Occupational Therapy to Improve Activities of Daily Living of People With Parkinson’s Disease

Clinical Case

Lawrence is an 80-yr-old White man who was referred to outpatient occupational therapy by his primary care physician because of increasing difficulty with ADLs related to PD. Lawrence was diagnosed with PD 4 years ago and is currently assessed as being in Stage 3 on the Hoehn and Yahr (H&Y; 1967) scale (Forwell et al., 2021), indicating mild to moderate disability with bilateral impairment and impairment of postural reflexes. His comorbidities are hypertension, glaucoma, and chronic myeloid (nonlethal) leukemia.

Occupational Therapy Assessment and Findings

The occupational therapist, Josefina, used the Occupational Profile Template (American Occupational Therapy Association [AOTA], 2021) to guide her in developing a clinical picture of Lawrence. The results are as follows.

Lawrence is a college graduate and a retired nuclear engineer who resides with his adult daughter in a two-story house in a suburb of a southern metropolitan city. His daughter is home in the evenings but works outside of the home during the day. He and his daughter have a good relationship, and she is very supportive. Lawrence’s wife died 4 years ago from conditions related to dementia. There are three steps to enter his house, with rails on each side. Lawrence’s bedroom and full bath are on the first floor, and he does not use the second floor of the house. His bathroom has a tub–shower combination.

Lawrence reports that he can complete most self-care tasks without assistance but that these require increased time, and he experiences difficulty and frustration with some tasks. He requires minimal assistance for tub transfers; showering; walking down stairs if there is no rail; and, on occasion, donning a jacket. Lawrence also states that he experiences difficulty falling asleep and occasional coughing and choking when swallowing certain foods.

Lawrence has stable performance patterns, which consist of completing his self-care ADLs, folding and putting away laundry, fixing his breakfast and lunch, assisting his daughter with dinner, watering the garden, sweeping, and performing his daily exercises. He enjoys volunteering with a men’s committee at his church that assists persons in need with paying their utility bills. He also enjoys reading books, sitting on his porch, and doing watercolor painting. Lawrence states that his goals are to be able to consistently put on a jacket or coat without assistance; complete dressing, shaving, and grooming in less time; shower safely without assistance; sleep better; and swallow without coughing or choking.

Josefina used the Canadian Occupational Performance Measure (COPM; Law et al., 2019) to quantify Lawrence’s current perception of his performance and satisfaction on the 10-point scale in four of his prioritized goal areas. The COPM is a reliable and validated tool for gathering this information. As seen in Table 1, Lawrence’s areas of lowest performance and satisfaction are in showering and speed of completing ADLs.

Josefina then administered several other assessments that are appropriate for use with persons in H&Y Stage 3 of PD. She used the Functional Reach Test (FRT; Duncan et al., 1990) to assess standing balance by measuring the distance that Lawrence could reach forward without moving his feet. To provide an objective and standardized baseline from which to measure Lawrence’s progress toward his goal of completing common tasks more quickly, Josefina chose two assessment tools: the Physical Performance Test (PPT; Reuben & Siu, 1990) and the Sock Test for Sitting Balance (STSB; Franc et al., 2020). The PPT consists of nine tasks (e.g., write a sentence, simulate eating, pick up a penny from the floor) that are each timed in seconds. The STSB uses the task of donning and doffing slipper socks and provides a standardized protocol for measurement of speed of completion. To assess Lawrence’s current level of sleep function, Josefina used the Pittsburgh Sleep Quality Index (Buysse et al., 1989), a 19-item questionnaire on which a person self-rates their sleep quality, latency, duration, efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. Finally, Josefina used the Swallowing Clinical Assessment Score for Parkinson’s Disease (Loureiro et al., 2013) to measure Lawrence’s swallowing performance using three consistencies of food: liquid, paste, and solid. Clients are scored on performance in the oral and pharyngeal phases and on signs of aspiration. The results of these assessments are given in Table 1.

After the assessments were completed, Josefina reviewed the results with Lawrence and his daughter. Although Lawrence was surprised that his FRT score indicated a high risk for falls, he was otherwise unsurprised by the results and excited about getting started on trying to beat some of his scores. All three of them then collaborated on creating his intervention goals.

Occupational Therapy Intervention

All of Lawrence’s desired goals were ADL tasks; therefore, Josefina reviewed the evidence for interventions found to be effective in improving ADL performance in persons with PD included in the systematic review by Doucet et al. (2021). She found the following information that could guide her in choosing interventions:

▪ moderate strength of evidence for multimodal exercise and mindfulness to improve ADL and sleep performance,

Josefina noted that many of the studies in the systematic review had small numbers of participants and none of the relevant intervention categories had a strong strength of evidence. In developing her treatment plan, she therefore did not rely solely on the results from the review but also performed a literature search on recommended sleep hygiene routines, consulted with an experienced occupational therapist coworker, reflected on her own clinical experiences, and kept Lawrence’s preferences and interests in mind. Josefina and Lawrence agreed on a schedule of outpatient occupational therapy 2 times per wk for 6 wk. Desired outcomes included independent and safe performance of showering, more efficient performance of other ADLs, faster initiation of sleep, and a decline in coughing and choking with swallowing.

Multimodal Exercise Intervention

Although exercise had not been one of Lawrence’s interests in the past, he expressed a willingness to try new activities that could potentially improve his independence and speed in getting things done. The evidence from most of the studies that showed improvement in ADLs had used multimodal exercise at a frequency of 3 times per wk (Doucet et al., 2021). Josefina found a community Dance for PD^® program (Dance for Parkinson’s, 2022) that he was excited to start 2 times per wk while completing supervised multimodal exercise in his occupational therapy sessions 1 time per wk. Both types of exercise incorporated elements that had been found to be effective: a combination of exercise that targets aerobic capacity, strength, coordination, and balance.

Gaming Intervention

Lawrence had enjoyed playing Wii games with his grandchildren in the past and was open to trying new games that have been shown to be effective in improving ADL performance. Using the evidence, and on the basis of the protocols from the studies that used the Wii with persons with PD by Gonçalves et al. (2014) and Herz et al. (2013), Josefina created a program consisting of a combination of Wii tennis, bowling, boxing, and ski slalom. Lawrence performed these games during occupational therapy so that cues could be provided, and the games graded for progress, in addition to creating a home program of Wii games. Josefina also incorporated non–computer-based games that could easily be performed at home with few materials and that use the whole body while also engaging the mind.

Interventions to Improve Sleep: Cognitive–Behavioral Therapy and Bright Light Therapy

Although frustrated with how long it was taking him to fall asleep, Lawrence was initially resistant to changing his sleep preparation routine. Josefina used cognitive–behavioral interviewing techniques, such as asking open-ended questions that gradually pointed out the discrepancy between his sleep hygiene habits and his goals, combined with education on recommended sleep hygiene tasks (Hershner & Shaikh, 2020). Lawrence then agreed to change his current sleep preparation habits for a 2-wk period while also tracking the amount of time it took him to fall asleep, and his total number of sleep hours, in a journal. One of the studies in the systematic review by Doucet et al. (2021) used a combination of CBT with bright light therapy for sleep (Rios Romenets et al., 2013). Lawrence had the financial resources to consider bright light therapy in addition to a new sleep hygiene routine to improve his sleep initiation. Josefina provided him with a picture of a 10,000-lux light box and her recommendations for its use and asked Lawrence to bring it with him on his next scheduled physician’s appointment. If his physician agreed with the recommendation, Lawrence would purchase the light box online and set it up at home with the assistance of his daughter.

Interventions to Improve Swallowing: Multimodal Exercises

Josefina searched the AOTA website to access additional issues of AJOT using the keywords adult, swallowing, and assessment. A systematic review of occupational therapy interventions for adverse events in inpatient and home health care addressed suggested interventions for dysphagia and swallowing difficulties (Hunter & Rhodus, 2022). Two dysphagia exercises in particular—chin tucks performed against resistance and strong forced expirations—resulted in notable improvements when performed regularly with therapist supervision. Because multimodal exercises were noted to be of benefit for the PD population in Doucet et al.’s (2021) review, Josefina combined these exercises with additional oro-facial movements, such as extreme grinning, frowning, pursing of lips, puffing of cheeks, and so on, into Lawrence’s sessions. As mentioned previously, Lawrence did not care for exercising, but performing these movements evoked laughter and emotion from Lawrence (and Josefina as well), and it became a routine they both enjoyed. In addition, one article from Doucet et al.’s (2021) review found that patients who performed singing 1 to 2 times per wk could improve laryngeal function for swallowing (Stegemöller et al., 2017). Because Lawrence enjoyed singing, he and Josefina sang at least two familiar songs as part of their sessions. They completed the session with Lawrence enjoying a drink of water or juice with cookies or crackers while he actively worked on limiting the amount of food intake per bite, managing the bolus within the oral cavity, and using strong swallowing to avoid coughing and choking.

After 6 wk, Lawrence was scheduled to be discharged from occupational therapy; the plan was to continue his activity program at home with the assistance and encouragement of his daughter as needed. Josefina carefully considered client-centered activities that would motivate Lawrence and facilitate this carryover. Lawrence’s daughter was instrumental in challenging him to perform his dressing and grooming tasks in a more timely manner. Josefina recommended a tub bench for Lawrence’s bathroom that would allow him to perform his showering more independently from a seated position. Josefina set up the tub bench and educated Lawrence and his daughter in its use. They both reported that Lawrence was able to transfer and shower safely with only supervision from this seated position. Josefina readministered the instruments from Lawrence’s initial evaluation. The results of these measures are given in Table 2.

Conclusion

With targeted and multimodal exercise program components as well as task-specific practice in ADLs, Lawrence’s discharge scores showed gains in performance of functional daily tasks and progress toward his desired goals. By using current evidence within occupational therapy and the health sciences, Josefina was able to translate the findings from systematic reviews and other studies to create an occupation-focused intervention plan to address Lawrence’s desired outcomes. Given the typical progressive nature of PD, maintenance as well as improvement of ADL performance can be possible when evidence-based strategies are used consistently for occupational therapy intervention.