Tips from: Physical Therapist | Occupational Therapist | Social Worker

Authored by:
Elicia Dunn Cruz, PhD, OTR
Assistant Professor Department of Occupational Therapy, The University of Texas Medical Branch, Galveston , Texas

Dr. Cruz’ research and professional practice has focused on studying and improving the health and quality of life of elders and their family caregivers. She has conducted research about how elders and family caregivers adapt in the face of age-related life changes.

Occupational therapists use a variety of approaches during intervention with clients who have dementia. The goals of therapy include maintaining, restoring, and improving occupational performance; promoting health and quality of life; and easing caregivers’ burden (American Occupational Therapy Association, 1994). In the early stages of dementia clients may be able to learn or re-learn self-care or other forms of occupational performance, particularly if they benefit from medications that aim to slow the progression of dementia. Most clients, however, will not be able to learn or re-learn skills. The clients’ cognitive deficits necessitate compensatory strategies that promote their performance in daily life tasks despite cognitive impairments.

Compensatory strategies for cognitive impairment improve or maintain occupational performance within remaining capabilities by changing the way the task is performed or the environment in which it is performed. Occupational therapy intervention needs to focus on the people who will actually implement various compensatory strategies, including clients and their caregivers, be they formal (paid) or informal (unpaid, such as family). Compensatory strategies should result in improved daily life satisfaction for both the client and the caregiver. Often, it is assumed that therapists must aim to facilitate independent performance among clients with dementia. It is important to recognize, however, the value of shared occupational performance (or interdependence), in which a caregiver assists with task performance in a way that meets the needs of and promotes satisfaction among both the client and the caregiver. For example, a client may be able to dress themselves in the morning with a good deal of verbal cues and physical prompts. However, the time and energy that it takes to facilitate this “independent” dressing may result in the client and caregiver avoiding other necessary or desired tasks, such as sitting down to a good breakfast. Thus it might benefit this client and caregiver to share the chore of dressing so that they have time and energy for other desired activities. Therapists should discuss clients’ and caregivers’ wishes in order to negotiate an ideal plan for independent and shared occupational engagement. This plan should address current and anticipate future needs.

Occupational therapists have employed a variety of ways to compensate for memory or learning deficits and to promote satisfying occupational performance. Beatrice Abreu’s “quadraphonic approach” is a theoretical model that nicely synthesizes a variety of intervention approaches. It can be applied in efforts to teach independent performance or to teach clients and caregivers strategies for shared occupational performance. Her model incorporates practice, feedback about performance, and environmental modifications that are based on the clients’ and caregivers’ needs. Practice involves repetitious performance of desired behaviors, followed by feedback about the client’s performance. Most clients with dementia will not benefit from practice or feedback, due to their cognitive deficits. However, OTs can use these specific approaches when training caregivers to assist with or promote the client’s occupational performance. In this case the therapist has the caregiver practice new skills, such as assisting with dressing or bathing, then the therapist and caregiver discuss what worked and did not work during the activity. The therapist also provides helpful feedback about the caregivers’ actions and how they related to performance outcomes.

The use of environmental modifications is critical to task success and to satisfaction with performance. Modification can be made in the client’s approach to the task, in the therapist’s or caregiver’s approach, and in how the occupation, task, or exercise is set up or performed (Abreu, 2000). The following table lists specific modifications that may be made to the context in order to promote occupational performance.

adapted from: Abreu, B. C. (1990). The quadraphonic approach: Evaluation and treatment of the brain injured patient. New York: Therapeutic Service Systems.

Suggested Resources:

• Abreu, B. C. (2000). Self-care management for persons with cognitive deficits after Alzheimer’s disease and traumatic brain injury. Ways of Living: Self-Care Strategies for Special Needs, 2 nd Edition. Maryland: American Occupational Therapy Association.
• American Occupational Therapy Association (1994). Statement: Occupational therapy services for persons with Alzheimer’s disease and other dementias. American Journal of Occupational Therapy, 48, 1029-1031.
• Birnesser LR. (1999). Treating dementia: Practical strategies for long-term-care residents. OT Practice. 2(6):16-21.
• Corcoran MA. Gitlin LN. ( 2001). Family caregiver acceptance and use of environmental strategies provided in an occupational therapy intervention. Physical & Occupational Therapy in Geriatrics. 19(1) :1-20,.
• Dowling J R (1995). Keeping busy: A handbook of activities for persons with dementia. Baltimore: Johns Hopkins University Press.
• Gitlin LN. , Corcoran M., Winter L., Boyce A., & Hauck W.W., (2001). A randomized, controlled trial of a home environmental intervention: Effect on efficacy and upset in caregivers and on daily function of persons with dementia. Gerontologist. 41(1) :4-14.
• Griffin P. M. (1990). Protocols for adapting activities to the changing needs of people with dementia. Baltimore , MD : CHESS Publications.
• Perrin T. (1998). The role and value of occupation in severe dementia. An exploration of the role of occupational therapy in the care of persons with severe dementia, and an investigation into the impact upon the well-being of such persons of a range of occupations commonly used in dementia care. British Journal of Occupational Therapy. 61(11) : 516.
• Perrin, T.,  Hazel M. (2000). Wellbeing in dementia : A n occupational approach for therapists and carers . Edinburgh ; New York : Churchill Livingstone.
• Tip Sheet for Persons Dealing with Alzheimer’s Disease by the American Occupational Therapy Association. Can be found at: http://www.aota.org/featured/area6/links/link02a.asp
• Warchol K. (2000). The challenge of dementia care: focusing on remaining abilities, not deficits, creates a positive foundation for treatment. OT Practice. 5(22): 15-9.

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