By Monique McIntyre
Master of Occupational Therapy,
University of Canberra
It is estimated that there are over 250,000 Australians living with dementia and this number is predicted to rise to close to one million people by 2050 (Access Economics 2011). Worldwide it is estimated that there are over 35 million people living with dementia and, with an ageing population and the cost of care, dementia has been raised as a public health priority (WHO 2012). Dementia is described by the World Health Organisation (2012) as “a syndrome that affects memory, thinking, behaviour and ability to perform everyday activities” (p3). Bennett, Shand and Liddle (2011) explain that the term dementia covers a group of conditions where an individual is affected by a progressive decline in cognitive functions such as memory, thinking and orientation and commonly displays changes to personality, emotional control, social behaviour and motivation. The symptoms of dementia impact on an individual’s ability to complete daily activities, with the Australian Institute of Health and Welfare (2013) reporting that the majority of people with dementia require assistance in most areas of daily living. Evidence of the benefits of occupational therapy for people with dementia continues to grow (Bennett et al 2011; Graff, Vernooij-Dassen, Thijssen, Dekker, Hoefnagels, & Rikkert 2006).
The focus of occupational therapy is to promote health and well-being through participation in activities of daily life (Occupational Therapy Australia 2013). Furthermore, occupational therapy is consistently reported to decrease the burden commonly placed on family and friends of people with dementia who act as the primary care giver (Graff et al 2006; D’Amico 2012). Falls prevention is one aspect of care for people with dementia in which occupational therapy plays a major role. People with dementia are reported to be twice as likely to suffer a fall as those with intact cognitive ability (Wesson, Clemson, Brodaty, Lord, Taylor, Gitlin, & Close 2013). That places the likelihood of a person with dementia having a fall at 70-85 per cent (Shaw 2002). Additionally, people with dementia who suffer a fall experience a longer period of hospitalisation, poorer prognosis and a higher rate of moving to a residential aged care facility (Shaw 2002). Falls and injuries sustained from falls are one of the most common causes for a reduced ability to care for oneself and to participate in meaningful occupation (Tinetti & Kumar 2010). The unique skills of occupational therapists enable them to maximise safety while promoting independence and participation among people with dementia.
This paper will discuss the role of occupational therapy in assessing the person, the environment and the occupations of people with dementia to prevent falls, while improving independence (and reducing caregiver burden) and participation in daily activities.
Occupational therapy promotes health and well-being of people, organisations and populations through participation and engagement in occupations (AOTA 2008). Occupational therapists are educated to evaluate the transactional relationship of the person, the environment and the person’s occupations to maximise the person’s occupational performance (AOTA 2008). Occupational performance is the person’s ability to engage in meaningful occupations. The term occupation refers to all activities of life including Activities of Daily Living (ADLs) (activities required to take care of one’s own body such as bathing, toileting, eating, hygiene, dressing, mobilising, sleeping), Instrumental ADLs (IADLs) (activities that support daily living such as cleaning, transportation, food preparation, communication, financial management, caregiving for pets or others), work, education, play, leisure and social participation (Birge James 2009).
Occupational therapists work across many settings and with all age groups. In particular, occupational therapists work with people with dementia in hospital wards; residential aged care facilities; outpatient memory clinics; within clients’ homes; day therapy centres; or rehabilitation, community or respite facilities (Bennett, Shand & Liddle 2011). Referrals to occupational therapy for people with dementia are most commonly for home assessment and home safety, environmental modification, ADL assessment, cognitive assessment and intervention, personal care intervention, behavioural management, care support and equipment prescriptions (Bennett et al 2011). This list highlights that the role of the occupational therapists in falls prevention is not only to increase the safety of the clients but also to enable them to continue to engage in meaningful occupations while promoting safety.
Reviews of the research found evidence that occupational therapy intervention is effective in preventing falls in people with dementia (Steultjens, Dekker, Bouter, Jellema, Bakker & van den Ende 2004; Arbesman & Lieberman 2011). Furthermore, a cost effectiveness study found that occupational therapy intervention with people with dementia is cost-effective and reduces the cost of informal care giving (Graff, Adang, Vernooij-Dassen, Dekker, Jonasson, Thijssen, Hoefnagels & Rikkert 2008). Peterson, Finlayson, Elliott, Painter and Clemson (2012) reported that occupational therapists’ attention to and understanding of the factors that influence occupational performance and the transactional relationship between the person, environment and the occupation is increasingly being recognised as important to the assessment of falls risk and implementation of falls prevention.
Many personal factors can contribute to people’s functional ability and affect their risk of falls. Occupational therapists are skilled in evaluating these personal factors to understand the client’s functional ability. Personal factors include: body structures such as joints, muscle and the cardiovascular system; body functions such as joint mobility and stability, muscle power and blood pressure; and cognitions including beliefs, values and spirituality (AOTA 2008).
These skills are particularly necessary when working with people with dementia as the course and symptoms of dementia vary for person to person (Padilla 2011a). The symptoms of dementia can affect the person’s body structures, body functions and cognition and these changes often increase the person’s risk of a fall. As described by Bennett, Shand and Liddle (2011) dementia covers a group of conditions were an individual is affected by a progressive decline in cognitive functions. Changes to cognitive ability caused by dementia that play a role in increasing the risk of falls includes: impaired judgement; gait initiation; decision-making capacity; memory; ability to negotiate traffic ways; anxiety and depression; risk identification and risk-taking behaviour; less alert or careful; deficits in perception; having a need to pace or wander; and having a fear of falling (Shaw 2002; Feldman et al 2008; Bennett, Shand & Liddle 2011).
Some body functions that can be affected by dementia, and the associated decline in cognitive ability, that increase the risk of a fall include: step length, height and symmetry; how far apart the feet are when walking; steadiness on turning; balance; reaching; climbing; stepping over objects; postural stability; vision; reaction time; dehydration and malnutrition; and low blood pressure (Cumming, Thomas, Szonyi, Frampton, Salkeld & Glemson 2001; Shaw 2002; Feldman & Chaudhury 2008; Tinetti & Kumar 2010).
While the occupational therapist is skilled in understanding the person and how their personal factors contribute to their ability to function and their risks of falls, due to the progressive nature of dementia, occupational therapy is not often aimed at changing the person, but rather focuses on their remaining abilities and utilising their strengths through a change in the occupation or their environment (Letts, Minezes, Edwards, Berenyi, Moros, O’Neill & O’Toole 2011).
Symptoms of dementia lead to the need for special attention when designing and accessing the physical environment of people living with dementia (Feldman & Chaudhury 2008). For example, some people with dementia may not scan their environment effectively, may suffer tunnel vision when moving about, are not likely to anticipate hazards or do not anticipate the consequences of actions (Wesson, Clemson, Brodaty, Lord, Taylor, Gitlin & Close 2013). Evidence suggests that modifications to the living environment of people with dementia are not only effective in reducing falls (Cumming, Thomas, Szonyi, Frampton, Salkeld & Glemson 2001) but also slows the rate of decline in frail older people, reduces the likelihood of moving to a residential aged care facility and improves occupational participation (Padilla 2011b).
While environmental assessment and modifications are useful to determine one’s safety within their environment, they are also important in determining functional ability in performing activities of daily living, and in promoting continued engagement and independence (Cumming et al 2001). Furthermore, an additional benefit of environment modifications is that changes to the environment increased safety for all people living within the environment (Feldman et al 2008). Occupational therapists’ skills in understanding the transactional relationship between the person, environment and occupation make them most suitable for assessment and modification of the physical environment for people with dementia. For example, while furniture placement may appear as an obstacle and therefore a risk to falling, an observational assessment of the client in their home might identify the client’s habit in using the furniture for stability and that movement of the furniture would result in a falls risk for that client (Feldman et al 2008). The success of home modifications rely on implementation by the client or their family and, as such, the occupational therapist must approach recommendations for home modifications as a joint decision-making process with the client and care giver and provide options and choices in resolving identified risks (Cumming et al 2001).
The most common environmental modifications implemented by occupational therapists for people with dementia include: improving lighting (eg using automatic lights); removing obstacles such as electrical cords and removing clutter; installing ramps if stairs are an issue or highlighting step edges; removing mats or using non-skid backing or anchoring mats; redesigning storage areas for easy reach (eg lowering cabinets); installing handrails on stairs; redesigning toilets and bathrooms (eg installing grab rails, using non-slip bathmats, raising toilet seats); managing floor surfaces such as reducing glare or installing carpets with low stiffness to reduce the impact forces of a fall; evaluating placement of furniture to prevent obstacles; and providing training to care givers on how to set up work areas that promote easy access (Feldman et al 2008; Padilla 2011a; Wesson et al 2013).
A study by Wesson, Clemson, Brodaty, Lord, Taylor, Gitlin and Close (2013) provides an example of a successful individualised approach where occupational therapy services successfully reduced the incidence of falls in people with dementia in Australia. The occupational therapist conducted a systematic audit to identify environmental and behavioural fall hazards using the Westmead Home Safety Assessment. Clients were provided with a booklet of recommendations to be implemented during further visits from the occupational therapist. The recommendations were tailored to the hazards identified, and provided a description of selected hazards, explanation of the hazards (as some people with dementia do not recognise hazards or secondary effects of actions) and provided sections on habits to change (assessment is made by the occupational therapist on the client’s ability to learn new routines (with assistance), items to buy and home modification service referral. The format of the booklet was adapted to suit cognitive ability.
A further example which recognises the need to not only improve safety but do so with a focus on enabling participation in meaningful occupations while decreasing the risk of falls would include environmental modification to allow a client access to their backyard to continue their love of gardening. A hand rail could be installed over stairs to facilitate safer access in and out of the house, raised garden beds could be used to reduce the need to kneel and from repeatedly needing to come from kneeling/sitting to standing, a level path could be maintained between the door and the garden beds and clutter can be removed to minimise the likelihood of tripping.
Occupational therapy also plays an important role at the population level in promoting the use of universal design in public spaces which allows accessibility and useability for all people including those with a disability such as dementia (Joines 2009).
An occupation can be modified in many ways to enable people to use their strengths to participate and to reduce barriers to participation. Evidence shows that modifying tasks to utilise the client’s highest level of functional ability improves participation in occupations (Padilla 2011b). Furthermore, research suggests that modifying activities to suit the person’s skills and interests is a useful intervention strategy (Padilla 2011b). Some examples of task modification include: using assistive devices, using compensatory techniques and implementing routines.
Assistive devices can improve safety by improving the client’s stability and mobility or by reducing the requirements of the task. Examples of assistive devices include: bathroom aids such as commodes, shower chairs or bath boards; mobility aids such as walking sticks or wheelie walkers; falls alarms or bells at the front door to prevent wandering; pill boxes and long reach tools (Letts, Edwards, Berenyi, Moros, O’Neill, O’Toole & McGarth 2011; Padilla 2011b).
Compensatory techniques simplify the activity through measures such as: reducing distractions; placing objects in the client’s line of sight; providing one part of the task at a time; providing short, clear instructions; extending the time to complete the task; using visual cues; and breaking tasks down into smaller steps (Padilla 2011b). For example, to increase safety while undertaking the task of having a shower, assistive devices could be used along with compensatory techniques such as orientating the room and using visual cues so that clothing is in an appropriate area to get dressed (rather than on slippery tiles in the bathroom); breaking the task down into a sequence of smaller steps (eg so that clients do not get undressed in the shower or get their hands tangled in a unbuttoned shirt while trying to step into their pants); and providing simple, clear instructions for parts of the tasks the clients find difficult.
In an example of the use of cuing to improve orientation and way finding in people with dementia in residential care facilities, Letts, Minezes, Edwards, Berenyi, Moros, O’Neill and O’Toole (2011) found the use of colour, numbers, nameplates and lights to assist clients to find their own room. Furthermore, the use of identifying photos and pre-programmed numbers was found to improve a clients’ ability to use the telephone (Letts et al 2011). Visual cues could also include posting emergency telephone numbers (Padilla 2011b).
Routines are also successful in reducing the risk of falls in people with dementia. An understanding of the person and the environment, along with observation of behavioural patterns leads to identification of the benefits to implement or change a routine (Padilla 2011b). Some examples of how routines could prevent falls includes: preventing dizziness caused by a lack of food or dehydration by implementing a schedule of events in which the clients can follow to ensure they eat a meal at certain times throughout the day; the need to use stairs in poor lighting in the night to get to the bathroom could be managed through the use of a commode on the upper level when the toilet is needed during the night (Cumming, Thomas, Szonyi, Frampton, Salkeld, & Glemson 2001); a routine can also help to manage the use of medications and can facilitate the consumption of medications at an appropriate time to manage any side-effects (Shaw 2002); and additionally, routines can assist to reduce falls in people with dementia by encouraging them to undertake more physically demanding tasks when they have the highest energy (Arbesman & Lieberman 2011).
While there is evidence of the benefits of occupational therapy in preventing falls in people with dementia, further research is required in two main areas. Firstly, Feldman and Chaudhury (2008) reported a lack of attention in the literature on the occupation being engaged in at the time of a fall. Letts, Edwards, Berenyi, Moros, O’Neill, O’Toole and McGarth 2011) described how further research in this area could assist occupational therapy practice by informing occupational therapists’ assessment, planning and interventions. Secondly, the need for further multidisciplinary studies was repeatedly recognised, given the complexity of dementia and the commonality of occupational therapists working within multidisciplinary teams (Feldman & Chaudhury 2008; Arbesman & Lieberman 2011; Peterson, Finlayson, Elliott, Painter & Clemson 2012). Additionally, multidisciplinary research could be a step towards the identified need for further education and lobbying of occupational therapy amongst stakeholders (Letts et al 2011).
Occupational therapy is effective in reducing the risk of falls in people with dementia. Occupational therapists’ unique skills in understanding the relationship between the person, the environment and the occupation allows them to both identify falls risks and to implement strategies to prevent falls. There is strong evidence for the use of occupational therapy intervention including occupation modification and environmental adaptation to reduce the risk of falls in people with dementia, while maintaining their engagement in meaningful occupations.
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