Effectiveness of Environment-Based Interventions That Address Behavior, Perception, and Falls in People With Alzheimer's Disease and Related Major Neurocognitive Disorders: A Systematic Review

Exploring Factors for Inclusive Occupational Therapy for People With Dementia in Australia: A Qualitative Study

IMPORTANCE

Occupational therapy interventions are a crucial part of dementia care and have been shown to be effective in research trials. However, the acceptability and inclusivity of occupational therapy interventions to treat dementia for people from diverse groups are unclear.

OBJECTIVE

To explore factors contributing to the delivery of acceptable and inclusive community-based occupational therapy interventions for people with dementia from diverse groups in Australia.

DESIGN

Exploratory qualitative study in which interviews and focus groups were used. Data were analyzed with reflexive thematic analysis.

SETTING

Community-based occupational therapy in Australia.

PARTICIPANTS

Purposive sampling was used to recruit 26 participants. Eight people with experience of dementia from diverse groups (ethnic minority, sexual minority, and socially or economically disadvantaged groups) participated in individual interviews; occupational therapists participated in focus groups (n = 10) and interviews (n = 8).

RESULTS

Three key themes were developed to support inclusivity: (1) knowing the person at the center of the care, (2) collaboration, and (3) perception of occupational therapy for people with dementia. Acceptable and inclusive occupational therapy interventions for dementia occurred when people from diverse groups felt valued and received tailored interventions, were confident in and partnered with the therapist, and understood the purpose of therapy.

CONCLUSIONS AND RELEVANCE

Therapists require support to apply cultural humility and to build skills to overcome barriers to providing culturally safe and acceptable care. Plain-Language Summary: People from diverse groups include ethnic minority, sexual minority, and socially or economically disadvantaged groups as well as Indigenous populations. We know community-based occupational therapy interventions improve function and quality of life for people with dementia and their families, but we do not know whether they work for people from diverse groups. We asked people with experience of dementia from diverse groups and occupational therapists in Australia what they thought. We found that occupational therapy interventions for dementia are acceptable to diverse groups when the therapist works in partnership, providing an intervention that is meaningful to them. To be inclusive, therapists need to empower people from diverse groups to participate equally in the intervention. They need to make sure families understand the purpose of the intervention. Some occupational therapists may need training to build skills and knowledge as well as support to overcome barriers and to provide acceptable and inclusive interventions.

Caregivers' Role in In-Home Video Telehealth: National Survey of Occupational Therapy Practitioners

BACKGROUND

Older adults face barriers to specialty care, such as occupational therapy (OT), and these challenges are worse for rural older adults. While in-home video telehealth may increase access to OT, older adults' health- and technology-related challenges may necessitate caregiver assistance.

OBJECTIVE

This study examines caregiver assistance with in-home OT video telehealth visits from the perspectives of OT practitioners at Veterans Health Administration (VHA).

METHODS

A web-based national survey of VHA OT practitioners about caregivers' role in video telehealth was conducted between January and February 2022. Survey items were developed with input from subject matter experts in geriatrics and OT and identified patient factors that necessitate caregiver participation; the extent to which caregivers assist with different types of tasks (technological and clinical tasks); and the perceived facilitators of, benefits of, and barriers to caregiver involvement.

RESULTS

Of approximately 1787 eligible VHA OT practitioners, 286 (16% response rate) participated. Not all survey items required completion, resulting in different denominators. Most respondents were female (183/226, 81%), White (163/225, 72.4%), and occupational therapists (275/286, 96.2%). Respondents were from 87 VHA medical centers, the catchment areas of which served a patient population that was 34% rural, on average (SD 0.22). Most participants (162/232, 69.8%) had >10 years of OT experience serving a patient cohort mostly aged ≥65 years (189/232, 81.5%) in primarily outpatient rehabilitation (132/232, 56.9%). The top patient factors necessitating caregiver involvement were lack of technical skills, cognitive impairment, and advanced patient age, with health-related impairments (eg, hearing or vision loss) less frequent. Technological tasks that caregivers most frequently assisted with were holding, angling, moving, repositioning, or operating the camera (136/250, 54.4%) and enabling and operating the microphone and setting the volume (126/248, 50.8%). Clinical tasks that caregivers most frequently assisted with were providing patient history (143/239, 59.8%) and assisting with patient communication (124/240, 51.7%). The top facilitator of caregiver participation was clinician-delivered caregiver education about what to expect from video telehealth (152/275, 55.3%), whereas the top barrier was poor connectivity (80/235, 34%). Increased access to video telehealth (212/235, 90.2%) was the top-rated benefit of caregiver participation. Most respondents (164/232, 70.7%) indicated that caregivers were at least sometimes unavailable or unable to assist with video telehealth, in which case the appointment often shifted to phone.

CONCLUSIONS

Caregivers routinely assist VHA patients with in-home OT video visits, which is invaluable to patients who are older and have complex medical needs. Barriers to caregiver involvement include caregivers' challenges with video telehealth or inability to assist, or lack of available caregivers. By elucidating the caregiver support role in video visits, this study provides clinicians with strategies to effectively partner with caregivers to enhance older patients' access to video visits.

Occupational Therapy Practice Guidelines for Adults Living With Alzheimer's Disease and Related Neurocognitive Disorders

IMPORTANCE

There are currently 55 million adults living with declining functional cognition-altered perception, thoughts, mood, or behavior-as the result of Alzheimer's disease (AD) and related neurocognitive disorders (NCDs). These changes affect functional performance and meaningful engagement in occupations. Given the growth in demand for services, occupational therapy practitioners benefit from consolidated evidence of effective interventions to support adults living with AD and related NCDs and their care partners.

OBJECTIVE

These Practice Guidelines outline effective occupational therapy interventions for adults living with AD and related NCDs and interventions to support their care partners.

METHOD

We synthesized the clinical recommendations from a review of recent systematic reviews.

RESULTS

Twelve systematic reviews published between 2018 and 2021 served as the foundation for the practice recommendations.

CONCLUSION AND RECOMMENDATIONS

Reminiscence, exercise, nonpharmacological behavioral interventions, cognitive therapy, sensory interventions, and care partner education and training were found to be most effective to support adults living with AD and related NCDs. Plain-Language Summary: These Practice Guidelines provide strong and moderate evidence for occupational therapy practitioners to support adults living with Alzheimer's disease (AD) and related neurocognitive disorders (NCDs) and their care partners. They provide specific guidance for addressing the decline in cognition, behavioral and psychological symptoms of dementia, and pain experience of adults living with AD and related NCDs. The guidelines also describe interventions to support care partners. With support from the evidence, occupational therapy practitioners are better equipped to address the unique needs of adults living with AD and related NCDs and their care partners.

Feasibility of Telehealth Occupational Therapy for Behavioral Symptoms of Adults With Dementia: Randomized Controlled Trial

IMPORTANCE

Supporting community residency of adults with Alzheimer's disease (AD) is a critical public health initiative. Occupational therapy can contribute to this goal.

OBJECTIVE

To assess the feasibility of a novel telehealth intervention to support occupational engagement in community-residing people with AD.

DESIGN

Single-blind, three-arm, parallel, randomized controlled trial.

SETTING

Occupational therapy delivered through telehealth in participants' homes.

PARTICIPANTS

People with AD who reside in the community with behavioral symptoms and their care partners (dyads).

INTERVENTIONS

(1) HARMONY (Helping older Adults cReate & Manage OccupatioNs successfully), a telehealth intervention that applies principles of individualized guided discovery with environmental cueing for caregivers of persons with AD to promote activity participation and manage behavioral symptoms; (2) standardized training regarding the use of a sensory-based approach in dementia care; and (3) a control, including home safety education and weekly monitoring of behaviors.

OUTCOMES AND MEASURES

Feasibility was assessed as the primary outcome measured by completion of at least 75% of the telehealth sessions. Secondary outcomes included change in functional activity performance and neuropsychiatric behavioral symptoms.

RESULTS

Twenty-eight dyads participated. The intervention was feasible, with high adherence to weekly visits (M number of visits = 5.4 for HARMONY, 4.9 for standardized training, and 4.6 for control), with high participant retention in the intervention arms. HARMONY demonstrated promise in improving patient performance and behavioral symptoms.

CONCLUSIONS AND RELEVANCE

HARMONY is feasibly delivered through telehealth service and has a positive effect on occupational performance and behavioral symptoms of AD. Additional studies are needed to explore effectiveness in a broader population. What This Article Adds: Use of HARMONY for community-residing adults with AD is feasible and has promise for improving functional activity performance and behavioral symptoms, as well as caregiver satisfaction.

Beyond garden design: A review of outdoor occupation in hospital and residential care settings for people with dementia

INTRODUCTION

Access to outdoor space is widely recommended for people with dementia. However, there is limited information on the occupations of people with dementia within these spaces. We sought to review the research literature to identify the occupations of people with dementia in outdoor spaces in residential aged care and/or hospitals and report on features that support occupational participation as well as the benefits of occupational participation in these spaces.

METHODS

Scoping review. We searched electronic databases involving health, design, and horticulture literature. Studies were included if they involved people with dementia and considered occupations within gardens or garden-like spaces of hospitals, subacute rehabilitation facilities, or residential aged care.

RESULTS

We identified 19 articles meeting the review criteria. Outdoor spaces for people with dementia varied in design and supported a range of occupations with the most common being social occupations, gardening, and physical activities. Quantitative studies suggested that benefits of outdoor occupations for people with dementia were improvements in activity participation, social connection, mood, agitation, light exposure, and sleep. Qualitative studies supported these findings and identified additional perceived benefits such as engagement, maintaining identity, health, and reduced levels of distress. Benefits were also reported for families and staff.

CONCLUSIONS

Current literature shows that many occupations can be done outside and that these are beneficial for people with dementia. Despite the wide range of benefits, multiple studies reported that outdoor spaces remain under-utilised. More work is required to design spaces for occupational engagement, support access to outdoor spaces, and promote occupational participation.

Non-Pharmacological Interventions for Feeding and Eating Disorders in Persons with Dementia: Systematic Review and Evidence Summary

BACKGROUND

Feeding and eating disorders related to cognitive and psycho-behavioral symptoms are strongly associated with health status in persons with dementia (PWD). Non-pharmacological interventions have been the priority selection to address this significant issue. However, the direct targets of non-pharmacological interventions are unclear and there is no consistent evidence of recommendations on the intervention of different dementia stages and the settings of intervention practice.

OBJECTIVE

To provide caregivers with a set of self-help non-pharmacological interventions for feeding and eating disorders in PWD.

METHODS

Based on the process of evidence summary, a systematic literature search was performed on dementia websites and seven databases. Two researchers screened the studies independently and appraise the quality. The evidence was graded by Joanna Briggs Institute Grades of Recommendation.

RESULTS

Twenty-eight articles were included. Twenty-three non-pharmacological intervention recommendations were categorized into six themes containing oral nutritional supplementation, assistance with eating and drinking, person-centered mealtime care, environmental modification, education or training, and multi-component intervention. These interventions corresponded to three direct targets including improving engagement, making up for loss ability, and increasing food intake directly. They were applied to different stages of dementia and most interventions were targeted at PWD in long-term care institutions.

CONCLUSION

This article summarized the direct targets and the specific implementation of recommendations at different stages of dementia to provide caregivers with self-help non-pharmacological interventions. The practice of recommendations was more applicable to institutionalized PWD. When applied to PWD at home, caregivers need to identify the specific feeding and eating conditions at different stages and adopted the interventions in conjunction with the wishes of the PWD and professional advice.

Built Environment Design Interventions at the Exits of Secured Dementia Care Units: A Review of the Empirical Literature

PURPOSE

To review evidence around design interventions that influence exiting attempts in dementia care units, informing architectural and clinical practice.

BACKGROUND

Built environment design is recognized as important in the care and management of responsive behaviors for those living with Alzheimer's disease and other dementias in secured dementia care units (e.g., exiting attempts, agitation). The repetitious behavior of "walking with purpose" (previously termed wandering) in those with dementia has influenced safety-related architectural design components of dementia care units that decrease exiting attempts. Empirical literature addressing design interventions to prevent exiting for those with dementia is lacking and outdated.

METHODS

We sought to describe known design techniques through a topical analysis of experimental studies. A thorough search for empirical studies that assessed interior design interventions at exit doors within dementia care units was undertaken. The review included an extensive search for existing literature and a screening of each study identified for its relevance, quality, and applicability.

RESULTS

The experimental studies included in the review collectively assessed five interior design interventions at egress doorways: implementing horizontal and vertical floor grid patterns, mirrors, murals, conditioning responses to color cues, and camouflaging door hardware or vision panels. Why empirical studies have not continued more recently as built environment trends have shifted toward promoting meaningful and purposeful movement through design are considered. Advances in our understanding around the pathophysiology of dementia which might affect future design interventions related to egress are also identified.

CONCLUSION

The built environment is an important part of dementia care, and further prospective research is needed on the role of design interventions in the context of exiting attempts within secured units and subsequent behavior outcomes.

Frequency of changed behaviours in residential aged care and common mitigation strategies - A retrospective review of behavioural report logs

BACKGROUND

Changed behaviours in residential aged care facilities (RACF) are frequently reported in the literature. How RACF staff routinely respond to these observed changed behaviours represents a significant gap.

OBJECTIVE

To analyse the frequency of changed behaviour reported within RACF behavioural report logs and to ascertain how staff typically manage these behaviours.

METHODS

Residents (N = 25) with varying levels of cognitive function were recruited from a 160 bed RACF in Queensland, Australia. A retrospective analysis of behavioural report logs was conducted to elucidate prevalence of reported changed behaviours as categorised by RACF staff. Thematic analysis of staff recorded behavioural mitigation strategies was used to categorise staff actions. A case analysis was also conducted to highlight the challenges faced by RACF staff managing persistent acute changed behaviours using identified common mitigation strategies. The STROBE guidelines were followed for reporting.

RESULTS

There were 395 behaviours recorded in a two-month period. Physical agitation, interfering while wandering, trying to get to inappropriate places, verbal refusal of care, physical aggression, and verbal disruption were most frequently reported by staff. Management strategies included redirection, PRN psychotropic medication, reassurance, routine care practices, offering of beverages, repositioning, and rarely analgesia. A 24-h case analysis highlighted how staff utilised redirection and multiple doses of a PRN benzodiazepine with limited effectiveness.

CONCLUSION

This study reveals current mitigation strategies employed by RACF staff in response to acute changed behaviours often associated with dementia. Agitation and wandering are prevalent and are difficult for staff to manage effectively.

RELEVANCE TO CLINICAL PRACTICE

This study highlights that careful consideration should be taken to avoid overuse of PRN benzodiazepines in management of changed behaviours. Short-term mitigation strategies, such as redirection, may not be effective if underlying causes such as pain, physiological, mental, emotional, or social needs are not met.

PATIENT AND PUBLIC CONTRIBUTION

A RACF participated in project design and review.

"Can Everyday Assistive Technologies Provide Meaningful Support to Persons With Dementia and Their Informal Caregivers? Evaluation of Collaborative Community Program"

One of the most challenging caregiving roles today is providing informal care to an individual with dementia. A new program, "AT-Home with Dementia," was created by three collaborative social service agencies to offer simple assistive technologies to persons with dementia and their informal caregivers. Staff, equipped with a traveling kit of everyday devices, offered items during home visits to enhance memory, functional activities, safety, and comfort of persons with dementia. A limited formative program review led to improvements in the new program's reach, service delivery, and data. The results showed that the program enhanced the home environment of the caregiving dyad and led to greater independence of persons with dementia (PWD) and self-assurance among caregivers. Existing community agencies may refer to this program to serve individuals with early-stage dementia. Finally, community agencies and funders may consider adapting this program to provide support to the informal care providers and PWD.

A framework for rehabilitation for older adults living with dementia

Introduction & Background

The aging of the population assures increased prevalence of Individuals Living with Dementia (ILwD) and there will be an increased representation of this cohort requiring physical rehabilitation. If physical therapists (PTs) manage these patients as they do their age-matched, cognitively-intact peers, they will likely be unsuccessful. ILwD have unique needs related to interpersonal and pragmatic components of rehabilitation. Therapeutic nihilism (doubting the benefit of therapy) is well-documented in PTs, either because of existing biases about dementia or previous challenges in working with ILwD. Physical rehabilitation eligibility and placement decisions are often made by PTs without special training in dementia, based upon brief exposure to patients in environments not well-designed for their best functioning. This can lead to underestimation of rehabilitation potential and denial of future PT services. PTs who work with ILwD desire more practical knowledge and targeted skills. Those with more education and training have a more positive attitude and outlook related to ILwD.

Purpose

The purpose of this paper is to introduce a framework for rehabilitation with ILwD equipped with pragmatic ideas to facilitate therapeutic success. The four primary components of the model are: (1) Establish a personal RELATIONSHIP, (2) Use intentional verbal and nonverbal COMMUNICATION, (3) Understand and optimize MOTOR LEARNING capabilities, and (4) Create a safe, purposeful ENVIRONMENT. Specific strategies to help PTs optimize each component are provided with supporting evidence. The model is intended to be dynamic, encouraging PTs to capitalize on the most accessible strategies within their control for a given patient and setting.

Implications

This framework provides a practical resource for working with ILwD with immediate implications for facilitating therapeutic success. The model is displayed in a schematic that reminds the reader of ideas at a glance within the context of each of the components. If an appreciation for this content was among core competencies required among PTs working with ILwD, perhaps there would be significantly fewer patients written off as “uncooperative” or “unable to participate” in PT.

Sensory Processing Abnormalities in Community-Dwelling Older Adults with Cognitive Impairment: A Mixed Methods Study

Mild cognitive impairment (MCI) or dementia often leads to behavioral and psychiatric symptoms of dementia (BPSD). Sensory processing abnormalities may be associated with BPSD. The purpose of this study was to explore relationships among sensory processing, behavior, and environmental features within the homes of people with MCI or dementia. This project used mixed methods to assess participants' sensory processing, care partner perspectives on behaviors, and in situ observations of the home environment. Nine participants with cognitive impairment (MCI n = 8, early dementia = 1) and their care partners were included. Seven participants with cognitive impairment were reported to have abnormal sensory processing. Findings suggest that unique environmental adaptations, tailored to personal and sensory preferences for each participant, were associated with a decreased level of behavioral disruption during the observation periods. Implementing sensory-based approaches to maximize environment adaptation may be beneficial in reducing disruptive behaviors for adults with cognitive impairment.

The Effectiveness of Facial Expression Recognition in Detecting Emotional Responses to Sound Interventions in Older Adults With Dementia

This research uses facial expression recognition software (FaceReader) to explore the influence of different sound interventions on the emotions of older people with dementia. The field experiment was carried out in the public activity space of an older adult care facility. Three intervention sound sources were used, namely, music, stream, and birdsong. Data collected through the Self-Assessment Manikin Scale (SAM) were compared with facial expression recognition (FER) data. FaceReader identified differences in the emotional responses of older people with dementia to different sound interventions and revealed changes in facial expressions over time. The facial expression of the participants had significantly higher valence for all three sound interventions than in the intervention without sound (p < 0.01). The indices of sadness, fear, and disgust differed significantly between the different sound interventions. For example, before the start of the birdsong intervention, the disgust index initially increased by 0.06 from 0 s to about 20 s, followed by a linear downward trend, with an average reduction of 0.03 per 20 s. In addition, valence and arousal were significantly lower when the sound intervention began before, rather than concurrently with, the start of the activity (p < 0.01). Moreover, in the birdsong and stream interventions, there were significant differences between intervention days (p < 0.05 or p < 0.01). Furthermore, facial expression valence significantly differed by age and gender. Finally, a comparison of the SAM and FER results showed that, in the music intervention, the valence in the first 80 s helps to predict dominance (r = 0.600) and acoustic comfort (r = 0.545); in the stream sound intervention, the first 40 s helps to predict pleasure (r = 0.770) and acoustic comfort (r = 0.766); for the birdsong intervention, the first 20 s helps to predict dominance (r = 0.824) and arousal (r = 0.891).

Effectiveness of Therapeutic Gardens for People with Dementia: A Systematic Review

This paper is a systematic review of quantitative studies conducted on the benefits of visiting gardens and gardening therapy for people with dementia (PWD) in an effort to assess the effectiveness of such treatments and obtain information on the most appropriate garden design for this population. This review followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA) guidelines. Four databases were searched (PubMed, Web of Science, PsycINFO, Scopus), with no time limits. Out of a total of 480 articles considered, 16 studies were selected for review. In all but two of the studies examined, gardening therapy and the use of therapeutic gardens induced psychophysiological improvements in PWD. The areas showing the greatest effects were Engagement, Agitation, Depression/Mood, Stress, and Medication. It also emerged that interest in this sphere has been growing in the last decade, but there is still a shortage of empirical evidence of the beneficial effects of therapeutic gardens in relation to the type and severity of dementia, and of garden design guidelines. Despite the limited number of studies investigated, the review confirmed the benefits of gardening and therapeutic gardens in PWD. There is nonetheless a need to conduct more quantitative research to support currently-available evidence and generate more information, focusing on garden design criteria, in-garden activities, the type and severity of dementia examined, and effects on caregivers as well as on PWD.

Promoting Quality of Life in Advanced Dementia Care: Reading Buddies Program as Service-learning

The Reading Buddies Program was developed as a service-learning component of an Occupational Therapy Practice with Older Adults course as a collaboration between Tufts University and the VA Bedford Health Care System. The purpose of this service-learning program was to challenge graduate students' implicit biases and improve communication skills when working with older adults with significant cognitive impairments. Through this collaboration, occupational therapy students provided individualized, activity-based care to Veterans with advanced dementia. In this qualitative study, a total of 55 guided reflection papers submitted by students were analyzed using NVivo. Four major themes emerged: "I was a fish out of water," "I finally took a risk," "And then I thought, maybe I should give myself a little credit," and, "I am still experimenting with how I feel," illustrating student outcomes and perceived benefits of participation in the Reading Buddies Program. Each theme reflected the development of clinical reasoning which was the targeted impact. Outcomes confirm service-learning as an effective tool and suggest further use for academic programs, emphasizing the potential of creative partnerships to meet educational goals while providing valuable programming to vulnerable populations.

Effectiveness of Interventions for Preventing People With Dementia Exiting or Getting Lost

BACKGROUND AND OBJECTIVES

People with dementia are at risk of exiting premises unsupervised, eloping, or getting lost, potentially leading to harmful or distressing consequences. This review aimed to estimate the effectiveness of interventions for preventing people with dementia from exiting or getting lost.

RESEARCH DESIGN AND METHODS

A systematic review of English sources was undertaken. Health care (EMBASE, BNI, Medline, PubMed, CINAHL, PsycINFO, AMED, HTA, CENTRAL) and gray literature (OpenGrey) databases were searched using prespecified search terms. Additional studies were identified by hand-searching bibliographies of relevant reviews and included studies. Wide inclusion criteria were set to capture a range of intervention types. Data extraction and risk of bias assessment were completed independently by two reviewers. Methods were preregistered on PROSPERO.

RESULTS

Individual and overall risk of bias was too high for statistical meta-analyses. A narrative synthesis was therefore performed. Twenty-five studies with 814 participants were included, investigating a range of nonpharmacological interventions aiming to prevent exiting, facilitate retrieval, educate participants, or a combination of these. Seventeen (68%) of the included studies had critical risks of internal bias to outcomes, providing no useful evidence for the effectiveness of their respective interventions. The remaining 8 (32%) studies had serious risks of bias. Narrative synthesis of results yielded no overall robust evidence for the effectiveness of any interventions.

DISCUSSION AND IMPLICATIONS

No evidence was found to justify the recommendation of any interventions included in this review. Future studies should focus on high-quality, controlled study designs.

Home-Based Occupational Therapy for Adults With Dementia and Their Informal Caregivers: A Systematic Review

IMPORTANCE

People with dementia require tailored interventions to support participation and performance in their desired occupations, and informal caregivers need interventions that reduce caregiving burden to enable them to continue with their roles.

OBJECTIVE

This systematic review investigated whether home-based occupational therapy interventions for adults with dementia and their informal caregivers optimized care recipients' performance of daily occupations and reduced caregiving burden and improved caregivers' sense of competence.

DATA SOURCES

Eight databases were searched from 1946 to November 2019 using MeSH terms, keywords, and subject headings as appropriate for each database. Inclusion criteria were quantitative studies investigating the effects of home-based therapy provided by a qualified occupational therapist for adults with dementia and their informal caregivers.

STUDY SELECTION AND DATA COLLECTION

Study selection, data collection, and methodological quality assessments using the Critical Appraisal Skills Programme criteria tool were performed independently by two reviewers. Data analysis involved a two-stage process.

FINDINGS

From 1,229 articles identified through searches, 970 titles and abstracts were screened for eligibility after removal of duplicates. Twenty studies reported in 22 articles were included. Moderate evidence supported interventions provided jointly for adults with dementia and their informal caregivers using a combination of intervention strategies. Included studies demonstrated high risk of bias, particularly in blinding of outcome assessments.

CONCLUSIONS AND RELEVANCE

Combining individualized interventions framed in client-centeredness can enhance occupational performance for adults with dementia, reduce caregiving burden, and improve informal caregivers' sense of competence. Further research on leisure and home management occupations is warranted.

WHAT THIS ARTICLE ADDS

The findings provide evidence supporting the effectiveness of home-based occupational therapy for people with dementia and their informal caregivers for consideration by funders of services.

Sensory-Based Interventions for Adults with Dementia and Alzheimer's Disease: A Scoping Review

The purpose of this review was to explore the effectiveness of sensory-based interventions for clients with dementia and Alzheimer's disease living in residential facilities. Nine databases and key sources were searched from 2002 to September 2017. Forty-seven articles met the inclusion criteria. There was strong evidence for use of massage. There was moderate evidence for occupationally and environmentally based multisensory activities including light, gardening, mealtime, music, Montessori, animal assisted therapy, dance, and yoga interventions. There was inconclusive evidence for aromatherapy, art, Snoezelen rooms, and combined visual and auditory interventions. Future research should focus on defining protocols for efficacious interventions.

Cognition, Cognitive Rehabilitation, and Occupational Performance

The American Occupational Therapy Association (AOTA) asserts that occupational therapists and occupational therapy assistants, through the use of occupations and activities, facilitate clients’ cognitive functioning to enhance occupational performance, self-efficacy, participation, and perceived quality of life. Cognitive processes are integral to effective performance across the broad range of daily occupations such as work, educational pursuits, home management, and play and leisure. Cognition plays an integral role in human development and in the ability to learn, retain, and use new information to enable occupational performance across the lifespan.

This statement defines the role of occupational therapy in evaluating and addressing cognitive functioning to help clients maintain and improve occupational performance. The intended primary audience is practitioners1 within the profession of occupational therapy. The statement also may be used to inform recipients of occupational therapy services, practitioners in other disciplines, and the wider community regarding occupational therapy theory and methods and to articulate the expertise of occupational therapy practitioners in addressing cognition and challenges in adapting to cognitive dysfunction.

Actigraphy for Assessing Light Effects on Sleep and Circadian Activity Rhythm in Alzheimer's Dementia: A Narrative Review

Background:

Alzheimer's Disease (AD) is often accompanied by severe sleep problems and circadian rhythm disturbances which may to some extent be attributed to a dysfunction in the biological clock. The 24-h light/dark cycle is the strongest Zeitgeber for the biological clock. People with AD, however, often live in environments with inappropriate photic Zeitgebers. Timed bright light exposure may help to consolidate sleep- and circadian rest/activity rhythm problems in AD, and may be a low-risk alternative to pharmacological treatment.

Objective & Method:

In the present review, experts from several research disciplines summarized the results of twenty-seven light intervention studies which used wrist actigraphy to measure sleep and circadian activity in AD patients.

Results:

Taken together, the findings remain inconclusive with regard to beneficial light effects. However, the considered studies varied substantially with respect to the utilized light intervention, study design, and usage of actigraphy. The paper provides a comprehensive critical discussion of these issues.

Conclusion:

Fusing knowledge across complementary research disciplines has the potential to critically advance our understanding of the biological input of light on health and may contribute to architectural lighting designs in hospitals, as well as our homes and work environments.

Smartphone-Based Interventions to Foster Simple Activity and Personal Satisfaction in People With Advanced Alzheimer's Disease

OBJECTIVES

This study assessed a smartphone-based program to promote practical and mildly demanding arm responses and personal satisfaction and increase physical exertion (heart rates) in people with advanced Alzheimer's disease.

METHODS

The program relied on a Samsung Galaxy A3 smartphone with Android 6.0 operating system. Two groups of 10 and 11 participants, respectively, were assigned different responses (ie, placing cards into an elevated box and moving bottles with water from a table into a container). Responses activated the smartphone, which produced brief periods of preferred stimulation. Lack of responding led the smartphone to produce a verbal prompt.

RESULTS

All participants had significant increases in independent response frequencies, level of personal satisfaction, and heart rates during program sessions as opposed to baseline or control sessions.

CONCLUSION

A smartphone-based program may help people with advanced Alzheimer's disease increase independent occupation with possible benefits in terms of satisfaction and physical condition.

In-Home Video Telehealth for Dementia Management: Implications for Rehabilitation

PURPOSE OF REVIEW

The progressive nature of dementia requires ongoing care delivered by multidisciplinary teams, including rehabilitation professionals, that is individualized to patient and caregiver needs at various points on the disease trajectory. Video telehealth is a rapidly expanding model of care with the potential to expand dementia best practices by increasing the reach of dementia providers to flexible locations, including patients' homes. We review recent evidence for in-home video telehealth for patients with dementia and their caregivers with emphasis on implications for rehabilitation professionals.

RECENT FINDINGS

Eleven studies were identified that involved video visits into the home targeting patients with dementia and/or their family caregivers. The majority describe protocolized interventions targeting caregivers in a group format over a finite, pre-determined period. For most, the discipline of the interventionist was unclear, though two studies included rehabilitation interventions. While descriptions of utilized technology were often lacking, many reported that devices were issued to participants when needed, and that technical support was provided by study teams. Positive caregiver outcomes were noted but evidence for patient-level outcomes and cost data are mostly lacking.

SUMMARY

More research is needed to demonstrate implementation of dementia best care practices through in-home video telehealth. Though interventions delivered using in-home video telehealth appear to be effective at addressing caregivers' psychosocial concerns, the impact on patients and the implications for rehabilitation remain unclear. Larger, more systematic inquiries comparing in-home video telehealth to traditional visit formats are needed to better define best practices.

Alzheimer Dementia in the Orthopaedic Patient

Alzheimer disease is a neurologic disorder characterized by the progressive cognitive decline. As the population continues to age, orthopaedic surgeons need to become familiar with surgical and nonsurgical treatment considerations in this complex population. Despite the advances in geriatric and dementia care, surgical and postoperative management of both elective and emergent surgery remain complex and controversial in this patient population. Appropriate perioperative and postoperative management can optimize outcomes, and the management can significantly affect the quality of life of patient and caregiver and limit disease burden. Any treatment decision should be guided first and foremost by the goals of care as agreed between the surgeon, other providers, and family. Surgical management must be demand matched to the patient accounting for the severity of disease, life expectancy, and the social support system. The authors conducted a literature review of Alzheimer dementia care in orthopaedic patients via a Pubmed search of relevant articles published since 1980.

Tablet-based intervention to foster music-related hand responses and positive engagement in people with advanced Alzheimer’s disease

Purpose

Music stimulation is considered beneficial for people with advanced Alzheimer’s disease. The purpose of this paper is to assess a tablet-based program to promote music-related hand responses and positive engagement (e.g. singing or moving the body with the music) in people with advanced Alzheimer’s disease.

Design/methodology/approach

The program was implemented with 20 participants according to a non-concurrent multiple baseline design across participants. The participants were provided with a tablet whose screen worked as a sensor. During the intervention, sensor activations by hand responses led the tablet to present 10 s segments of preferred songs; an absence of sensor activation led the tablet to produce a prompt.

Findings

The participants’ mean frequencies of hand responses (i.e. sensor activations) per 5 min session increased from mostly zero during baseline to between about 9 and 20 during the intervention. The mean percentages of observation intervals with participants’ positive engagement increased from 0 to 12 during the baseline to between 13 and 55 during the intervention. The differences between baseline and intervention data were statistically significant for all participants.

Originality/value

A tablet-based program, such as that used in this study, may help people with advanced Alzheimer’s disease develop specific music-related responses and positive engagement.

Technology-Based Behavioral Interventions for Daily Activities and Supported Ambulation in People With Alzheimer's Disease

OBJECTIVES

These 2 studies evaluated technology-based behavioral interventions for promoting daily activities and supported ambulation in people with mild-to-moderate and moderate-to-severe Alzheimer's disease, respectively.

METHODS

Study 1 included 8 participants who were taught to start and carry out daily activities on their own using a tablet or smartphone device, which provided activity reminders, step instructions, and praise. Study 2 included 9 participants who were taught to engage in brief periods of ambulation using a walker combined with a tilt microswitch and a notebook computer, which monitored step responses and provided stimulation and prompts.

RESULTS

The participants of study 1 succeeded in starting the activities independently and carrying them out accurately. The participants of study 2 largely increased their ambulation levels and also showed signs of positive involvement (eg, smiles and verbalizations).

CONCLUSION

The aforementioned technology-based interventions may represent practical means for supporting people with Alzheimer's disease.

Occupational Therapy Interventions for People With Alzheimer's Disease

Evidence Connection articles provide a clinical application of systematic reviews developed in conjunction with the American Occupational Therapy Association's (AOTA's) Evidence-Based Practice Project. In this Evidence Connection article, we describe a case report of a person with Alzheimer's disease. The occupational therapy assessment and intervention process in the home setting is described. Findings from the systematic reviews on this topic were published in the November/December 2017 issue of the American Journal of Occupational Therapy and in AOTA's Occupational Therapy Practice Guidelines for Adults With Alzheimer's Disease and Related Major Neurocognitive Disorders. Each article in this series summarizes the evidence from the published reviews on a given topic and presents an application of the evidence to a related clinical case. Evidence Connection articles illustrate how the research evidence from the reviews can be used to inform and guide clinical reasoning.

Effectiveness of interventions aimed at improving physical and psychological outcomes of fall-related injuries in people with dementia: a narrative systematic review

BACKGROUND

The annual prevalence of falls in people with dementia ranges from 47 to 90%. Falls are a common reason for hospital admission in people with dementia, and there is limited research evidence regarding the care pathways experienced by this population. In addition to immediate management of an injury, prevention of further falls is likely to be an important part of any successful intervention. This review aims to assess the effectiveness of interventions for improving the physical and psychological wellbeing of people with dementia who have sustained a fall-related injury.

METHODS

Systematic review methodologies were employed utilising searches across multiple databases (MEDLINE, CENTRAL, Health Management Information Consortium, EMBASE, CINAHL, Web of Science, Allied and Complementary Medicine Database, and Physiotherapy Evidence Database (PEDro)) and citation chaining. Studies including people with a known diagnosis of dementia living in the community and who present at health services with a fall, with or without injury, were included. Outcomes of interest included mobility, recurrent falls, activities of daily living, length of hospital stay, and post-discharge residence. Results were independently reviewed and quality assessed by two researchers, and data extracted using a customised form. A narrative synthesis was performed due to heterogeneity of the included studies.

RESULTS

Seven studies were included. Interventions clustered into three broad categories: multidisciplinary in-hospital post-surgical geriatric assessment; pharmaceuticals; and multifactorial assessment. Multidisciplinary care and early mobilisation showed short-term improvements for some outcomes. Only an annual administration of zoledronic acid showed long-term reduction in recurrent falls.

CONCLUSIONS

Due to high heterogeneity across the studies, definitive conclusions could not be reached. Most post-fall interventions were not aimed at patients with dementia and have shown little efficacy regardless of cognitive status. Minor improvements to some quality of life indicators were shown, but these were generally not statistically significant. Conclusions were also limited due to most studies addressing hip fracture; the interventions provided for this type of injury may not be suitable for other types of fractures or soft tissue injuries, or for use in primary care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016029565 .

Supporting Adults With Alzheimer's Disease and Related Major Neurocognitive Disorders and Their Caregivers: Effective Occupational Therapy Interventions

Occupational therapy practitioners play a significant role in supporting adults with Alzheimer's disease and related major neurocognitive disorders, as well as their caregivers, through all phases of the disease process. This editorial highlights the systematic reviews completed in collaboration with the American Occupational Therapy Association's Evidence-Based Practice Project that summarize the evidence for the effectiveness of interventions within the scope of occupational therapy practice for this population. Readers are encouraged to translate and integrate this updated knowledge into everyday practice.

Effectiveness of Interventions for Caregivers of People With Alzheimer’s Disease and Related Major Neurocognitive Disorders: A Systematic Review

OBJECTIVE. The goal of the evidence review was to evaluate the effectiveness of interventions for caregivers of people with Alzheimer’s disease and related major neurocognitive disorders that facilitate the ability to maintain participation in the caregiver role.

METHOD. Scientific literature published in English between January 2006 and April 2014 was reviewed. Databases included MEDLINE, PsycINFO, CINAHL, OTseeker, and the Cochrane Database of Systematic Reviews.

RESULTS. Of 2,476 records screened, 43 studies met inclusion criteria. Strong evidence shows that multicomponent psychoeducational interventions improve caregiver quality of life (QOL), confidence, and self-efficacy and reduce burden; cognitive reframing reduces caregiver anxiety, depression, and stress; communication skills training improves caregiver skill and QOL in persons with dementia; mindfulness-based training improves caregiver mental health and reduces stress and burden; and professionally led support groups enhance caregiver QOL.

CONCLUSION. Strong evidence exists for a spectrum of caregiver interventions. Translation of effective interventions into practice and evaluation of sustainability is necessary.