Abstract
Evidence Connection articles provide a clinical application of the evidence from the systematic reviews developed in conjunction with the American Occupational Therapy Association’s (AOTA’s) Evidence-Based Practice Project. In this Evidence Connection article, we describe a case report of an older adult recently diagnosed with Parkinson’s disease. The occupational therapy assessment and intervention process in the outpatient clinic is described. This Evidence Connection article is based on findings from an AOTA systematic review on interventions within the scope of occupational therapy practice to improve and maintain participation in education, work, volunteering, and leisure and social activities among adults with Parkinson’s disease. Each article in this series summarizes the evidence from the systematic reviews on a given topic and presents an application of the evidence as it relates to a clinical case. Evidence Connection articles illustrate how the research evidence from the reviews can inform and guide professional reasoning.
The authors describe a case report of an older adult recently diagnosed with Parkinson’s disease.
Parkinson’s disease (PD) is the second most common neurodegenerative disease among older adults (Tysnes & Storstein, 2017). It is estimated that 1 million people are living with PD in the United States (Marras et al., 2018). PD typically affects men age 50 yr and older; however, men and women younger than this age are diagnosed every year (Marras et al., 2018). The number of people diagnosed with PD continues to increase, and the combined prevalence for men and women older than age 45 yr is 572 per 100,000 (Marras et al., 2018). As the number of people living with PD increases, the need for occupational therapy services rises because of the multifaceted effects on one’s life.
PD is the progressive loss of the voluntary fine and gross motor movements of the extremities, trunk, face, and muscles of the voice (Foster et al., 2018). Declines in coordination, flexibility, movement quality, and speed affect activity participation. Hypophonia and micrographic deficits are also noted with PD. People living with PD typically experience symptoms such as bradykinesia, tremor, and rigidity (Tysnes & Storstein, 2017). These traits affect all activities, leading to a higher risk of falls, isolation, and other physical and psychosocial impairments (Foster et al., 2018). Additionally, nonmotor symptoms associated with medications to treat PD can result in dementia, anxiety, depression, impulsivity, sleep disturbances, pain, and visual deficits (Foster et al., 2018). All these symptoms can affect performance and participation in education, work, volunteering, and social and leisure activities.
As identified in the Occupational Therapy Practice Framework: Domain and Process (4th ed.; OTPF–4; American Occupational Therapy Association [AOTA], 2020b), occupational therapy practitioners value occupational engagement to promote health, well-being, and participation in life. When working with people with PD, practitioners should not solely focus on strength, flexibility, cardiovascular health, and balance without a connection to meaningful engagement in occupation. Considering use of a top-down assessment approach enables the discovery of the meaningfulness associated with occupational engagement (Weinstock-Zlotnick & Hinojosa, 2004).
Clinical Case
John is a 78-yr-old real estate broker diagnosed with PD who was referred to an outpatient occupational therapy clinic because of a series of falls and a decline in self-care, leisure, and social participation.
Occupational Therapy Assessments and Findings
John’s occupational therapist, Nancy, conducted the assessment and completed the Occupational Profile (AOTA, 2021), which revealed the following information: John and his wife Mary live in an urban area within 10 mi. of the nearest medical center. His residence is located in the Midwest, which experiences all seasons, including winters, so weather may limit outdoor activity. John’s bedroom and bathroom are located on the main level of the home. John’s bathroom is not accessible with his four-wheeled walker. John’s bathroom has a standard-height commode, a walk-in shower with a 2-in. threshold, and a built-in shower seat. There are no grab bars. John accesses the home through the garage, where two steps are required to enter. A handrail is not present. Mary provides 50% assistance with self-care and completes most home management activities. She has a housekeeper who assists twice monthly, although she has discontinued this service because of the coronavirus disease 2019 (COVID-19) public health emergency. Because of urinary urgency, Mary assists with urinal use to prevent accidents. John routinely engages in Rock Steady boxing classes (a noncontact boxing program designed for people with PD; https://www.rocksteadyboxing.org/) 3 to 4 times per week, although he has not attended since the beginning of the COVID-19 public health emergency. John has been engaging virtually in a voice therapy group; Mary assists with computer setup and use. John enjoys spending time with friends and attending performances at the theater, although he has also restricted these activities because of the pandemic. John has a transport chair that Mary pushes when they engage in activities outside the home. Over the past 9 mo, John has experienced numerous falls (2–3 per week) and increased isolation. He and Mary report limiting activities outside the home to physician appointments.
In addition to obtaining information through informal interview to complete the Occupational Profile (AOTA, 2021), Nancy administered the Canadian Occupational Performance Measure (COPM; Law et al., 2014) and the Activity Card Sort (ACS; Baum & Edwards, 2001) as part of a client-focused evaluation process. All the assessment tools were used to obtain John’s occupational history and areas of concern and to collaborate on goal setting. Self-assessments also administered included the Fatigue Severity Scale (FSS; Krupp et al., 1989), the 9-item Patient Health Questionnaire (PHQ–9; Kroenke et al., 2001), and the 39-item Parkinson’s Disease Questionnaire (PDQ–39; Jenkinson et al., 1998). Standardized testing also included the Timed Up and Go test (TUG; Podsiadlo & Richardson, 1991), the Berg Balance Scale (BBS; Berg et al., 1995), and the Nine Hole Peg Test (Mathiowetz et al., 1985; Table 1).
Assessment Findings
Note. ACS = Activity Card Sort; ADLs = activities of daily living; BBS = Berg Balance Scale; COPM = Canadian Occupational Performance Measure; FSS = Fatigue Severity Scale; IADLs = instrumental activities of daily living; PDQ–39 = 39-item Parkinson’s Disease Questionnaire; PHQ–9 = 9-item Patient Health Questionnaire; TUG = Timed Up and Go test.
Nancy reviewed the assessment findings with John and Mary and collaboratively focused on information obtained when completing the Occupational Profile (AOTA, 2021), the COPM (Law et al., 2014), and the ACS (Baum & Edwards, 2001) in goal setting. John specifically wanted to explore different ways to engage in leisure and social activities, discuss how to make his home safer, and find ways to get around his home and the community without falling.
Occupational Therapy Intervention
To address John’s goal to engage in leisure and social activities, Nancy reviewed the evidence from the systematic review on interventions to improve or maintain performance in leisure and social participation among adults with PD (Reiling Ott & Kolodziejczak, 2020). She intended to use the findings to help guide her interventions. However, Nancy discovered that most of the studies in the systematic review had low strength of evidence. Only one intervention, Argentine tango dance classes, presented moderate strength of evidence and resulted in significant benefits. Because John had no interest in attending dance classes, Nancy also reviewed other sources to guide the intervention plan, including the OTPF–4 (AOTA, 2020b) and the AOTA Official Document “Occupational Therapy in the Promotion of Health and Well-Being” (AOTA, 2020a).
To address John’s goals related to making his home safer and preventing falls, Nancy reviewed the systematic review on the effect of home modification interventions on participation of community-dwelling adults with health conditions (Stark et al., 2017), the systematic review on fall prevention interventions for community-dwelling older adults (Elliott & Leland, 2018), the systematic review on falls self-management interventions for people with PD (Owen et al., 2019), and the AOTA Official Document, “Assistive Technology and Occupational Performance” (AOTA, 2016).
Using the best evidence available, clinical expertise, and John’s preferences, Nancy developed a client-centered intervention plan that included activity- and occupation-based interventions to support John’s occupational performance. Nancy also made a plan to collaborate with John’s medical team to address John’s fall history and safety concerns. John attended 20 of 20 sessions over a 7-wk period. The sessions focused on social and leisure participation strategies, home assessment and modification guidance to address falls and safety concerns, and a seating and mobility evaluation.
Intervention 1 (Social Participation)
John’s ability to engage in his typical social participation routines (e.g., Rock Steady boxing and going to the theater with friends) was limited because of restrictions associated with the COVID-19 public health emergency. Nancy collaborated with John and Mary to explore new social participation routines that he could engage in at home during quarantine. Recognizing that John was engaging in a virtual voice therapy group, Nancy worked in collaboration with John and Mary to explore additional virtual options for leisure and social participation. Nancy assisted John in identifying community-based classes that used a virtual platform and group-based approach as a potential strategy to increase leisure and social participation, and John (with Mary’s assistance) signed up to participate in two classes within the first week. Nancy also encouraged John to invite his friends to virtual get-togethers over a video meeting platform to discuss past theater performances and recent movies.
Intervention 2 (Home Modification)
Nancy requested permission to schedule a time to complete a home safety assessment. Because of the COVID-19 public health emergency, John and Mary were apprehensive about hosting a visitor. Nancy suggested using a virtual meeting platform to conduct the home assessment, and John and Mary agreed to proceed. Nancy wanted to complete the virtual home assessment to address fall prevention and accessibility. The assessment process included gaining additional information about the client’s personal abilities, identifying the barriers in the home environment in relation to the client’s occupational goals, providing recommendations to address barriers, supporting the implementation of recommendations, and providing caregiver training (Stark et al., 2017).
After the virtual home assessment, Nancy met with John and Mary to review the results and to discuss potential solutions, and she made the following recommendations: Rearrange furniture to create space and placement when needed as an external support. Remove throw rugs. Place grab bars next to the commode, on the wall when entering the shower, and on a wall within the shower. Place nonslip strips on the floor of the shower. Convert the walk-in shower to a roll-in shower. Install a therapeutic-height commode to assist with sit-to-stand transitions. Widen the bathroom doorway for ease in access. Install a motion-activated light sensor. Add a bed rail to assist with getting in and out of bed. Install a wheelchair-accessible ramp or wheelchair lift to assist when entering the home from the garage.
Additionally, in the clinic, Nancy taught John and Mary strategies related to energy conservation, fall recovery, and other fall prevention (i.e., reducing impact of postural hypotension, ensuring adequate lighting, and providing appropriate nutrition and hydration, continence management, and relaxation techniques; Elliott & Leland, 2018). Nancy also created scenarios simulating a fall by which John and Mary were able to work together to problem solve through the situation. John and Mary used furniture as supports and handling techniques for which Nancy provided guidance and feedback as needed. Further discussions centered around the consideration of footwear to help prevent falls (Elliott & Leland, 2018). Nancy encouraged John to wear lace-up, low-heeled, enclosed footwear with rubber soles. Nancy also encouraged continued participation in the Rock Steady boxing classes as a means of physical activity to promote balance (Owen et al., 2019).
Intervention 3 (Home and Community Mobility)
Because of John’s fall history, Nancy completed an assistive technology evaluation focused on seating and mobility to identify the safest option for John when navigating his home and community environments and performing daily occupations. Nancy evaluated John’s occupational participation needs and his current capabilities; she also examined the contexts that presented barriers to his performance (AOTA, 2016). On the basis of John’s needs, interests, goals, supports, and barriers affecting participation in meaningful occupations, a power wheelchair was recommended. Nancy worked with John, Mary, and the assistive technology professional to ensure that the specifications of the recommended equipment aligned with John’s needs, goals, and abilities.
Conclusion
Using evidence-based and client-centered interventions, John met his goals after completing 7 wk of outpatient occupational therapy. John and Mary reported increased engagement in meaningful activities and improved satisfaction with the level of engagement (Table 2).
Outcome Measures at Discharge
Note. ACS = Activity Card Sort; BBS = Berg Balance Scale; COPM = Canadian Occupational Performance Measure; FSS = Fatigue Severity Scale; IADLs = instrumental activities of daily living; PDQ–39 = 39-item Parkinson’s Disease Questionnaire; PHQ–9 = 9-item Patient Health Questionnaire; TUG = Timed Up and Go test.
This Evidence Connection article provided an example of how occupational therapy practitioners can apply evidence from a systematic review on interventions to improve performance in leisure and social participation among adults with PD (Reiling Ott & Kolodziejczak, 2020) in addition to other sources to inform their clinical decision-making process.