Occupational Therapy Improves Functioning for Dementia Patients and Caregivers

NIJMEGEN, The Netherlands, Nov. 20 -- Community-based occupational therapy for patients with dementia improves their ability to cope with the condition, Dutch researchers found.

Caregivers attending the occupational therapy sessions as well also achieved some benefit, particularly a sense of competence. Maud J. L. Graff, M.D., of the University Medical Center Nijmegen, and colleagues, reported in a study published online in the BMJ.

"The primary focus of such a therapy," Dr. Graff and colleagues wrote, "is to improve patients' ability to perform activities of daily living and hence promote independence and participation in social activities and to reduce the burden on the caregiver by increasing their sense of competence and ability to handle the behavioral problems they encounter."

"These outcomes are increasingly being considered equally or even more clinically relevant than measures of cognitive outcome," the investigators added.

Ten sessions of therapy over five weeks increased process skills and reduced the need for assistance in daily activities for patients and reduced the burden for caregivers, they said.

The achievements were measured by the Assessment of Motor and Process Skills (AMPS), an innovative observational assessment that is used to measure the quality of a person's activities of daily living. The quality of the person's activities of daily living performance is assessed by rating the effort, efficiency, safety, and independence of 16 motor and 20 process skill items.

As an example of an activity of daily living, the investigators cited the preparation of a jam sandwich. The activities include a walk to the cupboard, finding and selecting the correct bread, reaching for and lifting the bag of bread, carrying the bread to the workspace, holding and opening the bread by removing the twist tie, applying jam on the bread and spreading it with an appropriate amount of force so that the bread does not tear, using a knife (not a spoon) to cut the sandwich, and cleaning up the workspace.

The researchers randomized 135 community-living patients ages 65 or older with mild to moderate dementia and their primary caregivers to control or occupational therapy. Occupational therapy consisted of cognitive and behavioral interventions training patients to use aids to compensate for cognitive decline and teaching caregivers coping behaviors and how to supervise patients.

At week six, 84% of patients in the intervention group had clinically relevant process skill improvements compared with 9% in the control group. The therapy group also had substantially more frequent clinical improvement in performance of daily living activities (78% versus 12%).

Among caregivers, 58% in the therapy group, compared with 18% in the control group, had a clinically relevant improvement in sense of competence.

Most of the caregivers were partners (79 of 135) or daughters (43) of the patients. Baseline characteristics of patients and caregivers were similar between groups although ages were lower for the therapy group (mean 79.1 patients and 66.0 caregivers versus 77.1 and 61.3 control).

Patients with high depression scores, severe behavioral or psychological symptoms, or severe illness were excluded. Caregivers with severe illness were excluded as well.

The intervention was administered by experienced occupational therapists to the therapy group during the study and to the control group after completion of the study. Occupational therapy took a total of 18 hours for patients and caregivers.

It was effective in significantly improving all scores compared to baseline by one week after completion. Compared to control, the findings for occupational therapy were:

• Improvement by 1.5 (95% confidence interval 1.3 to 1.7) points on the process scale of the assessment of motor and process skills (mean scores 1.2 versus 0.2),
• Reduction of 11.7 points (95% CI ? 13.6 to ? 9.7) on the performance scale of the interview of deterioration in daily activities in dementia (mean scores 14.4 versus 25.3), and
• Improvement of 11.0 points for the caregiver burden assessed with the sense of competence questionnaire (95% CI 9.2 to 12.8).

Effect sizes were 2.5, 2.3, and 1.2, respectively, at six weeks and 2.7, 2.4, and 0.8, respectively, at 12 weeks.

"The effect sizes of all primary outcomes were higher than those found in trials of drugs or other psychosocial interventions for people with dementia," Dr. Graff and colleagues wrote.

The caregivers also reported significant improvements in their feeling of competence (mean score 104.6 versus 88.4 compared to 89.7 versus 90.4 at baseline).

By seven weeks after completion of the intervention, "the daily functioning of patients who had received occupational therapy was still much better than that in the control group," the researchers said. The findings for the intervention and control groups were:

• Better mean process scores (difference from baseline 1.2 versus ? 0.02),
• Superior mean performance interview scores (difference from baseline 13.6 versus 27.2), and
• Significantly better caregiver sense of competence (mean 107.3 versus 89.4).

In an analysis correcting for age differences between groups, the difference at 12 weeks compared with baseline was significant for the process scores (1.6, 95% CI 1.3 to 1.8) and the performance interview (? 13.6, 95% CI ? 15.8 to ? 11.3).

At three months, 37% of the intervention group still had a clinically relevant difference from baseline in all three outcome measures compared to 2% of the control group.

"We believe that the benefit was sustained because a component of the intervention was to train care givers in providing the supervision patients needed to sustain their performance of daily activities," the researchers said.

The intervention requires trained occupational therapists, but the authors said they believe "it is worth implementing in clinical practice because of its relevant effects and high efficacy, which makes it reasonable to expect cost effectiveness in clinical practice."

While the study was not blinded for patients, it was for the clinicians assessing outcomes and in 82% of the cases blinding was successful.

The researchers said their population sample might not be representative of all patients with mild to moderate dementia since participants were recruited primarily from an outpatient clinic of a university hospital rather than other institutions or general practices.

The study was supported by the Dutch Alzheimer Association and the Dutch Occupational Therapy Association.