with moderate Alzheimer's disease improve activities and mood via instruction technology

BACKGROUND

Three studies assessed the (a) effectiveness of verbal instructions presented via technology in helping persons with moderate Alzheimer's disease perform daily activities and (b) impact of activity engagement on mood.

METHODS

The 3 studies targeted coffee preparation with 2 women, use of make-up with 2 women, and use of make-up and tea preparation with 3 women. Intervention effects on activity performance were assessed through nonconcurrent multiple baseline designs across participants or multiple baseline designs across activities. The impact of activity on mood was assessed by recording indices of happiness during activity trials and parallel nonactivity periods.

RESULTS

Verbal instructions presented via technology were effective in helping all participants perform the target activities. The participants also showed mood improvement (ie, increases in indices of happiness) during the activity.

CONCLUSION

These results suggest that the approach reported may be a useful strategy for helping persons with Alzheimer's disease.

Helping persons with mild or moderate Alzheimer's disease recapture basic daily activities through the use of an instruction strategy

PURPOSE

The present three pilot studies assessed the effectiveness of verbal instructions, presented automatically through simple technology, in helping persons with mild-to-moderate Alzheimer's disease recapture basic daily activities. The activities were morning bathroom routine, dressing, and table-setting.

METHOD

The studies that focused on morning bathroom routine and on table-setting included three participants each, while the study that focused on dressing involved four participants. A non-concurrent multiple baseline design across participants was used for each study. The instructions and technology were available only during the intervention phases.

RESULTS

Data showed that the intervention strategy involving verbal instructions for the single activity steps presented automatically through technology was effective in helping all participants on each of the activities. The participants' mean percentages of correct steps across activities raised from 13 - 54 during the baseline periods to above 80 or 90 during the intervention periods.

CONCLUSIONS

The results suggest that the intervention strategy reported may represent a suitable approach for helping persons with mild or moderate Alzheimer's disease to recapture basic daily activities. New research should target other activities and check maintenance and generalization issues.

The home environment and disability-related outcomes in aging individuals: what is the empirical evidence?

PURPOSE

Building on the disablement process model and the concept of person-environment fit (p-e fit), this review article examines 2 critical questions concerning the role of home environments: (a) What is the recent evidence supporting a relationship between home environments and disability-related outcomes? and (b) What is the recent evidence regarding the effects of home modifications on disability-related outcomes?

DESIGN AND METHODS

Using computerized and manual search, we identified relevant peer-reviewed original publications and review articles published between January 1, 1997, and August 31, 2006. For Research Question 1, 25 original investigations and for Research Question 2, 29 original investigations and 10 review articles were identified.

RESULTS

For Research Question 1, evidence for a relationship between home environments and disability-related outcomes for older adults exists but is limited by cross-sectional designs and poor research quality. For Research Question 2, evidence based on randomized controlled trials shows that improving home environments enhances functional ability outcomes but not so much falls-related outcomes. Some evidence also exists that studies using a p-e fit perspective result in more supportive findings than studies that do not use this framework.

IMPLICATIONS

Considerable evidence exists that supports the role of home environments in the disablement process, but there are also inconsistencies in findings across studies. Future research should optimize psychometric properties of home environment assessment tools and explore the role of both objective characteristics and perceived attributions of home environments to understand person-environment dynamics and their impact on disability-related outcomes in old age.

Family influence on caregiver resistance, efficacy, and use of services in family elder care

This research investigated how resistance to use of services attributed to family members and primary caregiver self-efficacy and resistance influenced actual use of services. Data were analyzed from questionnaires completed by 224 persons engaged in informal elder care in the community. Tests of 6 hypotheses revealed that family influence on caregivers had a consistent, important influence on behavior and views of caregivers. Family resistance to use of formal services framed caregivers' feelings, preferences, and decisions ranging from their own perceived self-efficacy to actual obtainment of help outside the family. Professionals must include family members in their dialogue with primary caregivers about their plans for elder care. Suggestions for interventions to better understand family and caregiver resistance are discussed.

Reaping caregiver feelings of gain: the roles of socio-emotional support and mastery

OBJECTIVES

Existing studies indicate that the presence of social support increases the likelihood of caregivers experiencing feelings of gain from caregiving; however, researchers have not yet investigated the mechanism through which social support is linked to caregiver feelings of gain. Informed by Bandura's Social Cognitive Theory, the present study investigated whether a sense of caregiving mastery serves as a key mechanism.

METHOD

Sixty-three family caregivers of dependent elders completed surveys to assess caregiver feelings of gain, socio-emotional support (from family, friends, spouse/partner) and mastery. To evaluate the hypothesized mediation model, a series of structural equation modeling (SEM) analyses were conducted with the maximum likelihood method by Lisrel 8.8.

RESULTS

Socio-emotional support from family members was found to be an important resource for caregiver feelings of gain. SEM analyses further revealed that the mechanisms by which socio-emotional support influences caregiver feelings of gain vary depending on its source (i.e. family members, friends, and partners).

CONCLUSION

As hypothesized, caregiving mastery played a mediating role for non-partner family socio-emotional support whereas it did not for partner socio-emotional support. Based on availability or absence of specific sources of support, caregiver intervention programs should be individually tailored to enhance their potential impact.

Persons with mild or moderate Alzheimer's disease managing daily activities via verbal instruction technology

Four studies assessed the effectiveness of verbal instructions presented via technology in helping persons with mild or moderate Alzheimer's disease perform daily activities. The first 2 studies were replication efforts concerning morning bathroom routine and table setting and included 4 and 2 participants, respectively. The third study targeted coffee preparation with 3 participants. The fourth study assessed maintenance and generalization of morning bathroom routine and dressing with 1 participant. Nonconcurrent multiple baseline designs served for the first 3 studies and a 5-month postintervention data collection for the fourth study. Verbal instructions for the activity steps presented via technology were effective in helping the participants of the first 3 studies reacquire basic daily activities and the participant of the fourth study retain the reacquired activities across time and settings. These results suggest that the approach reported may be a useful strategy for helping persons with Alzheimer's disease.

Effektivität einer optimierten Ergotherapie bei Demenz im häuslichen Setting (ERGODEM)

In einer randomisierten und kontrollierten Studie wird die Wirksamkeit einer optimierten Ergotherapie im häuslichen Setting bei Patienten (Alter: > 55 Jahre) mit leichten und mittelschweren Demenzen im Vergleich zu einer TAU-Behandlung untersucht. Insgesamt werden 200 Patienten in die Studie eingeschlossen. Primäres Ziel ist die Untersuchung individuell ausgeführter Alltagsaktivitäten, die mit den Patienten und pflegenden Angehörigen als wichtig identifiziert werden. Sekundäre Outcomevariablen umfassen die kognitive Leistungsfähigkeit, Verhaltensauffälligkeiten, Lebenszufriedenheit der Betroffenen und ihrer pflegenden Angehörigen sowie Behandlungskosten. In der experimentellen Intervention wird, unter Einbeziehung der Angehörigen, eine umfassende ergotherapeutische Befunderhebung, eine patientenzentrierte Befund- und Zielklärung mittels COPM und eine darauf aufbauende ergotherapeutische Behandlung über einen Zeitraum von sechs Wochen (à 12 Sitzungen) mit dem Patienten und seinem pflegenden Angehörigen durchgeführt. Die Kontrollgruppe wird nach den Leitlinien der DGPPN und DGN ohne optimierte Ergotherapie behandelt. Es erfolgt eine klinische Verlaufskontrolle 3 und 6 Monate nach Interventionsabschluss.

Assistive technology in medicaid home- and community-based waiver programs

PURPOSE

As consensus emerges concerning the need to extend publicly funded home- and community-based services that support the independence of seniors, studies have reported the efficacy and cost effectiveness of assistive technology (AT). This article presents the latest available national AT expenditure and participation trends (1999-2002) for Medicaid 1915(c) waivers, the largest Medicaid home- and community-based service program.

DESIGN AND METHODS

We collected annually reported Centers for Medicare and Medicaid Form 372 data from state officials for each waiver providing AT for the period from 1999 to 2002. Descriptive statistics examined trends in national participation and expenditures, interstate variations in participation and expenditures, and differences in provision between elderly persons and persons with developmental disabilities.

RESULTS

Although we report a rise in the number of waivers providing AT, there has been much slower participant growth compared with the broader waiver program, and there is wide interstate variation in waiver AT provision. Not only do most waivers with AT serve persons with developmental disabilities, AT spending for that target group is almost twice that for aged or disabled waiver participants.

IMPLICATIONS

This study highlights three policy concerns: first, the large interstate variations in AT provision in Medicaid waivers may signal access problems in some states; second, policy choices in some states may favor Medicaid spending on AT for the developmental disability population over that for the elderly population; and third, data limitations prevent a comparable state-by-state analysis of Medicare AT provision.

The factorial validity and internal consistency of the Instrumental Activities of Daily Living Profile in individuals with a traumatic brain injury

The objective of the study was to investigate the factorial validity and internal consistency of the Instrumental Activities of Daily Living (IADL) Profile. A group of 96 patients aged 16 to 65 years, with moderate to severe traumatic brain injuries, was recruited from 12 rehabilitation hospitals in Quebec. The IADL Profile was administered by an occupational therapist in each subject's home and community environment. Principal axis factoring and confirmatory factor analysis provide preliminary support for six correlated factors (F): (F1) going to grocery store/shopping for groceries, (F2) having a meal with guests/cleaning up, (F3) putting on outdoor clothing, (F4) obtaining information, (F5) making a budget, (F6) preparing a hot meal for guests. Total explained variance was 73.6%. Cronbach's alpha analysis revealed high to very high internal consistency for all scales ranging from .81 to .98; internal consistency of the total scale was very high (0.95). The findings suggest that the IADL Profile is a promising means of documenting both IADL independence and the repercussions of executive function deficits on everyday tasks in real-world environments.

[Efficacy of interventions aimed at the main carers of dependent individuals aged more than 65 years old. A systematic review]

BACKGROUND

In our environment, care of the dependent elderly is usually provided by family members, thereby ensuring autonomy and avoiding institutionalization of the dependent adult. Thirty-three percent of Spanish caregivers have acknowledged the importance of acquiring the knowledge and skills necessary for daily care. Consequently, several interventions have been developed by health professionals from distinct disciplines.

OBJECTIVE

The purpose of this study was to systematically review and evaluate the efficacy of published interventions for the caregivers of dependent elderly individuals.

MATERIAL AND METHODS

We conducted a systematic review of the literature on interventions in the caregivers of the dependent elderly (older than 65 years old) published between 1996 and 2006. The inclusion criteria included controlled clinical trials with outcome measures related to effectiveness in reducing caregiver burden, anxiety and depression. Our search yielded 15 reports.

RESULTS

The interventions produced statistically significant reductions in burden (40%), anxiety (50%) and depression (90%). Interventions requiring active participation by caregivers and those based on cognitive-behavioral therapy were more effective than those focused on knowledge acquisition.

CONCLUSION

Due to the heterogeneity of caregiving interventions, evaluation of both the clinical and statistical significance of these interventions is essential. Reducing the chronic stress experienced by caregivers is difficult to achieve. Consequently, future experimental designs should take into account the needs reported by caregivers as well as promote active participation.

Tailored activities to manage neuropsychiatric behaviors in persons with dementia and reduce caregiver burden: a randomized pilot study

OBJECTIVE

To test whether the Tailored Activity Program (TAP) reduces dementia-related neuropsychiatric behaviors, promotes activity engagement, and enhances caregiver well-being.

DESIGN

Prospective, two-group (treatment, wait-list control), randomized, controlled pilot study with 4 months as main trial endpoint. At 4 months, controls received the TAP intervention and were reassessed 4 months later.

SETTING

Patients' homes.

PARTICIPANTS

Sixty dementia patients and family caregivers.

INTERVENTION

The eight-session occupational therapy intervention involved neuropsychological and functional testing, selection, and customization of activities to match capabilities identified in testing, and instruction to caregivers in use of activities.

MEASUREMENTS

Behavioral occurrences, activity engagement, and quality of life in dementia patients; objective and subjective burden and skill enhancement in caregivers.

RESULTS

At 4 months, compared with controls, intervention caregivers reported reduced frequency of problem behaviors, and specifically for shadowing and repetitive questioning, and greater activity engagement including the ability to keep busy. Fewer intervention caregivers reported agitation or argumentation. Caregiver benefits included fewer hours doing things and being on duty, greater mastery, self-efficacy, and skill enhancement. Wait-list control participants following intervention showed similar benefits for reductions in behavioral frequency and caregiver hours doing things for the patient and mastery. Caregivers with depressed symptoms derived treatment benefits similar to nondepressed caregivers.

CONCLUSIONS

Tailoring activities to the capabilities of dementia patients and training families in activity use resulted in clinically relevant benefits for patients and caregivers. Treatment minimized trigger behaviors for nursing home placement and reduced objective caregiver burden. Noteworthy is that depressed caregivers effectively engaged in and benefited from the intervention.

Reporting of Randomized Controlled Trials in Occupational Therapy and Speech Therapy: Evaluation Using an Expansion of the Consort Statement

Research in occupational therapy is necessary for the validation of therapeutic interventions. Randomized controlled trials (RCTs) control against potentially confounding variables and provide validating evidence, if properly reported. The purpose of this study was to evaluate the quality of reporting RCTs in occupational therapy and speech therapy by use of an expansion of the Consolidated Standards of Reporting Trials (CONSORT) statement. The Nelson—Moberg—Norton Expanded CONSORT Instrument (NMNECI) was used to evaluate 15 occupational therapy RCTs and 15 speech therapy RCTs. After the principal investigator evaluated all 30 articles, a masked research assistant evaluated 16 randomly selected RCTs to test for inter-rater reliability. An intraclass correlation coefficient of .93 confirmed overall inter-rater agreement. On average, the 30 articles were consistent with 119.5 NMNECI sub-items ( SD = 25.48) of the 212 possible sub-items. Occupational therapy RCTs (mean = 130.07, SD = 20.21) were more consistent with the CONSORT statement than speech therapy RCTs (mean = 108.93, SD = 26.40), t(28) = 2.46, p = .02. RCTs in occupational therapy and other allied health professions could benefit from using the CONSORT statement as a tool for reporting future research studies.

A non-pharmacological intervention to manage behavioral and psychological symptoms of dementia and reduce caregiver distress: design and methods of project ACT3

Project ACT is a randomized controlled trial designed to test the effectiveness of a non-pharmacological home-based intervention to reduce behavioral and psychological symptoms of dementia (BPSD) and caregiver distress. The study targets 272 stressed racially diverse family caregivers providing in-home care to persons with moderate stage dementia with one or more behavioral disturbances. All participants are interviewed at baseline, 4-months (main trial endpoint), and 6-months (maintenance). The four-month intervention involves up to 13 visits from an occupational therapist who works with families to problem-solve potential triggers (communication style, environmental clutter) contributing to behaviors, and instruct in strategies to reduce caregiver stress and manage targeted behaviors. To rule out infection or other potential medical contributors to behaviors, a nurse obtains blood and urine samples from the dementia patient, and conducts a medication review. Participants in the no-treatment control group are offered the nurse arm and one in-home session following trial completion at 6-months. This paper describes the research methods, theoretical and clinical aspects of this multi-component, targeted psycho-social treatment approach, and the measures used to evaluate quality of life improvements for persons with dementia and their families.

Community occupational therapy for older patients with dementia and their care givers: cost effectiveness study

OBJECTIVE

To assess the cost effectiveness of community based occupational therapy compared with usual care in older patients with dementia and their care givers from a societal viewpoint.

DESIGN

Cost effectiveness study alongside a single blind randomised controlled trial.

SETTING

Memory clinic, day clinic of a geriatrics department, and participants' homes. Patients 135 patients aged > or =65 with mild to moderate dementia living in the community and their primary care givers.

INTERVENTION

10 sessions of occupational therapy over five weeks, including cognitive and behavioural interventions, to train patients in the use of aids to compensate for cognitive decline and care givers in coping behaviours and supervision.

MAIN OUTCOME MEASURES

Incremental cost effectiveness ratio expressed as the difference in mean total care costs per successful treatment (that is, a combined patient and care giver outcome measure of clinically relevant improvement on process, performance, and competence scales) at three months after randomisation. Bootstrap methods used to determine confidence intervals for these measures.

RESULTS

The intervention cost 1183 euros (848 pounds sterling, $1738) (95% confidence interval 1128 euros (808 pounds sterling, $1657) to 1239 euros (888 pounds sterling, $1820)) per patient and primary care giver unit at three months. Visits to general practitioners and hospital doctors cost the same in both groups but total mean costs were 1748 euros (1279 pounds sterling, $2621) lower in the intervention group, with the main cost savings in informal care. There was a significant difference in proportions of successful treatments of 36% at three months. The number needed to treat for successful treatment at three months was 2.8 (2.7 to 2.9).

CONCLUSIONS

Community occupational therapy intervention for patients with dementia and their care givers is successful and cost effective, especially in terms of informal care giving.

A European consensus on outcome measures for psychosocial intervention research in dementia care

Psychosocial intervention makes a vital contribution to dementia care. However, the lack of consensus about which outcome measures to use to evaluate effectiveness prevents meaningful comparisons between different studies and interventions. This study used an iterative collaborative, evidence-based approach to identify the best of currently available outcome measures for European psychosocial intervention research. This included consensus workshops, a web-based pan-European consultation and a systematic literature review and a rigorous evaluation against agreed criteria looking at utility across Europe, feasibility and psychometric properties. For people with dementia the measures covered the domains of quality of life, mood, global function, behaviour and daily living skills. Family carer domains included mood and burden, which incorporated coping with behaviour and quality of life. The only specific staff domain identified was morale, but this included satisfaction and coping with behaviour. In conclusion twenty-two measures across nine domains were recommended in order to improve the comparability of intervention studies in Europe. Areas were identified where improved outcome measures for psychosocial intervention research studies are required.