Haley Johnson and Kee Jeong Kim*
Department of Human Development and Family Science, College of Liberal Arts and Human Sciences, Virginia Tech,United States.
Corresponding Author Details: Kee Jeong Kim, Associate Professor, Department of Human Development and Family Science, College of Liberal Arts and Human Sciences, Virginia Tech, Blacksburg, VA 24061, United States.
Received date: 23th November, 2023
Accepted date: 09th January, 2024
Published date: 11th January, 2024
Citation: Johnson, H., and Kim, K. J., (2024). A Systematic Review of Occupational Therapy Care Programs for Dementia Patients: Accomplishments and Suggestions for Improvement. J Soci Work Welf Policy, 2(1): 105.
Copyright: ©2024, This is an open-access article distributed under the terms of the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
The primary goal of the present study was to critically review previous research on an increasingly important role that occupational therapy (OT) plays in dementia care. OT interventions such as cognitive training, memory strategies, and engagement in meaningful activities have been shown to improve cognitive function in individuals with dementia. The present study found that (1) strength based, (2) patient-centered, and (3) caregiver-collaborative OT interventions were significantly more effective in helping dementia patients maintain and/or improve their cognitive abilities (e.g., attention, memory, problem-solving, and decision-making skills) as well as their functional ability to perform instrumental activities of daily living including bathing, dressing, grooming, meal preparation, and managing finances. On the contrary, there is a growing need for providing occupational therapists with tailored training and education programs designed specifically for their intervention services for clients with dementia. Evidence-based interventions also need to be applied to address the specific needs of individuals with dementia. Given an exponentially growing number of dementia patients each year worldwide, it is imperative to have affordable and effective OT intervention services. The current study suggests a holistic OT intervention approach based on the biopsychosocial theoretical framework as the future of OT in dementia care.
Key Words: Occupational Therapy, Strength-based, Patient-centered, Caregiver Collaborative, Evidence-based Interventions
Occupational therapy is a highly impactful profession dedicated to enhancing the well being of individuals facing diverse challenges, ranging from congenital disabilities and neurological disorders to accidents and injuries. Regardless of the specific impediment, the overarching goal is to empower people to lead independent lives [1]. Occupational therapy offers strategies that enhance function and retain existing strengths [2]. With the global population on the rise and life expectancy increasing, the demand for care for the elderly is growing significantly. Notably, dementia is a rapidly expanding concern, affecting a substantial portion of the senior population.
Current statistics suggest that more than 7 million individuals aged 65 or older in the United States are living with dementia, and the global annual diagnosis count surpasses 10 million cases [3]. Alarmingly, projections indicate that by 2060, Alzheimer’s disease, the most prevalent form of dementia, is expected to afflict approximately 14 million people [4].
In an era marked by the growth of an aging population and the accompanying increase in the prevalence of dementia, the role of occupational therapy in dementia care has never been more significant [5,6]. This paper is crafted with the intent to embark on a comprehensive critical review of existing research, shedding light on the accomplishments of occupational therapy in the realm of dementia care, while also pinpointing avenues for improvement. We critically reviewed the successful interventions and strategies employed by occupational therapists that yielded positive outcomes for dementia patients. Moreover, we assessed the impact of these interventions on the over well-being and quality of life of individuals living with dementia. This paper also proposes strategies for improvement, envisioning a future in which occupational therapy can offer even more comprehensive and effective support for dementia patients. By critically analyzing previous research and identifying areas where further improvement is needed, we aim to contribute to the ongoing refinement of dementia care practices, ultimately enhancing and improving the quality of life for both patients and their families.
For the present study on occupational therapy care programs and dementia patients, we conducted a thorough literature review by performing a systematic search across various databases to gather relevant scholarly articles and studies. The primary databases we used for the literature review included PubMed, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO. We chose these databases because they comprehensively cover healthcare, allied health, psychology, and interdisciplinary studies related to occupational therapy and dementia.
To ensure a comprehensive and exhaustive search strategy, we employed several key search terms and keywords. These keywords included occupational therapy and dementia patients, occupational therapy effectiveness, occupational therapy interventions, and occupational therapy rehabilitation, among others. We aimed to retrieve peer-refereed articles published within the past two decades up to the cutoff date of the literature review, encompassing both quantitative and qualitative research articles, systematic reviews, meta analyses, clinical trials, observational studies, and qualitative inquiries related to occupational therapy.
Following the initial search, we carefully screened the retrieved articles. This screening involved examining titles, abstracts, and full texts, where necessary, to ascertain their relevance to the research objectives and inclusion criteria. Studies that met the inclusion criteria were then subjected to data extraction and analysis. Approximately twenty articles were extracted during this comprehensive literature review process, forming the foundation for the synthesis, analysis, and discussion of the findings to be presented in the next several sections.
Occupational therapy interventions have achieved remarkable accomplishments in the realm of dementia care. This section focuses on three pivotal areas of major achievement that have brought a revolution in the care of dementia patients: the strengths-based approach, patient centered care, and the involvement of caregivers. Together, these accomplishments represent a significant shift in how dementia care is perceived, provided, and experienced.
Occupational therapy has proven to be helpful in working with dementia patients, and one theoretical approach commonly used is the biopsychosocial approach [7]. This framework considers the biological, psychological, and social processes that shape one's life. Occupational therapists who work with dementia patients can use this theoretical framework to provide care that addresses the biological, psychological, and social aspects of the patient's life, with the ultimate goal of improving their quality of life. The biopsychosocial approach also provides a holistic model for guiding current research and identifying new areas for future research.
Stemming from the biopsychosocial approach, a strength-based framework emphasizes an individual's capabilities and strengths instead of their deficits. This framework can be effective in enabling patients to live a satisfying life on their own terms [8]. Occupational therapists can use this approach to increase patients' physical abilities, psychological confidence, and social opportunities. Although this approach is already a core belief within the field, professionals can sometimes become overly focused on curing deficits rather than emphasizing strengths. To shift this perspective, it is necessary to use strength-based language and consider how traits that are often labeled as ‘bad’ can actually be beneficial and provide an opportunity for growth. While it may be challenging to use this approach when working with patients who have severe dementia, a positive environment created by strength based approaches can still benefit both the patient and caregiver.
A study conducted by McCormick [9] aimed to improve the care of dementia patients. To accomplish this goal, the researcher recruited four women with memory loss to review a handbook for occupational therapists and other healthcare providers working with memory-impaired patients. The focus of the study was on adopting a strengths-based perspective in care, which shifts “the emphasis from a clinical focus to assessing and promoting strengths the person retains and can use to promote his or her own health,” [9]. By doing this, occupational therapists can help patients regain a sense of control over their actions, choices, and consequences [10], which can often fade after a dementia diagnosis. Another study sought to create a guideline book for occupational therapists and found similar results while looking at different types of treatment [5]. Although they did not include memory-impaired patients in the process, they formed a multidisciplinary guideline adaptation committee responsible for refining the scope of present guidelines. Their revisions emphasized the need for OTs to spend the majority of their time focusing on interventions that have proven to be effective. Focusing on the patient’s strengths fosters a sense of independence which can lead to a determined patient, improving the psychological and biological sides and continued physical growth. Shifting the mindset from rebuilding what is already gone to promoting improvement on what one still has can be challenging for providers, but it may be a way to improve dementia care within occupational therapy.
One effective approach for promoting strengths in patients is through health coaching. Health coaching aims to foster growth in every aspect of a patient’s life and aligns closely with the biopsychosocial model. In a recent article review, the researchers explored the potential benefits of implementing a holistic approach to occupational therapy using health coaching, which aims to help patients overcome challenges and achieve their goals [11]. The review examined 67 articles that discussed the use of health coaching in occupational therapy and sought to determine whether this approach has universally positive effects when working with clients who are suffering with various issues. They found that health coaching contributes to improving lifestyle behaviors, medication adherence, health status, goal attainment, and self esteem. While there was an overall theme of positive outcomes, they cautioned that this is a new concept that requires customization to each patient and setting. Although there are no specific articles connecting health coaching with dementia patients, based on their positive findings, it is possible that coaching could be beneficial when working on memory strategies and information recall. This strength-based approach could strengthen the bond between the occupational therapist and the patient to accomplish their goals.
A paper written by Miller [12] discusses how occupational therapy can facilitate growth for dementia patients. In this study, a ten-week program for dementia patients and their caregivers called “COPE,” was created. The goal of COPE was to highlight the person with dementia’s strengths and increase the caregiver's awareness of their remaining capabilities. Occupational therapists facilitated group sessions for ten weeks, where they did collaborative problem-solving and demonstrated various strategies to implement as they continue to grow their strengths and complete ADLs. By the end of the sessions, both caregivers and people with dementia wished the program could continue as they experienced a positive change in their everyday lives. This study reinforces the idea that maximizing abilities can help people with dementia gain a sense of control and capability in their life. It also encourages a strengths-based approach, which can shift how we see the normal role of occupational therapy. Instead of working mostly one on one, there seems to be a positive impact when OTs demonstrate strategies and highlight the client's capabilities in a group setting. This shift in approach could prove to be powerful as we look to the future of occupational care for the memory impaired.
Patient-centered care is a healthcare approach that values the unique differences of each patient and involves them in decision-making, listening, and advocacy [13]. Research has shown that implementing patient-centered care not only improves the patient’s experiences and overall quality of life but also fosters growth and improves the patient-provider relationship, resulting in increased trust and better quality of care [14]. This approach could prove beneficial for occupational therapists working with dementia patients.
Additional studies have shown that patients are more likely to enjoy, interact, and see improvements in occupational therapy when they have a say in how they desire to grow. A strength-based and patient-centered approach has been found to be important for memory care. One study presented a ten-week program called COPE [12]. This program was special because it encouraged collaborative problem-solving between the therapists, patients, and caregivers. This program included every patient in every part of the treatment, encouraging them to recall the strategies they used, why they used them, and how they were helpful. The therapists asked questions at each group meeting to specifically hear from every patient. For instance, “What did you learn last week that you were able to use at home?” This allowed each patient to be honest about their growth and gave them a sense of autonomy.
The UCLA Alzheimer’s and Dementia Care Program has recently published an article outlining their strategy to establish a patient centered care system [15]. Based on the data collected from 2,619 participants, their care strategies have shown positive results in terms of an improvement in behavioral symptoms of patients, a reduction in depressive symptoms, and a decrease in the overall strain experienced by caregivers. This was accomplished by setting patient-centered goals, which involved an intensive assessment of the patient’s needs and preferences before creating a personalized plan of care. Throughout the treatment, patients and caregivers were encouraged to participate in achieving their goals, and the plans could be revised or adjusted as necessary. This approach gave patients more autonomy and control over their emotional and physical health and could be beneficial for occupational therapists working with memory impaired patients. Based on the program’s results, these goals seem to produce positive outcomes within the biological, psychological, and social aspects of the patient’s life and prove to strengthen the importance of implementing patient-centered care.
Another study conducted in Ireland also adopted a patient-centered approach by creating individualized plans for each dementia patient [16]. The study included 58 community-dwelling adults with dementia and aimed to examine the impact of a group rehabilitation program on everyday memory function and quality of life. The occupational therapists in this study set realistic and meaningful goals alongside their dementia patients. Each participant was enrolled in the SMART program which lasted for 5 weeks and included 90 minute sessions, six participants per group, and new personalized goals each week. At the end of the 5 weeks, the patient-centered approach resulted in a slight increase in memory scores but a significant improvement in self-reported quality of life. Setting new and individualized goals every week increased self-confidence and sense of independence, improving their quality of life and reducing pressure on caregivers. Occupational therapists who encourage their patients to set meaningful goals can help them adjust to their diagnosis of dementia.
The study by McCormick [9] that we discussed above took patient centered to the next level. They included four women suffering from memory loss to help them create a handbook for occupational therapists and other healthcare providers when facilitating care [9]. The study had three specific goals: to develop a user-friendly patient and family handbook that was relevant to patients and their family's experience, to involve people with memory loss in the development of care that affects them, and to demonstrate and promote the message that people with memory loss have many strengths to draw on and contribute. These goals reflect a desire to include and involve those who are seeking treatment. The study received feedback from people with memory loss and incorporated it into the handbook. The feedback consisted of adding more step-by-step examples and using simplified language and terminology easier to accomplish at home. After more suggestions and revisions, this handbook could prove to be valuable for occupational therapists. Not only could this be given to their patients, but it could allow OTs to better understand how people with impaired memory want to improve and grow. By creating a plan based on how dementia patients want to grow and gain independence, OTs can implement more patient-centered sessions that foster a higher quality of life.
When a family member, spouse, or dependent is diagnosed with dementia, the caregiver takes on an intense and consuming role. Dementia affects not only the patient but also the caregiver, who is often referred to as the “invisible second patient,” [17]. Caregivers are critical in assisting a person with dementia at any level, but their responsibilities can lead to social isolation, high rates of burden, and psychological morbidity. Moreover, being a caregiver is associated with an increased risk of cardiovascular problems, lower immunity, slower wound healing, and other physical health concerns. Broadaty [17] highlights the importance of caregivers and explains how a positive outlook, collaborative interventions, and a strong support system can increase the caregiver's quality of life. The article also mentions that involving both the dementia patient and caregiver in a structured treatment program is a strong predictor of successful strategies. Occupational therapy could benefit from this insight by creating strategies and interventions that allow both caregiver and person with dementia to see growth, which could alleviate caregiver burnout, increasing the quality of life for both parties.
A study by Neely [18] illustrates the importance of collaboration between caregivers and dementia patients when seeking treatment. The study created tasks specifically designed to challenge dementia patients and compared the performance of two groups: a person with dementia and their primary caregiver, and only the person with dementia. The study found that active participation from a caregiver allowed patients to perform better, particularly in their episodic memory performance. The tasks were split equally and showed an increase in recall for the person with dementia and a decrease in recall for the caregiver. Working collaboratively improves the dementia patient’s abilities while taking pressure off of the caregiver.
According to a study conducted in Australia, the interaction between caregivers and care receivers plays an important role in enhancing their quality of life. The study audited 87 case notes from occupational therapists, which highlighted the burden and workload that caregivers face when a family member, spouse, or other dependent is diagnosed with dementia [6]. This study found that limited consultations included the caregiver in the process of education, problem-solving, and skills-building interventions, which hindered the potential improvement in both the caregiver and dementia patient’s quality of life. Occupational therapists can reduce functional dependence and enhance caregiver well-being by including the caregiver in strategies of care for the dementia patient.
Another study, as discussed earlier, created a program called COPE, which was an occupational therapy group for dementia patients and their caregivers [12]. This program’s goal was to address the needs of both caregivers and persons with dementia. Taking a strengths based and patient-centered approach, the occupational therapists encouraged the caregivers to see the strengths remaining in their care recipient. By shifting their mindset from one of complete care to allowing the care recipient to partake in meaningful activities and independence, the caregivers were able to acknowledge the abilities within the care recipient and experience relief from their responsibilities. Empowering the caregiver as an associate in the problem-solving process increased partnership and led to positive outcomes for both the caregiver and the dementia patient.
Although there have been significant accomplishments in dementia care through occupational therapy, the journey towards excellence in this field remains ongoing. In this section, we will discuss two critical areas that require improvement: theory-driven research and specialized training for occupational therapists who work with dementia patients. By focusing on these areas, we can build upon existing strengths and further improve the quality of care provided to individuals living with dementia. Through theory-driven research and specialized training, we aim to deepen our understanding of the complexities of dementia care and equip occupational therapists with the expertise required to address the evolving needs of their patients with the utmost competence and compassion.
Our thorough analysis of the existing literature on occupational therapy and dementia has revealed an important observation. The majority of these studies lack a specific theoretical framework. This is in contrast to the common practice in the behavioral and social sciences, where researchers usually use theoretical frameworks to give structure and direction to their research. Using theoretical frameworks in research is crucial as it provides a structured approach to inquiry and enables new findings to be linked with prior knowledge. This creates a cohesive body of evidence that enhances the reliability of study outcomes. The amalgamation of findings from various studies helps refine our understanding and allows for significant progress within specific domains of knowledge.
Upon examining the articles, we found a significant gap in the utilization and acknowledgment of specific theoretical frameworks in dementia care. This led us to explore potential connections between our research findings and the major accomplishments highlighted earlier. The biopsychosocial approach, a comprehensive theoretical framework, surfaced as a suitable guide for our investigation. This approach recognizes the complex interplay of biological, psychological, and social factors in health and illness and has been useful in drawing connections between positive and negative findings in dementia care. For example, if a patient is attending occupational therapy due to a hand injury, the occupational therapist would not only take care of the physical need but address the psychological and social aspects. As the patient regains use and mobility, their confidence would increase, thus addressing the psychological aspect, and they would also begin to participate in social activities they love, like fishing or tennis. When applied to dementia care, it is a helpful tool when assessing necessary treatment and current difficulties. It gives OTs a stronger sense of the patient's new feelings, physical decline, and emotional reaction to the disease.
We believe that incorporating more theoretical approaches as the field of occupational therapy and dementia research advances can offer numerous benefits. The use of theoretical frameworks can provide a structured foundation for research endeavors and help consolidate knowledge. This can promote an integrated understanding of the multifaceted aspects of dementia care. By adopting theoretical frameworks, researchers can contribute to a deeper and interconnected body of knowledge, eventually leading to evidence-based and effective interventions that can significantly impact the lives of dementia patients and their caregivers.
The study discussed in Rahja's 2018 research examined the current practices of occupational therapists when working with dementia patients. The study audited 87 case notes to investigate the strengths and weaknesses in dementia care provided by occupational therapists. While the research highlights the positive contributions of occupational therapists in this field, it also underscores areas that need improvement. Notably, the audited case notes showed that occupational therapists are uncertain about the most effective strategies and protocols for dementia care.
One key takeaway from this study is the need for growth and development in how occupational therapists treat dementia patients. Occupational therapists genuinely desire to help their patients but often encounter limitations in the range of treatment options and their abilities to provide comprehensive care. The study also highlights the time constraints that occupational therapists face when working with dementia patients. The pressure to focus on short-term safety assessments can impede a holistic approach to memory care. Conversely, when occupational therapists have the opportunity to dedicate more time to long-term care and improvement, they have observed a higher quality of life for patients and a deceleration in the progression of dementia. Shifting from the conventional short-term mindset to long-term goals represents a valuable change, although it would necessitate additional training and time commitments for the therapists.
Healthcare professionals, including occupational therapists, encounter various challenges when treating dementia patients. Van't Leven [19] assessed the potential effectiveness of an evidence based occupational therapy guideline course tailored to occupational therapists working with dementia patients. Data was gathered from focus groups comprising 17 occupational therapists, 10 physicians, and 4 managers to evaluate their confidence in providing care to older adults with dementia. The findings revealed that a significant portion of occupational therapists did not feel adequately prepared to care for individuals with dementia. In response, a guideline course known as COTiD (Community Occupational Therapy in Dementia) was introduced, consisting of a 5-week program with ten one-hour sessions, available from 1999 to 2007, albeit with limited participation due to its extensive nature. While the guidelines within this course may not be a one-size-fits-all solution, the idea of implementing a comprehensive course like COTiD represents a promising step towards improving dementia care by occupational therapists.
Occupational therapy is a diverse field with numerous specialization opportunities, each requiring specific certifications. One such specialization is gerontology, achieved through board certification by the AOTA. This specialization equips therapists with the skills to care for older adults in various domains, including post-stroke recovery, fall prevention, mobility issues, and cognitive changes [20]. To advance occupational therapy's role in dementia care, integrating a dementia care training module within the gerontology certification program seems a feasible and beneficial step. This minor adjustment can significantly enhance the confidence of therapists aspiring to work with dementia patients.
Surveying 47 occupational therapists primarily working in primary care settings, McGrath [21] also reported a prevalent sense of unpreparedness and a lack of education among occupational therapists regarding the appropriate treatment of dementia patients. These professionals expressed the absence of globally recognized strategies to guide them in approaching memory care effectively. While many occupational therapists acknowledged their lack of specialized training, they expressed a keen interest in further education to enhance their practice. Although certifications or qualifications specialized for occupational therapists working with dementia patients are limited, it is evident that their care can be profoundly beneficial.
This study underscored that the combination of occupational therapy and nursing has demonstrated lower levels of patient dependence in performing activities of daily living and increased engagement. With additional training, the strategies and treatment plans employed by occupational therapists can undoubtedly improve. Therefore, promoting specialization for occupational therapists aiming to work with dementia patients could lead to heightened confidence, enhanced abilities, and ultimately more effective treatment.
Occupational therapy has emerged as an effective and practical approach for treating individuals with dementia. To measure progress made in this field, it is essential to consider the biopsychosocial framework [7]. From a biological perspective, occupational therapists have recorded significant improvements in dementia patients' short term memory, episodic memory, and overall recall abilities. Their strategies for facilitating biological restructuring and cognitive growth have demonstrated remarkable benefits.
Psychologically, occupational therapists have consistently enhanced the quality of life for dementia patients, instilling confidence, and a sense of enjoyment. The approaches discussed revolve around creating an environment that accentuates patients' strengths and fosters a positive mindset. This strength-based and patient-centered approach has proven to be a catalyst for providing superior psychological care. Patients with dementia have experienced a range of psychological benefits through this approach. On a social level, occupational therapists have made considerable strides in improving the personal experience of dementia patients by actively involving caregivers. This approach offers dementia patients increased support and helps caregivers maintain a fulfilling social life, both with and without the care recipient present. Addressing these specific aspects of the patient's life represents a significant achievement in the field of occupational therapy.
More specifically, strength-based, and patient-centered programs have been recognized as effective strategies for treating dementia patients [9]. The research emphasized the importance of understanding the patient, leveraging their strengths, setting realistic goals, and supporting independence. These strategies have been consistently reliable and integral to patient care. Implementing these approaches that focus on maintaining and empowering patients' strengths is essential for occupational therapists. Successful occupational therapy should aim to sustain the patient's functioning for as long as possible and create personalized plans for their growth.
Implementing these strategies should not only yield positive results for dementia patients but also reduce caregiver burnout and alleviate their burden. Involving caregivers in the journey of dementia patients' recovery empowers them to recognize the patients' existing strengths and provides practical guidance for fostering improvement within the home. This collaborative approach encourages caregivers to trust their care recipients and support their independence, ultimately enhancing the overall care experience.
Looking to the future, a crucial recommendation is the development of specialized training and education for occupational therapists in dementia care. Many therapists have expressed a sense of inadequacy in terms of memory strategies. They recognize the tremendous potential of occupational therapy in delivering remarkable outcomes for dementia patients but are eager to see growth in this area. As the demand for dementia care continues to rise with the aging population, providing occupational therapists with more comprehensive education and training will result in more effective treatment strategies. Ultimately, this will solidify occupational therapy as a recognized and respected path for the treatment of dementia.
The author(s) declare there are no conflicts of interest.
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