Exploring the need for a new UK occupational therapy intervention for people with dementia and family carers: Community Occupational Therapy in Dementia (COTiD). A focus group study

How context influences person-centred practice: A critical-creative case study examining the use of research evidence in occupational therapy with people living with dementia

BACKGROUND

Occupational therapists are encouraged to use research evidence to guide therapeutic interventions that holistically address the consequences of dementia. Recent efforts to use research evidence in practice have emphasized the challenges of doing so in ways aligned to person-centred and professional principles. Using research evidence is a complex process influenced by multiple contextual factors and layers. The influence of context in occupational therapy for dementia is currently unclear.

AIMS

To explore the contextual complexities of using research evidence in practice with people with dementia, and to develop knowledge to improve the approach to using evidence in person-centred, occupation-focused practice.

MATERIAL & METHODS

A case study methodology was used, in which the contextual conditions of practice were clarified through the facilitation of critical and creative reflection using the following methods - Think Aloud, practice observation, creative expression and reflective dialogue.

RESULTS

Cultural beliefs that affected evidence use included technically-orientated understandings of evidence-based practice. These were underpinned by apprehensions about losing professional identity and taking risks when processes derived from research evidence were adjusted to incorporate a persons' occupations. These cultural factors were perpetuated at the organizational layers of context, where systemic priorities and other team members' needs disproportionately influenced occupational therapists' decisions.

CONCLUSIONS & SIGNIFICANCE

Occupational therapists' potential to make reflexive and responsive decisions by adjusting evidence-based processes can be affected by their perceived freedom to address organizational tensions. Raising consciousness of the influence of the organizational context on decision-making about evidence use could adjust occupational therapists' perceptions of their freedom and ability to be person-centred. Intentionality in reflective processes in practice are required to foster reflexivity.

Explaining Caregivers' Perceptions of Palliative Care Unmet Needs in Iranian Alzheimer's Patients: A Qualitative Study

Introduction: The needs of Alzheimer's patients are very complex and diverse and many of them are considered unmet needs. Understanding and responding to the unmet and complex needs of Alzheimer's patients can affect the quality of care. Therefore, the present study aimed to explain the perception of formal and informal caregivers of the unmet needs of Iranian Alzheimer's patients. Methods: The present qualitative study employed a Directed Content Analysis approach and was conducted in Iran in 2020. This research was done through in-depth and semi-structured interviews with 19 qualified caregivers enrolled (11 informal caregivers and 8 formal caregivers) with the mean age of 46.05 ± 10.98 years in a purposive sampling method. Interviews continued until data saturation. Data analysis was performed simultaneously with data collection. After recording and transcribing, the data were analyzed using the Elo and Kyngas method based on the National Consensus Project framework (NCP). Data management was done with MAXQDA software. In order to achieve the accuracy and validity of the study, the criteria presented by Lincoln and Guba Credibility, Dependability, Confirmability, and Transformability were considered and used. Results: The mean age of participants was 46.05 ± 10.98. Participants in this study acknowledged that Alzheimer's patients need comprehensive needs management with a holistic approach to increase quality of life. This theme based on the NCP framework consists of seven main categories including "Structure and processes of care," "Physical aspects of care," "Psychological and psychiatric aspects of care," "Social aspects of care," "Cultural aspects of care," "Care of the patient nearing the end of life," and "Ethical and legal aspects of care" with 16 subcategories. Conclusion: The findings of this study provide a deep understanding of the unmet needs of Alzheimer's patients in Iran. Identifying the unmet needs of patients can pave the way for the treatment team to provide effective solutions to meet the needs and empower caregivers to provide comprehensive care for patients.

Community Occupational Therapy for people with dementia and family carers (COTiD-UK) versus treatment as usual (Valuing Active Life in Dementia [VALID]) study: A single-blind, randomised controlled trial

BACKGROUND

We aimed to estimate the clinical effectiveness of Community Occupational Therapy for people with dementia and family carers-UK version (Community Occupational Therapy in Dementia-UK version [COTiD-UK]) relative to treatment as usual (TAU). We hypothesised that COTiD-UK would improve the ability of people with dementia to perform activities of daily living (ADL), and family carers' sense of competence, compared with TAU.

METHODS AND FINDINGS

The study design was a multicentre, 2-arm, parallel-group, assessor-masked, individually randomised controlled trial (RCT) with internal pilot. It was conducted in 15 sites across England from September 2014 to January 2018. People with a diagnosis of mild to moderate dementia living in their own home were recruited in pairs with a family carer who provided domestic or personal support for at least 4 hours per week. Pairs were randomised to either receive COTiD-UK, which comprised 10 hours of occupational therapy delivered over 10 weeks in the person with dementia's home or TAU, which comprised the usual local service provision that may or may not include standard occupational therapy. The primary outcome was the Bristol Activities of Daily Living Scale (BADLS) score at 26 weeks. Secondary outcomes for the person with dementia included the following: the BADLS scores at 52 and 78 weeks, cognition, quality of life, and mood; and for the family carer: sense of competence and mood; plus the number of social contacts and leisure activities for both partners. Participants were analysed by treatment allocated. A total of 468 pairs were recruited: people with dementia ranged from 55 to 97 years with a mean age of 78.6 and family carers ranged from 29 to 94 with a mean of 69.1 years. Of the people with dementia, 74.8% were married and 19.2% lived alone. Of the family carers, 72.6% were spouses, and 22.2% were adult children. On randomisation, 249 pairs were assigned to COTiD-UK (62% people with dementia and 23% carers were male) and 219 to TAU (52% people with dementia and 32% carers were male). At the 26 weeks follow-up, data were available for 364 pairs (77.8%). The BADLS score at 26 weeks did not differ significantly between groups (adjusted mean difference estimate 0.35, 95% CI -0.81 to 1.51; p = 0.55). Secondary outcomes did not differ between the groups. In total, 91% of the activity-based goals set by the pairs taking part in the COTiD-UK intervention were fully or partially achieved by the final COTiD-UK session. Study limitations include the following: Intervention fidelity was moderate but varied across and within sites, and the reliance on primarily proxy data focused on measuring the level of functional or cognitive impairment which may not truly reflect the actual performance and views of the person living with dementia.

CONCLUSIONS

Providing community occupational therapy as delivered in this study did not improve ADL performance, cognition, quality of life, or mood in people with dementia nor sense of competence or mood in family carers. Future research should consider measuring person-centred outcomes that are more meaningful and closely aligned to participants' priorities, such as goal achievement or the quantity and quality of activity engagement and participation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN10748953.

A second chance: Experiences and outcomes of people with dementia and their families participating in a dementia reablement program

Rationale:

Evidence-based reablement programs for people with dementia and their caregivers are not routinely implemented in practice. These programs have been shown to be effective in delaying functional decline and improving caregiver wellbeing. Yet, little is known about the experiences of those participating in such programs.

Aim:

To describe experiences and outcomes of participating in a dementia reablement program, the Care of Persons with dementia in their Environments (COPE), in Australia.

Methods:

Purposeful sampling was used and semi-structured interviews were completed with people with dementia and their caregivers who received the COPE program in two different states in Australia. The interviews explored the participants’ experiences with the program as well as how they are managing after program completion. Thematic analysis was used to identify themes from the interviews. A Likert scale was used to rate the value of the program.

Results:

Ten dyads (person with dementia and/or their caregiver) were interviewed. Participation in the program was rated (mostly) very valuable. The ongoing collaboration between the therapist and caregiver was considered empowering. The program promoted participation in everyday activities for the person with dementia and appeared to give a ‘second chance’ to remain in their own homes and communities.

Conclusion:

Participation in reablement programs (such as the COPE program) has the potential to re-engage people with dementia in meaningful roles and activities in their chosen environments. A therapeutic relationship and individualized intervention approaches tailored to the participants’ needs and readiness foster positive experiences and confidence.

Equipping staff with the skills to maximise recovery of people with dementia after an injurious fall

Objectives: People with dementia are more likely to fall and less likely to recover well after a fall than cognitively intact older people. Little is known about how best to deliver services to this patient group. This paper explores the importance of compensating for cognitive impairment when working with people with dementia. Methods: Qualitative methods - interviews, focus groups and observation - were used to explore the views and experiences of people with dementia, family carers and professionals providing services to people with dementia following an injurious fall. A thematic, iterative analysis was undertaken in which emerging themes were identified from each individual dataset, prior to an integrative analysis. Results: A key theme across all datasets was the need to deliver services in ways that compensate for cognitive impairment, such as negotiating meaningful activities that can be embedded into the routines of people with dementia. Professionals varied in their ability to adapt their practice to meet the needs of people with dementia. Negative attitudes towards dementia, a lack of knowledge and understanding of dementia limited the ability of some professionals to work in person-centred ways. Conclusion: Improving outcomes for people with dementia following a fall requires the principles of person-centred care to be enacted by professionals with a generic role, as well as specialist staff. This requires additional training and support by specialist staff to address the wide variability in current practice.

A cognitive occupation-based programme for people with multiple sclerosis: A new occupational therapy cognitive rehabilitation intervention

Introduction

Cognitive difficulties have been reported to have the greatest effect on function and quality of life in people with multiple sclerosis, affecting 50–60% of people. To date, few interventions have been developed to treat cognitive issues in multiple sclerosis. Here we report on a Cognitive Occupation-Based programme (COB-MS) for people with Multiple Sclerosis an evidence-based intervention to address everyday problems encountered due to cognitive difficulties. The aim of this research was to explore the views of people with multiple sclerosis and occupational therapists on the programme and its potential implementation in practice.

Methods

Data were elicited from a purposive sample of 12 people from two stakeholder groups, people with multiple sclerosis (n = 5) and occupational therapists (n = 7), through focus groups and interviews. The programme and related materials were presented, and contributions recorded, transcribed and thematically analysed.

Results

Two main themes were identified from analysis of the data: response to the intervention and challenges to implementing the programme. Occupational therapists agreed that the COB-MS is client-centred. People with multiple sclerosis thought that it was a validating intervention. The overall format was viewed to be useful and feasible.

Conclusion

The COB-MS for people with Multiple Sclerosis is the first known cognitive intervention using an occupation frame of reference to address difficulties faced among persons with multiple sclerosis and was found to be timely and relevant to the needs of the population.

Service organisation for people with dementia after an injurious fall: challenges and opportunities

Introduction

people with dementia are more likely to fall and less likely to recover well after a fall than cognitively intact older people. Little is known about how best to deliver services to this patient group. This paper explored current service provision to help inform the development of a new intervention.

Methods

qualitative approaches were used to explore the views and experiences of people with dementia, family carers and professionals providing services to people with dementia following an injurious fall. These data were analysed using a thematic, iterative analysis.

Findings

while a wide range of services potentially relevant to people with dementia was identified, there were no dedicated services for people with dementia with fall-related injuries in our three geographical areas. Factors influencing service uptake included a lack of knowledge of local provision amongst professionals and underdeveloped information sharing systems. Some aspects of current service organisation were incompatible with the needs of people with dementia. These include an emphasis on time-limited interventions; lack of longer-term follow-up; and service delivery in environments that could be challenging for people with dementia.

Conclusions

care pathways for people with dementia who fall are fragmented and unclear. This is likely to preclude people with dementia from receiving all appropriate support and contribute to poor recovery following a fall. The findings highlight the need for new approaches to service organisation and delivery which address the specific needs of people with dementia who fall.

What do we know about technologies for dementia-related wandering? A scoping review: Examen de la portée : Que savons-nous à propos des technologies de gestion de l'errance liée à la démence?

BACKGROUND

Occupational therapists use technologies to manage wandering-related risks to promote safety and independence among individuals with dementia living in the community.

PURPOSE

The purpose of this review was to examine types of technologies used to manage wandering behaviour.

METHOD

Using a modification of Arksey and O'Malley's methodology, we systematically searched peer-reviewed and grey literature on technologies used in home or supportive care environments for persons with dementia at risk for wandering. Data from the studies were analyzed descriptively.

FINDINGS

The literature described 83 technologies. Nineteen devices were clinically tested. Interventions ranged from alarm products to mobile locator devices. Benefits included reductions in risk and caregiver burden.

IMPLICATIONS

Occupational therapy strategies include technologies to enhance function in persons with dementia. Technologies can also reduce risks of wandering and should be affordable. Ethical issues of the use of technology must be addressed. More research is needed to increase levels of evidence.

Implementing Evidence-Based Interventions With Community-Dwelling Older Adults: A Scoping Review

OBJECTIVE

With the rapid growth of the community-dwelling older adult population, evidence-based occupational therapy interventions targeting older clients need to be effectively implemented. However, little is understood about the factors influencing effective intervention implementation into practice.

METHOD

We performed a scoping review to explore what strategies and factors relate to the uptake of older adult interventions into practice. Concepts from implementation science literature guided our review.

RESULTS

Our review yielded 13 articles that met our search criteria. Study designs examined barriers, facilitators, and strategies related to the implementation of evidence-based older adult interventions into practice. Effective implementation strategies included training sessions, workshops, consultations, and outreach meetings.

CONCLUSION

Our findings suggest that practitioners, administrators, and researchers should adopt strategies such as workshops, consultations, fidelity vignettes, peer mentoring, and standardized training to effectively implement research into practice with older adults.

The Role of Adult Day Services in Supporting the Occupational Participation of People with Dementia and Their Carers: An Integrative Review

The increasing numbers of people with dementia places considerable stress on health and aged care services and has resulted in the development of community adult day services. Aim: The aim of this integrative review is to determine the extent to which these services support the occupational participation of people with dementia, and how they impact their primary carers. Method: The mixed-methods appraisal tool (MMAT) was used to identify relevant studies in the period 2011–2016. Results: Nine databases were searched and yielded 16 articles with a variety of research designs for inclusion in the review. Conclusions: Findings indicate that adult day services use a range of approaches to support attendees and their carers. In spite of these efforts, there appears to be a lack of interest in utilizing these services while a person is in the early stages of dementia. This suggests that policies in aged care, such as aging-in-place, need to consider the pressure and stress they exert on carer’s quality of life. Another consideration is to better promote the benefits of participating in adult day services in the early stages of dementia for both the attendees and their carers, thereby delaying the tendency towards early institutionalization.

A step-by-step translation of evidence into a psychosocial intervention for everyday activities in dementia: a focus group study

OBJECTIVE

In order to increase the efficacy of psychosocial interventions in dementia, a step-by-step process translating evidence and public engagement should be adhered to. This paper describes such a process by involving a two-stage focus group with people with dementia (PwD), informal carers, and staff.

METHODS

Based on previous evidence, general aspects of effective interventions were drawn out. These were tested in the first stage of focus groups, one with informal carers and PwD and one with staff. Findings from this stage helped shape the intervention further specifying its content. In the second stage, participants were consulted about the detailed components.

FINDINGS

The extant evidence base and focus groups helped to identify six practical and situation-specific elements worthy of consideration in planning such an intervention, including underlying theory and personal motivations for participation. Carers, PwD, and staff highlighted the importance of rapport between practitioners and PwD prior to commencing the intervention. It was also considered important that the intervention would be personalised to each individual.

CONCLUSIONS

This paper shows how valuable public involvement can be to intervention development, and outlines a process of public involvement for future intervention development. The next step would be to formally test the intervention.

Benefits of Occupational Therapy in Dementia Patients: Findings from a Real-World Observational Study

BACKGROUND

There is a growing interest in developing non-pharmacological approaches in dementia. Clinical efficacy of occupational therapy (OT) under routine care conditions has not been investigated yet.

OBJECTIVE

To analyze the short-term effects of OT in patients with dementia; and to identify factors related to greater benefit.

METHODS

Patients referred to OT were evaluated before starting a 3-month intervention and at 3 and 6 months later. Measures included: Mini-Mental State Examination (MMSE), Disability Assessment in Dementia (DAD), Neuropsychiatric Inventory (NPI) Questionnaire, patients' quality of life (EQ 5D-VAS), caregivers' burden (Zarit scale), and amount of informal care. Linear mixed models were used to analyze trajectories of outcomes. Logistic regressions with stepwise descending selection were used to study factors associated with benefits.

RESULTS

421 dementia patients benefited from OT (mean MMSE = 17.3). Patients remained cognitively stable over time. Functional performances also remained stable at 3 months and significantly decreased at 6 months (crude reduction of 2.8 points, p < 0.01). Behavioral troubles were significantly reduced over the intervention period and remained stable after (p < 0.01). Patients' quality of life increased over the 3-month intervention (p = 0.16) and significantly decreased thereafter. Caregivers' burden and informal care significantly decreased over the 3-month intervention and remained stable thereafter. Patients who benefited from OT with regard to function were less educated and had higher cognitive level.

CONCLUSION

OT may be an effective intervention to maintain cognition and functionality and to reduce psychiatric symptoms in dementia patients. Mild stages of dementia could gain more benefits from OT with regard to functional decline.