Abstract
A review of the productive aging articles published in the American Journal of Occupational Therapy during 2011 was conducted and discussed in light of meeting the Centennial Vision charge of supporting practice through evidence. Twelve articles that specifically addressed productive aging were published in AJOT in 2011. The review of these 12 articles found seven Level I studies. Six of the articles were systematic reviews identifying effective interventions for people with Alzheimer’s disease and related dementias and their caregivers, and 1 was a randomized controlled trial of fall prevention in community-dwelling older adults. Five were basic research studies. Two of the 5 studies researched professional issues, and 3 addressed client-based issues. The quantity of productive aging research published in 2011 was consistent with the quantity reported in 2009 and 2010. More studies building the body of evidence about the effectiveness of occupational therapy with older adults are needed.
The Centennial Vision is the road map to the future of occupational therapy to commemorate the American Occupational Therapy Association’s (AOTA’s) 100th anniversary in 2017. AOTA’s mission as stated in the Centennial Vision is to promote research that supports the effectiveness of occupational therapy services. The vision statement projects a healing profession that “is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society’s occupational needs” (AOTA, 2007, p. 613).
Fulfillment of the Centennial Vision requires periodic measurement of occupational therapy’s progress to determine whether it is progressing along the specified path. One of the charges was to increase the publication of evidence-based practice related to occupational therapy. To that end, the American Journal of Occupational Therapy (AJOT) has endeavored to increase the publication quantity and quality of research studies focused on the areas outlined in the Centennial Vision. These types of research include
Effectiveness studies supporting practice,
Instrument testing to establish reliability and validity for occupational therapy assessments,
Correlational and descriptive studies that demonstrate linkages between occupational engagement and health,
Studies that answer important questions about topics related to the direction of the profession’s growth, and
Basic research studies that provide information about disabilities and their impact on functional participation (Gutman, 2008).
Also contained in the Centennial Vision is a call to sustain existing practice areas while embracing new and emerging practice areas to meet society’s needs. Productive aging is one of the practice areas singled out for examination (AOTA, 2007; Baum, 2006). In this review, I evaluate the progress of AJOT publications related to productive aging during 2011.
Method
The editor of AJOT screened all research articles published or accepted for publication in AJOT during 2011. Twelve articles were identified that related to productive aging practice, which represented approximately 16% of all research articles published in AJOT during the year. I read and reviewed all articles and have broad experience in productive aging, occupational therapy, and evidence-based practice. All articles were categorized according to research levels on the basis of the AOTA Evidence-Based Literature Review Project Levels of Evidence Rating System (Table 1; Lieberman & Scheer, 2002). Articles were evaluated using criteria provided by the AJOT editor and summarized in Table 2. The sections that follow are organized according to the categories set out in the Centennial Vision.
American Occupational Therapy Association Evidence-Based Literature Review Project Levels of Evidence Rating System
Note. From “Evidence-Based Medicine: What It Is and What It Isn’t” by D. L. Sackett, W. M. Rosenberg, J. A. Muir Gray, R. B. Haynes, & W. S. Richardson, 1996, British Medical Journal, 312, pp. 71–72. Copyright © 1996 by the British Medical Association. Adapted with permission.
Summary of Evidence From Studies
Note. AD = Alzheimer’s disease; ADLs = activities of daily living; AMPS = Assessment of Motor and Process Skills; BTW = behind the wheel; IADLs = instrumental activities of daily living; QoL = quality of life; RCT = randomized controlled trial; SR = systematic review.
Effectiveness Studies
Only 1 effectiveness study was published in 2011. Schepens, Panzer, and Goldberg (2011) conducted a three-group randomized controlled trial (RCT) for fall prevention education with community-dwelling older adults ≥65 yr old. Schepens et al. used a multimedia fall program (MFP) and two types of evidence-based instructional strategies. The authentic education group combined the MFP and Situated Learning Theory by using the participants’ real-life concerns. The motivation group combined MFP and the Attention–Relevance–Confidence–Satisfaction model (Keller, 1987, cited in Schepens et al., 2011). Schepens et al. found that using the MFP combined with either instructional strategy was beneficial to both education groups. However, they found that the motivation group engaged in more fall prevention strategies than the authentic group.
Six systematic reviews of intervention strategies for people with Alzheimer’s disease and related dementias and their caregivers were published in 2011 as part of the AOTA’s Evidence-Based Practice project (Jensen & Padilla, 2011; Letts, Edwards, et al., 2011; Letts, Minezes, et al., 2011; Padilla, 2011a, 2011b; Thinnes & Padilla, 2011). The systematic reviews focused specifically on delineating effective interventions for fall prevention; occupation to improve quality of life, health, and satisfaction for clients and caregivers; environmental modifications; perceptual abilities; modification of activity demands; and educational and supportive strategies for caregivers of people with Alzheimer’s disease and related dementias. All the studies strongly supported the inclusion of staff and caregiver education as an effective intervention to maximize participation, positive interactions, and health of both the clients and the caregivers. Thinnes and Padilla (2011) found that caregivers who received occupational therapy sessions providing education about problem solving, task simplification, communication strategies, and home modifications had a decreased need for assistance, experienced fewer behavioral occurrences, and had a greater sense of mastery and self-efficacy. They also found that provision of coping skills training mediated caregiver stress and depression and delayed institutionalization of the family member with Alzheimer’s disease.
Client-specific interventions that were most effective included providing structured, individually tailored leisure and self-care activities commensurate with the client’s abilities, Montessori activities, and small-group social participation opportunities (Letts, Edwards, et al., 2011; Padilla, 2011a, 2011b). Use of sensory integration techniques and multisensory stimulation to maintain perceptual abilities of people with Alzheimer’s disease had little to no evidence to support their benefit (Letts, Minezes, et al., 2011). Environmental modifications such as increased light intensity, environmental sounds, aromatherapy, and ambient music were found to have mixed or low benefit to mediate behavior and agitation among this population. However, the use of familiar music was found to be more effective in assuaging agitation and aggression (Padilla, 2011a). Other environmental modifications identified as effective were the use of visual barriers to deter wandering through doors, labeling drawers, and using names on people’s doors (Letts, Minezes, et al., 2011; Padilla, 2011a, 2011b). Jensen and Padilla’s (2011) systematic review of 12 studies related to people with Alzheimer’s disease and related dementias found strong support for a multifaceted approach to fall intervention that focused on gait, balance, and strength training along with staff education about environmental awareness for fall prevention.
Basic Research, Correlational, and Descriptive Studies
Five basic research studies related to productive aging were published in 2011. Two addressed professional issues, and 3 addressed client-based issues. Of the latter 3, one addressed assessment for return to driving (Dickerson, Reistetter, Davis, & Monahan, 2011), a second explored personal factors of healthy lifestyles in community-dwelling older adults (Peralta-Catipon & Hwang, 2011), and the last was a pilot study exploring the fear of falling among clients who had sustained a stroke (Schmid et al., 2011). Dickerson et al. (2011) concluded that Assessment of Motor and Process Skills process scores were indicative of success during behind-the-wheel assessment of driving skills, with lower scores correlating with unsuccessful behind-the-wheel assessment. Their study also argued for the benefits of using general practice occupational therapists’ observation and assessment skills as more cost effective and time sensitive than referrals to driving rehabilitation specialists.
Peralta-Catipon and Hwang (2011) identified healthy lifestyle categories as diet, exercise, stress management and spiritual participation, productive and social activities, leisure, activities of daily living (ADLs), and health promotion or risky behaviors. They found several factors that affected participation in healthy lifestyles, including the number of chronic diseases or impairments identified by the person, self-perception of health status, age, gender, race, education, and employment status. On the basis of their findings, they advocated that occupational therapists should consider strengths and vulnerabilities of clients’ personal health factors and demographic attributes for maximum effectiveness when creating intervention plans.
Schmid et al. (2011) found that clients who had fear of falling at hospital discharge had increased anxiety, depression, and lower quality-of-life scores at 6-mo follow-up assessments. These findings led Schmid et al. to advocate that occupational therapists and colleagues consider anxiety and depression when managing the needs of clients with stroke who experience fear of falling.
Directions for the Profession’s Growth
Two basic research studies explored professional growth related to the provision of driving and community mobility services. Stav, Snider Weidley, and Love (2011) conducted a survey of therapists and institutional leaders that explored barriers to developing and sustaining driving and community mobility programs. They found many barriers to developing these programs despite an aging U.S. population. They suggested that occupational therapists access the resource toolkit on AOTA’s Web site to engage in advocacy of the structural, policy, and systemwide changes needed to make driving and community mobility programs available. Yuen and Burik (2011) explored professional entry programs of occupational therapy driving evaluation and rehabilitation (DE/R) curricula. Of the 144 programs, 90 responded to their survey. They found that 80 of the programs included content related to DE/R in required courses and an additional 9 offered required DE/R courses. Some offered electives with DE/R content. Fifty percent of the programs had access to certified driving rehabilitation specialists as contributing educators on DE/R content, and approximately 77% had access to a driving rehabilitation program nearby. The implementation of this content meets the accreditation standards and society’s growing need.
Instrument Development and Testing, Occupational Engagement, and Health
No studies on productive aging published in AJOT in 2011 involved instrument development and testing or demonstrated linkages between occupational engagement and health.
Discussion
In contrast to previous reviews of productive aging (Murphy, 2010, 2011), AJOT published almost twice as many Level I studies in 2011. However, 6 of these were systematic reviews. Consistent with Murphy’s (2010, 2011) previous productive aging reviews, only a single Level I effectiveness study was published in 2011. Although the systematic reviews explored much literature published outside of occupational therapy and often did not specifically identify occupational therapists as team members, the interventions found most beneficial to people with Alzheimer’s disease and related dementia and their caregivers are well within the domain of occupational therapy practice. These interventions included occupation-based interventions, engagement in ADLs and leisure, activity and environmental adaptation and modification, social participation, and caregiver education. These reviews also identified many clinical recommendations that occupational therapists should consider and regularly include in their practice. Such recommendations included always providing caregiver education, using modern technology as a means of providing ongoing support for caregivers, and most important, participating in the creation of comprehensive programs for this population.
Occupational therapists’ ability to assess the complexity of people’s abilities and their contexts, including dynamic interactions with caregivers and both the clients’ and the caregivers’ social participation needs, make occupational therapists essential team members in creating comprehensive programs, and occupational therapists were recommended to advocate for themselves to be active participants of such programming development. Last, many limitations were noted in these systematic reviews, including small sample size, lack of replication, inconsistencies in variables measured, and low levels of evidence of the studies included in some of the reviews. All of these limitations indicate the need for further research.
Basic research increased to 41% from the previous review’s 28% (Murphy, 2011). The basic research studies that focused on client-based issues offered suggestions for improving practice. The two studies on professional issues identified the inclusion of driving rehabilitation in academic preparation while informing the profession that it needs to advocate more vigorously for driving rehabilitation programs to be accessible to an aging society. Basic research is essential for building the foundations and directions for practice evidence and professional growth. It is important that these studies do not fall by the wayside but that their content be extracted for the development of effectiveness studies and best practice.
No productive aging studies were published that involved instrument development and testing. Not only is pursuing instrument development important but so too is continuing to review and evaluate the effectiveness of assessments used in practice through research methods. No studies were published that demonstrated linkages between occupational engagement and health, which continues to be an important venue for occupational therapists to explore not only with people with disabilities, older and frail but well older adults, working older adults, and people experiencing life transitions.
The opportunity to publish in other journals about aging populations and interventions may limit the number of submissions to AJOT. Despite these other opportunities, Murphy’s (2011) review of 2009–2010 noted that although 15 effectiveness studies about occupational therapy were published in other journals, they tended to be pilot studies and lacked details indicating rigor. Thus, as a profession, occupational therapy may still be developing the skill set required to produce high-quality research.
Implications for Occupational Therapy Practice
Although many evidence-based recommendations in the articles reviewed would enhance the quality of occupational therapists’ practice, the following are a few highlights from the articles in each category. The first four bullet items are specifically from the AOTA reviews about effective intervention for people with Alzheimer’s disease and related dementias and their caregivers. The third and fifth bullets are relevant to fall prevention programs for all older adult clients. The last two bullets address the emerging area of driving rehabilitation, including occupational therapists’ expertise and the importance of advocacy for the quality of care for the public health that we value as a profession.
Individually tailoring and adapting leisure activities improves quality of life for both clients and caregivers.
Occupational therapy intervention that promotes clients’ abilities in ADLs and IADLs and educates caregivers in such methods improves satisfaction, participation, and quality of life for both the clients and the caregivers.
Educating caregivers and involving clients in motor-based occupations, exercises, and activities increase balance and decrease falls.
Caregiver education is essential, whether a family member or other health care provider, to improve the relationships, health, and participation of persons with Alzheimer's disease or related dementias.
Community-dwelling older adults benefit from multimedia training about fall prevention that is personally relevant to the participants.
Occupational therapists need to advocate for funding for community-based driving and mobility programs.
Occupational therapists should be engaged in assessing clients who desire to resume driving after a cerebral insult before a behind-the-wheel assessment recommendation is made.
Conclusions
A review of articles published in AJOT in 2011 yielded only 12 articles. Half of these were systematic reviews of the effectiveness of intervention with people with Alzheimer’s disease resulting from AOTA’s evidence-based literature review project. The bulk of the remaining articles were basic research, with three focused on driving rehabilitation. Driving evaluation and rehabilitation appears to have a sustained presence in AJOT and is still considered an emerging practice area. Only 1 RCT effectiveness study was published, indicating that AJOT continues to publish a small number of occupational therapy effectiveness studies on productive aging.
AJOT is AOTA’s flagship journal and, thus, that of the profession. A professional association’s flagship journal should reflect the best evidence of the breadth, depth, and effectiveness of the practice, education, and professional standards. The flagship journal of any association should have the highest impact factor in the profession, reflecting the quality of its contents and its larger societal value. When a profession is recognized by society for its value, it has powerful potential to affect and develop public policy. Therefore, AJOT will be, or should be, the first journal that occupational therapists, occupational therapy educators, other professionals, and policymakers access for the best publications reflecting the profession and the effectiveness of occupational therapy practice to benefit society.
AJOT is committed to assisting in the promotion and fulfillment of the Centennial Vision. The limited effectiveness publications and the large amount of basic research published in AJOT may indicate that the occupational therapy profession’s development is still young. It may be that occupational therapists are still developing the skill sets required to translate practice into research using the required scientific rigor, or perhaps more occupational therapists need to engage in the process of generating publishable evidence. The hope is that as occupational therapy continues to produce practitioners at the graduate level, this commitment to produce evidence for occupational therapy’s effectiveness and efficacy will see many more publications on the societal benefits in all practice areas. This year’s review of productive aging articles published in AJOT indicates that although occupational therapy is on the path to the Centennial Vision, many more quality publications need to be published and read along this path.