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Occupational Therapy Intervention is a Family Affair

By Janie L. Rosman, Staff Writer

 

Illness progression that includes loss of independence, initiative and participation in social and daily activities affects quality of life for those living with it, their loved ones, and their caregivers.

Whereas previous traditional therapy set goals to address, cure or minimize impairment, the primary rehabilitation focus is non-medical — modifying behaviors and/or the physical and social environment to help the person living with Alzheimer’s disease function and continue his or her participation in daily activities.

“Occupational therapy’s role with caregivers involves teaching them to understand the behaviors and the disease itself, and training them to help the person living with Alzheimer’s disease with daily activities,” says Coralie "Corky" Glantz, OT/L, BCG, FAOTA, of Glantz / Richman Rehabilitation Associates.

A caregiver directory developed by the Alzheimer’s Association defines an occupational therapist as someone who “helps residents change their activities or environment so they can eat, dress and bathe; may also help with other tasks  such as cooking, taking medication or driving; and may guide family members and caregivers.”

Researchers in The Netherlands concluded that 10 occupational therapy sessions improved daily functioning in patients 65 and under for up to three months, despite their limited learning ability, and also reduced caregiver burden, as reported in British Medical Journal. Patients learned to use aids to compensate for cognitive decline, and caregivers learned coping behaviors and supervision.

Occupational therapists can formulate a program attuned to the person’s skill set and level of understanding — sharing life story memories, adapting a home environment for exercise or movement — while advising the family and caregiver about making the home safer to avoid falls, purchasing or leasing equipment, and accessing other health care services that might be available.

Staff and family training are most times accompanied by a maintenance program for caregivers, taking the aforementioned into account. “Everything the OT does is taught to the caregiver,” Glantz says.

The American Occupational Therapy Association, Inc. suggests determining the person’s needs at various stages of illness progression, and focusing on his or her abilities (rather than deficits) to maximize engagement and setting, be it home or facility.

OT utilizes and analyzes abilities and strengths, in addition to social and perceptual abilities, then analyzes the task at hand, and seeing if they match — “Can the person living with Alzheimer’s disease do what you’re asking him or her to do?”

A complete evaluation should include an occupational profile of the person’s routines, hobbies and level of abilities. The caregiver’s input is crucial for providing information that the person living with Alzheimer’s disease is unable to supply or unaware of his or her ability level. “(It helps the caregiver to) know what current abilities are, and if you know they can’t do something, don’t ask,” says Glantz, an AOTA board member.

Compensating for lost cognitive skills — comprehension and action, attention, memory, logic and reasoning, auditory, visual and speed processing — while recognizing remaining abilities are goals for someone in the early stages of AD, since new learning might be impaired or absent as the condition progresses.

“The goal is to retain skills that were lost, continue those skills the person has, use compensatory skills, and to find a way to make them acceptable to the person and the caregiver,” Glantz says. OT instruction can help caregivers recognize abilities, and thus know if a task is too difficult.

“Analyze a task by looking at what memory a person needs to do the next step,” Glantz says. “He or she may need to be reminded what to do with the food since some people forget how to chew or use utensils.” Caregivers can learn how to segment tasks into smaller, manageable skills.

Appropriate cues are also helpful, like the caregiver putting undergarments on the outside of the hanger so the person will put those on first. Sometimes help is needed with choosing clothes; if a closet or drawer of garments is too overwhelming, the caregiver can select a few items to make the choice easier. 

If the person living with Alzheimer’s disease is distracted easily, then the environment shouldn’t be cluttered by objects or noise (an example would be two radios playing different music at the same time). If you don’t want him or her to walk out the door, hang the coat in a closet, not near the door. 

Working with the caregiver involves teaching him or her how to properly communicate. If the person living with Alzheimer’s disease understands visual cues more than verbal cues, incorporate these into activities. When during the day is the person most alert? If a pre-illness routine was working at night while sleeping during the day, keeping to a similar schedule may be more beneficial than reversing a once-familiar schedule.

Also consider physical limitations like hearing loss or visual impairment, as well as behavior (becoming difficult when given instructions). One challenge is for a caregiver is to understand a behavior, and then to understand its antecedent,” Glantz says. “What came first, and what is the cause?”

Identify habits and familiar routines that the person living with Alzheimer’s disease can maintain to prolong independence, in addition to helping the person get used to a new living situation (health care facility or relative’s home). Combing hair or brushing teeth can promote independence, as can engaging the person in favorite hobbies — like a jigsaw puzzle, for example.

Intervention later stages of AD includes adapting to the environment and helping caregivers promote routines, and learning how to minimize unwanted behaviors like agitation and aggression during caregiving, or complicating their condition with weight loss or falls. Addressing safety issues is of the utmost importance, especially if the person living with Alzheimer’s disease is unsteady. 

Laura N. Gitlin, PhD, Director of the Jefferson Center for Applied Research on Aging and Health (CARAH) at Thomas Jefferson University in Philadelphia, concluded similar results from a four-month Care of Persons with Dementia in their Environment (COPE) intervention. 

A four-month COPE intervention showed improvement in functional activities like using the telephone, shopping, preparing meals, and doing housework, and self-care activities like bathing, dressing and grooming. Caregivers who also had COPE treatment said they had improved well-being and confidence...

The amount of therapy covered is up to each insurance company, according to the Medicare Rights Center. While it limits the amount of allowable covered outpatient therapy, Medicare will pay for medically-necessary therapy above the cap, particularly for complex cases, and includes various settings — home, health care professional’s office, skilled nursing facility — where therapy would be administered.

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