Effect of Occupation- and Activity-Based Interventions on Instrumental Activities of Daily Living Performance Among Community-Dwelling Older Adults: A Systematic Review

Multicomponent Interventions.

Studies involving multicomponent interventions included interventions that were provided by more than one discipline (e.g., occupational therapy, physical therapy, nursing) and targeted a number of outcomes, such as activities of daily living (ADL) and IADL performance, falls efficacy, and habitual physical activity. Two Level I RCTs in three articles reported strong evidence that multicomponent interventions provided to older adults result in improved IADL performance. Gitlin et al. (2006) studied older adults with chronic conditions, and Zidén, Frandin, and Kreuter (2008) studied older adults recovering from hip fractures. In both studies, participants took part in home interventions, and the results indicated a reduction in older adults’ perceived functional difficulties, improvement in confidence and independence in IADLs, and greater improvement in functional activities compared with those who did not receive the interventions. Gitlin et al. (2006) found these effects remained 6 mo postintervention. In addition, people ≥80 yr old and those with less education reported greater self-efficacy in managing IADLs than the control group (Gitlin, Winter, Dennis, & Hauck, 2008). The multicomponent interventions reported in these studies were brief (ranging from five to six therapy contacts).

Occupational Therapy Interventions.

Included in this category were eight articles reporting on six studies that described Lifestyle Redesign interventions as well as other client-centered and occupation-based occupational therapy interventions provided to community-dwelling older adults. The evidence that the Lifestyle Redesign program, a lifestyle intervention provided by occupational therapists to slow age-related declines in older adults, improves IADL performance is mixed. The Level I Well Elderly study conducted with 361 older adults found that the Lifestyle Redesign program was effective in improving physical and role functions related to performance of some IADLs (Clark et al., 1997, 2001; Hay et al., 2002), had a long-term effect on these outcomes (Clark et al., 2001), and was cost effective (Hay et al., 2002) compared with social activity. Using the Lifestyle Redesign approach with a more ethnically diverse population and under less controlled experimental situations, the Well Elderly II study (Clark et al., 2011, a Level I RCT) did not find a difference between groups in improved physical function and role function related to performance of some IADLs. However, significant favorable change scores were found for the intervention group compared with the control group for bodily pain, vitality, and life satisfaction. In a Level I RCT of Lifestyle Redesign with 28 older adults in an adult day care program, Horowitz and Chang (2004) found no difference between treatment and control groups in role functioning and performance in IADLs.

Other studies found limited to moderate evidence for the effectiveness of client-centered occupational therapy home interventions in improving IADL performance in older adults. Hagsten, Svensson, and Gardulf (2006) provided occupational therapy to community-dwelling older adults after surgery for hip fracture in a Level I RCT conducted in Sweden. Although most of the intervention was provided in the hospital, a predischarge home visit was also included. Although no differences were found between the intervention and control groups at discharge and follow-up, significant differences were found between groups at 2 mo. Participants in the occupational therapy group reported significantly more indoor mobility, performance of light housework, and ease getting in and out of a car than did those in the control group. Fisher, Atler, and Potts (2007) conducted a Level II repeated-measures study that used the Occupational Therapy Intervention Process Model with 8 community-dwelling frail older adults and found that ADL motor ability significantly improved after intervention. In a Level II study of the effectiveness of an intervention for older adults with different functional abilities and with orthopedic, neurological, or chronic impairments, Matteliano, Mann, and Tomita (2002) found that participants who received occupational therapy services through a home care agency improved in the IADL of food preparation; however, the effect was not significantly different from that of the group that did not receive occupational therapy services. One Level IV study examined the effectiveness of an intervention for microwave oven use for meal preparation and found increased frequency of using cooking appliances and food items prepared and a reduction in the time spent preparing meals (Kondo, Mann, Tomita, & Ottenbacher, 1997).

Functional Task Exercise Programs.

Studies on functional task exercise programs reported on the effect of exercises such as transporting objects and moving objects from differing-height shelves as well as walking. Four studies (De Vreede, Samson, van Meeteren, Duursma, & Verhaar, 2005; De Vreede et al., 2004; Fisher & Li, 2004; Manini et al., 2007) found moderate evidence for the effectiveness of functional task exercise programs to improve IADLs. Two RCTS compared a functional task exercise program with a resistance exercise program in 122 older women (De Vreede et al., 2004, 2005). De Vreede et al. (2004) found that participants in both the functional task and the resistance exercise group significantly increased their functional task performance on several IADL tasks (N = 24). Although they found no significant differences between groups, effect sizes were greater for the functional task group. However, this study was likely underpowered to detect group effects.

A study with a larger sample size (N = 98) found that the functional task exercise group had significantly higher physical functional performance on several IADL tasks than the control and resistance groups (De Vreede et al., 2005). Only changes in the functional task group were sustained after 7 mo of intervention.

Similarly, Manini et al. (2007) compared the efficacy of three interventions on the number of task modifications needed and timed performance on IADL tasks of 33 lower functioning older adults in a Level I RCT. Task modification can be considered an essential characteristic for identifying older adults at risk of subsequent disablement. After training, all groups showed similar reduction in task modification. However, only the two groups with functional training had a significant reduction in timed performance of functional IADL tasks. Additionally, a Level I RCT conducted with 582 community-dwelling senior residents found evidence of the effectiveness of walking programs to increase the IADL of neighborhood walking (Fisher & Li, 2004).

Simulated IADL Programs.

Simulated IADL training programs are designed to mimic the performance of daily functional tasks, such as laundry and vacuuming. Limited evidence has been found for the efficacy of simulated functional IADL programs in older adults’ IADL performance. Richardson, Law, Wishart, and Guyatt (2000) conducted a Level I study that compared a simulated home- and community-setting program with a traditional treatment setting in the clinic for patients with compromised functional status. Participants in both groups demonstrated little change in IADL performance during the intervention and 8 wk after discharge. A Level II study by Dobek, White, and Gunter (2007) compared the effectiveness of an IADL-based training program with a control period of no intervention in 14 independent-living older adults and found significant improvement in the ability to perform some IADLs and physical fitness.

Physical Activity Interventions.

The physical activity intervention studies included a systematic review, a meta-analysis, 10 Level I RCTs, 1 Level II study, and 1 Level III study. These studies assessed the effectiveness of general exercise programs, resistance training, aerobics, balance training, flexibility exercises, cardiorespiratory fitness, tai chi, and general physical activity sessions. The evidence that physical activity interventions improve IADL performance is mixed.

In a large Cochrane review of 121 RCTs, Liu and Latham (2009) found evidence supporting the effectiveness of progressive resistance strength training in improving older adults’ strength and activity performance. Specifically, they found a positive impact on certain IADLs such as community mobility and preparing meals. Rejeski et al.’s (2008) Level I RCT (N = 424) found that participants in a physical activity intervention (400-m walk) had improved satisfaction with physical function and self-efficacy compared with an educational control group. They suggested that physical activity might be effective for improving self-efficacy, satisfaction with physical function, and time spent on activities of moderate or greater intensity in older adults with mobility deficits. Ginis, Latimer, Brawley, Jung, and Hicks (2006) compared weight training and weight training plus education and found that both groups showed improvement in a 16.5-m walk at the end of the study in comparison with baseline performance. In a multisite study by Wellman, Kamp, Kirk-Sanchez, and Johnson (2007; N = 620), significant improvements in tasks related to community mobility (e.g., steps taken per day, number of days walked per week) were found after intervention (Level III study).

Three of the studies discussed earlier as functional activity interventions (De Vreede et al., 2004, 2005; Manini et al., 2007) also assessed interventions involving physical activity. These studies also supported the use of physical activities as effective means to improve IADL performance, even though they supported functional activity interventions over physical activities alone.

Several studies, including a meta-analysis and various RCTs, did not find a direct effect of physical activity interventions (e.g., general exercise programs, strength training) on older adults’ IADL performance (Gu & Conn, 2008; Lee & King, 2003; Oida et al., 2003; Pahor et al., 2006; Rejeski et al., 2009; Timonen et al., 2006; Wellman et al., 2007; Wolf et al., 2003). However, several studies (Levels I and II) found significant differences between physical activity intervention groups and other intervention or control groups in functional and physical performance measures that are thought to be relevant constructs related to IADL performance (Gu & Conn, 2008; Pahor et al., 2006; Timonen et al., 2006). Timonen et al. (2006), for example, found changes in muscle strength, balance, and walking speed in an exercise group program but no changes in IADL performance as assessed by the Joensuu Classification. Pahor et al. (2006) found that a physical activity group had significantly higher scores on the Short Physical Performance Battery (Guralnik et al., 1994) than a health education control group after intervention.

In summary, some studies found direct evidence of improvement in IADL performance (such as community mobility, walking distances, preparing meals), and others did not find a direct effect of physical activity interventions. Various high-quality studies found improvement in functional performance and physical performance measures, which may or may not be related to IADL performance.

Cognitive Skills Intervention.

The effects of training in memory, inductive reasoning, and speed of processing on daily functioning of community-dwelling older adults were studied in a large (N = 2,832), multisite Level I RCT (Willis et al., 2006). The study involved three cognitive training groups and a control group. Although all groups reported less difficulty with IADLs 5 yr after training, significantly less functional decline in IADL performance (including meal preparation, housework, finances, health maintenance, telephone use, and shopping) was found only in the group targeting inductive reasoning at the 5-yr follow up.

Vision Rehabilitation.

Moderate evidence exists that vision rehabilitation improves function in adults with low vision. A Level I RCT (McCabe, Nason, Demers Turco, Friedman, & Seddon, 2000) provided multicomponent vision rehabilitation to older adults with low vision and examined whether an individual protocol (n = 49) or a family-focused protocol (n = 49) increased patients’ functional abilities. The vision rehabilitation team included staff from optometry, occupational therapy, and social work. Regardless of group assignment, intervention was offered on the basis of patients’ level of impairment and capacity. Changes in functional scores (i.e., decrease in dependence) and self-reported difficulty performing a task (e.g., preparing a meal, writing a check) were found in both groups using the Functional Assessment Questionnaire (Pfeffer, Kurosaki, Harrah, Chance, & Filos, 1982).