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Evidence-Based Practice

A comprehensive review of pertinent literature was performed to determine what

evidence could be found given the occupational needs of the target population. Twelve articles

were reviewed and were found to present the best evidence of efficacy for older adults with

dementia in a day services setting. Three major areas for intervention and programming

determined were: inclusion of caregiver education, use of sensory strategies, and inclusion of

wellness programming to increase quality of life. Use of these methods appears to be efficacious

for the population in question and this review will present findings relevant to the creation of a

specific occupation-based program for Neighborhood House.

Caregiver Education

Neighborhood House not only provides day services for adults with physical and

cognitive impairments, but also provides much needed respite to caregivers. Research suggests

that implementing caregiver education into programming for individuals with dementia in order

to address the needs and abilities of the caregiver while also providing hands-on training, is vital

to increasing caregiver perceptions of self-efficacy. Caregivers who are confident in their ability

to care for their loved one with dementia or other impairment are then able to provide more

effective supervision and care.

In a randomized control trial performed by Graff et al. (2006), 114 patients with mild to

moderate dementia as determined by the Brief Cognitive Rating Scale (BCRS) were randomly

assigned to either the intervention or the control group. Individuals and caregivers in the

intervention group received 10 sessions of occupational therapy services administered by trained

occupational therapists. During these services primary care givers were trained to use effective

supervision, problem solving, and coping strategies to sustain the patients and their own

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autonomy and social participation (Graff et al., 2006). Participants and caregivers in the control

group did not receive OT services until after the end of the study. Patients in both groups were

assessed at baseline, after six weeks, and at 12 weeks with the process scale of the Assessment of

Motor and Process Skills (AMPS) and the performance scale of the Interview of Deterioration in

Daily Activities in Dementia (IDDD); caregivers were assessed with the Sense of Competence

Questionnaire (SCQ). Results indicated that caregivers who received OT services felt

significantly more competent than those caregivers in the control group. Researchers saw a

maintained benefit in the intervention group from six weeks to the 12-week follow up and stated

We believe that the benefit was sustained because a component of the intervention was to train

caregivers in providing supervision patients needed to sustain their performance in daily

activities (Graff et al., 2006).

Another randomized control trial performed by DiZazzo-Miller, Winston, Winkler, &

Donovan (2017) used a sample of 36 caregivers of family members with dementia in order to

determine the effectiveness of a Family Caregiver Training Program (FCTP) to improve

caregiver knowledge and competence and improve caregiver attributes such as burden and

depression. Caregiver participants were randomly assigned to either the experimental or control

groups. The experimental group received a two-hour presentation which including three ADL

modules each followed by hands-on demonstration and practice and a handout to take home. The

control group received 90 minutes of standard care which included general information about

dementia and information concerning helpful resources accessible online. Caregivers were

assessed pre-test, post-test, and three months posttest using the Bristol Activities of Daily Living

Scale (BADLS), the ADL Knowledge Test, The Caregiver Confidence Scale, The Zarit Burden

Interview, The Beck Depression Inventory-II, The World Health Organization Quality of Life

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Brief (WHOQOL-BREF), and the performance and satisfaction scales of the Canadian

Occupational Performance Measure (COPM). Researchers found that an OT based information

session including specific ADL training resulted in significant improvement in knowledge and

maintenance of knowledge 3 mos. posttest (DiZazzo-Miller et al., 2017). Members of both

groups demonstrated an increase in confidence immediately post-test, which indicates that any

information provided is helpful to those caring for loved ones with dementia. Results indicated

that caregiver burden and depression scores for members of both groups were maintained

throughout the three-month follow-up period. This could be due to near normal scores for burden

and depression pre-test, which make it unlikely to see positive change. This study shows that

implementing a hands-on ADL intervention for caregivers would be helpful for increasing their

knowledge and use of any information increases measures of caregiver confidence.

In a systematic review performed by Piersol et al. (2017), researchers sought to determine

the most effective occupational therapy interventions for caregivers of people with Alzheimers

disease and other neurocognitive disorders. Forty-three articles met inclusion criteria for the

systematic review and were categorized by level of evidence. Common themes across the

reviewed literature included: case management interventions, group interventions, cognitive-

behavioral interventions, single-component interventions, and multicomponent

psychoeducational interventions. Case management was found to have limited evidence for

directly improving caregiver burden and well-being. Results indicated that group interventions

led by professionals improved caregiver well being and reduced burden, stress, and depression.

Group interventions also increased caregiver preparation and confidence in managing memory

loss (Piersol et al., 2017). Cognitive behavioral interventions were found to reduce caregiver

depression, anxiety, and stress. Single-component interventions based in the formation of

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communication skills were found to have the strongest evidence for assisting caregivers in

engaging with their loved one. Multicomponent psychoeducational interventions which include

dementia education, skills training, and coping strategies were found to be an effective

intervention strategy to improve caregiver quality of life, well-being, and self-efficacy. Results

of this systematic review indicate that there are many effective intervention methods for

caregivers of individuals with dementia in order to improve burden, depression, and well-being.

Sensorimotor interventions

Sensory-based interventions have long been used in occupational therapy interventions in

order to decrease behavioral challenges in individuals with sensory processing disorders and alter

the environment to improve an individuals sensory modulation. Research articles concerning

sensory-based and sensorimotor interventions for use with individuals with mild to moderate

dementia were reviewed in order to determine whether programming of this nature would be

optimal for the population at Neighborhood House.

In a study by Van Vracem, Spruytte, Declercq, & Van Audenhove (2015) researchers

sought to gain a greater understanding of caregiver knowledge and use of sensory strategies for

reducing agitation in individuals with dementia. Researchers questioned professional and family

caregivers concerning seven types of environmental interventions, which included: impact of

light, smell, noise, temperature, nature, color and spatial configuration on agitation. Reponses

indicated that caregivers understood the impacts of environmental modifications on behaviors

and took steps to improve the environment when problems arose. Some adaptations reported

through interview were: recognizing the need for natural light, maintaining familiar and trusted

smells, preference for a warm environment especially when bathing, adding nature and natural

materials, and using neutral spatial configuration to promote familiarity. Researchers stated that

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while more information is necessary about these environmental strategies, this information is

helpful for families coping with agitation in dementia (Van Vracem et al., 2015).

Another study by Heyn (2003) used a one-group pretest/posttest, quasi-experimental

design to determine the effects of a multisensory exercise program concerning engagement,

behavior and physiology of individuals with Alzheimers disease (AD). A multisensory exercise

program was provided three times a week for eight weeks for a convenience sample of 13 older

adults with dementia who were residents in a nursing home. Participants were assessed before

and after the intervention for resting heart rate, blood pressure, engagement, and weight; mood

and overall mood rating were measured subjectively after the intervention. The multisensory

exercise program provided to the 13 participants included soft and thematic music, storytelling,

and movement imagery instructions to facilitate engagement. Results indicate that use of sensory

strategies implemented into an exercise program increased engagement and showed positive

improvements in their overall mood. Researchers state, multisensory exercise approaches may

decrease RHR, increase exercise engagement, and preserve function in persons with AD (Heyn,

2003). Results show that implementing above stated sensory adaptations into current

Neighborhood House programming would increase engagement of this population.

In a two-phase research design completed by Buettner (1999) the research team

investigated the effects of 30 handmade sensorimotor recreational items on the behavior of

nursing home residents with dementia. Fifty-five residents with mild to moderate dementia were

assessed using the Mini Mental State Exam (MMSE); staff completed the Cohen-Mansfield

Agitation Inventory (CMAI), A ten item subscale of the Penn State Nursing Home Survey, The

Scanning Environment Tool, the Family Interview form, and the Time Engaged with Scale.

Participants were given Simple Pleasures sensorimotor items to choose from and use throughout

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the day while nurse assistants took notes about specific item use. Residents were assessed for

levels of agitated behaviors at four time points during the study: baseline, two midpoints, and at

the end point. Results of the study showed that use of multisensory items significantly decreased

the agitation levels of the participants who used them over time. Although these results were not

maintained after the intervention team left the facility due to little carry over in the facility.

Results from this study indicate that sensory interventions that utilize small tools and items that

are easily accessible by individuals with dementia may decrease the potential for agitated

behaviors over time but only if interventions are maintained and continue to be readily available.

In a study completed by Baillon et al. (2004) researchers aimed to compare the effects of

Snoezelen and reminiscence therapy for individuals with dementia in order to determine whether

Snoezelen methods effectively treat agitation in people with dementia. Participants were 20 older

adults with dementia and other mental health problems who came from a nursing home, which

provides inpatient and day care facilities. Participants were given three one-on-one sessions of

each intervention over the course of a two-week period. At baseline participants were assessed

using the Mini Mental State Exam (MMSE), the Clinical Dementia Rating Scale and the Cohen-

Mansfield Agitation Inventory - short (CMAI). Participants behavior was assessed using the

Agitated Behavior Mapping Instrument (ABMI), interaction was assessed using the Interact

Scale, and heart rate was recorded using a heart rate monitor. Results of the study determined

that there is no statistically significant difference between Snoezelen and reminiscence therapy

and researchers stated both reminiscence therapy and Snoezelen have a positive effect on mood

and behavior in this patient group (Baillon et al., 2004).

In a systematic literature review performed by Haigh & Mytton (2015) researchers sought

to determine the effectiveness of using sensory interventions to support the well being of

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individuals with dementia. Nine quantitative studies that fit the inclusion criteria were reviewed

and findings were determined. Researchers determined common themes concerning providing

sensory environments that hold a range of specific objects that target primary senses of sight,

hearing and touch (Haigh & Mytton, 2015). Researchers stated the primary research on the

relationship between well being and sensory interventions for people with dementia has indicated

positive effects on mood, social engagement, and occupational engagement (Haigh & Mytton,

2015).

Wellness based programming

More recent research completed concerning populations of older adults with dementia

and other neurocognitive decline has focused on the implementation of wellness programming in

order to increase quality of life. Wellness is defined as more than a lack of disease symptoms, it

is a state of mental and physical balance and fitness (AOTA, 2014). For the population served at

Neighborhood House wellness-based programming would be beneficial in assisting both clients

and caregivers in engaging in occupations that enrich their lives both mentally and physically.

In a chapter written by Gitlin & Vause-Earland (2010) authors sought to advance the role

of non-pharmacologic approaches in rehabilitation for the clinical management of patients with

dementia. This chapter looks specifically at the ways in which health professionals of individuals

with dementia can use effective communication such as clear language and demonstration, work

cohesively on an inter-professional team, and involve family caregivers in order to improve the

quality of life of their patients. Authors state consistently positive benefits have been shown for

the therapeutic use of activities with nursing home residents such as reduced agitation, decreased

restraint, and pharmacological use and enhanced quality of life (Gitlin &Vause-Earland, 2010).

This study shows that health professionals are able to positively affect the quality of life of their

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patients with dementia by taking calculated steps during their interactions to support their current

state and adequately address negative behaviors.

In a quasi-experimental research investigation completed by Logsdon, Pike, Korte, &

Goehring (2014) researchers sought to investigate whether memory care and wellness services

(MCWS) positively affected outcomes for older adults with dementia in an adult day services

setting. One hundred and eighty-seven dyads of participants with mild to moderate dementia and

their caregivers were included in the study; 162 received the MCWS and 25 received treatments

as usual. Participants were assessed at baseline, three months post and six months post using the

Mini Mental State Exam (MMSE), and quality of life was assessed using the QOL-AD. No

significant differenced were seen in quality of life (QOL) at three months post but differences

emerged between groups at six months post. Researchers noted that more days attended was

associated with improved QOL and decreased frequency of problem behaviors (Logsdon, Pike,

Korte, & Goehring, 2014).

In an open label randomized control trial conducted by Kumar et al. (2014) researchers

studied the effects of a novel occupational therapy program in improving QOL of subjects

having mild to moderate dementia. Participants were 77 older adults with dementia randomized

into two groups: the experimental group received ten sessions of OT interventions and the

control group received standard medical treatment. Participants in the OT group received 70

minutes of treatment per session consisting of the following interventions: relaxation, physical

exercise, personal activities, cognitive exercise, and recreational activity. Results show that by

the end of the experiment the overall QOL improved significantly in the experimental group

and declined significantly in the control group (Kumar et al., 2014). This study shows that even

though the natural progression of neurodegenerative diseases such as dementia is apparent, there

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are ways to improve QOL and perceptions of QOL through consistent occupation-based

treatment.

Researchers ORourke, Duggleby, Fraser, and Jerke (2015) completed a systematic

review of qualitative studied in order to determine common factors that affect QOL for people

with dementia. In this unique study researchers reviewed 12 articles that discussed quality of life

from the perspective of individuals with dementia and determined six common concepts

throughout the literature. Of the six concepts discussed, four factors that appeared to have the

largest impact on QOL of individuals with dementia were: relationships, agency in life today,

wellness and sense of place. Results of the literature review indicate that those with dementia

think social contact is important and vital to their well being, enjoy being able to express their

sense of self and have daily autonomy, perceive themselves as in good health, and like to feel at

home in their environment.

Summary

Given the results of the initial needs assessment with the staff and clientele served at

Neighborhood House in Salt Lake City, this literature review was completed to determine

effective interventions for older adults with dementia in an adult day services setting. Based on

what the facility already provides to their clientele and the stated needs of the administrative staff

concerning the lower functioning clients, certain types of programming were excluded from the

search. Through careful review of pertinent literature, evidence was found to justify three areas

of potential new programming with this population in mind. Strong evidence was found for

including caregiver education into any OT program provided in order to increase knowledge,

confidence and carry over into the home and decrease caregiver burden. Evidence concerning the

use of sensory interventions and environmental modifications for decreasing agitation was strong

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and would be useful for staff and caregivers at Neighborhood House. Although the evidence for

sensory-based programming was strong, interventions must remain consistent in order to reduce

agitation long term. Evidence for wellness-based interventions was present in the literature but

was not as strong. Using concepts from wellness-based OT treatments would be beneficial not

only for the clients served at Neighborhood House but also for the staff and caregivers. Although

a solely wellness based program is not entirely feasible at this time, implementation of wellness

promoting strategies to improve QOL into daily programming would be beneficial.

The proposed occupation-based program for Neighborhood House has two components.

One component addresses the populations sensory needs by making appropriate environmental

adaptations to assist with client comfort in the setting, and creation of a Snoezelen space for

clients seeking sensory breaks. The second component includes caregiver education concerning

the sensory needs of the population through a semi-annual information sessions provided by an

occupational therapist on a consult basis. Throughout the implementation of said program

Neighborhood Houses administration and staff will be educated concerning the need for

supporting client wellness through promotion of social interactions, increased sense of agency,

increased use of positive wellness perspectives, and increased sense of place in the program.

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References

American Occupational Therapy Association. (2014). Occupational therapy practice framework:

Domain and process (3rd ed.). American Journal of Occupational Therapy, 68(Suppl. 1),

S1S48. http://dx.doi.org/10.5014/ajot.2014.682006

Baillon, S., Van Diepen, E., Prettyman, R., Redman, J., Rooke, N., & Campbell, R. (2004). A

comparison of the effects of Snoezelen and reminiscence therapy on the agitated

behaviour of patients with dementia. International Journal Of Geriatric Psychiatry,

19(11), 1047-1052. doi:10.1002/gps.1208

Buettner, L. (1999). Simple Pleasures: a multilevel sensorimotor intervention for nursing home

residents with dementia. American Journal Of Alzheimer's Disease, 41-52.

DiZazzo-Miller, R., Winston, K., Winkler, S. L., & Donovan, M. L. (2017). Family Caregiver

Training Program (FCTP): A randomized controlled trial. American Journal of

Occupational Therapy, 71, 7105190010.

Gitlin, L. N. & Vause-Earland, T. (2010). Improving quality of life in individuals with dementia:

The role of nonpharmacologic approaches in rehabilitation. In J.H. Stone & M. Blouin

(Eds.), International Encyclopedia of Rehabilitation (pp. 1-22). Buffalo, NY: The Center

for International Rehabilitation Research Information and Exchange.

Graff, M., Vernooij-Dassen, M., Thijssen, M., Dekker, J., Hoefnagels, W., & Rikkert, M. (2006).

Community based occupational therapy for patients with dementia and their care givers:

randomised controlled trial. BMJ: British Medical Journal (International Edition),

333(7580), 1196-1199.

Haigh, J., & Mytton, C. (2016). Sensory interventions to support the wellbeing of people with

dementia: A critical review. British Journal Of Occupational Therapy, 79(2), 120-126.

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Heyn, P. (2003). The effect of a multisensory exercise program on engagement, behavior, and

selected physiological indexes in persons with dementia. American Journal Of

Alzheimer's Disease & Other Dementias, 18(4), 247-251.

Kumar, P., Tiwari, S. C., Goel, A., Sreenivas, V., Kumar, N., Tripathi, R. K., Gupta, V., & Dey,

A. B. (2014). Novel occupational therapy interventions may improve quality of life in

older adults with dementia. International Archives of Medicine, 7, 26.

Logsdon, R. G., Pike, K. C., Korte, L., & Goehring, C. (2016). Memory care and wellness

services: Efficacy of specialized dementia care in adult day services. Gerontologist,

56(2), 318-325.

O'Rourke, H. M., Duggleby, W., Fraser, K. D., & Jerke, L. (2015). Factors that affect quality of

life from the perspective of people with dementia: A metasynthesis. Journal Of The

American Geriatrics Society, 63(1), 24-38. doi:10.1111/jgs.13178

Piersol, C. V., Canton, K., Connor, S. E., Giller, I., Lipman, S., & Sager, S. (2017). Effectiveness

of interventions for caregivers of people with Alzheimers disease and related major

neurocognitive disorders: A systematic review. American Journal of Occupational

Therapy, 71, 7105180020. https://doi.org/10.5014/ajot.2017.027581

Van Vracem, M., Spruytte, N., Declercq, A., & Van Audenhove, C. (2016). Agitation in

dementia and the role of spatial and sensory interventions: experiences of professional

and family caregivers. Scandinavian Journal Of Caring Sciences, 30(2), 281-289.

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