Occupational Therapy Interventions for Older Adults With Alzheimer’s Disease and Related Dementias

Occupational Profile

Emery (he/him/his) is a 79-yr-old man who currently resides in an income-based ALF with an option of transitioning to a memory care unit as his dementia progresses. He grew up in an urban area and worked various jobs to make ends meet. Some of the jobs included a grocery store clerk, parking attendant, janitor, and short-order cook at a local diner. He never married or had children but has two nephews and a niece with whom he is very close. His hobbies include reading, photography, collecting vintage records, and playing chess at the local park. Emery was referred to a neurologist about 1 yr ago by his primary care physician and received a formal diagnosis of Alzheimer’s disease approximately 6 mo ago. His nephews and niece are Emery’s biggest supporters and helped him come to the decision that, given his recent diagnosis, an ALF would be the safest and most beneficial living situation.

Emery moved into the ALF just over 1 mo ago and continues to have a difficult time with the transition. He appears to have a difficult time accepting assistance from others, seems overwhelmed by having to adjust to a new routine, complains of pain, and reports feeling out of place eating in the dining room and participating in social events given that he is used to eating and engaging in hobbies mostly on his own. One of Emery’s nephews has asked the staff at the ALF if there is anything that can be done to assist his uncle in making the transition more successful. The staff requested a referral to occupational therapy for an evaluation.

Occupational Therapy Initial Evaluation and Findings

Emery’s occupational therapist, Isabella, completed an occupational therapy evaluation starting with an Occupational Profile (American Occupational Therapy Association, 2020). Emery’s niece and the ALF staff were interviewed and provided additional information.

The findings revealed the following:

▪ His prior medical history includes hypertension, osteoarthritis, atrial fibrillation, and glaucoma.

Table 1 presents the findings from the other assessments administered during the evaluation: the Rating Anxiety in Dementia (RAID; Snow et al., 2012), Pain Assessment in Advanced Dementia Scale (PAINAD; Warden et al., 2003), Katz Index of Independence in Activities of Daily Living (McCabe, 2019), Allen Cognitive Level Screen–II (Allen, 1991), and Allen Diagnostic Module–Second Edition (Earhart, 2006).

Isabella reviewed the assessment findings with both Emery and one of his nephews, and they determined that Emery would benefit most from interventions to address anxiety, pain, and cognitive function as well as to promote mood and social engagement.

Occupational Therapy Interventions

To begin the intervention planning process, Isabella reviewed the evidence from the Occupational Therapy Practice Guidelines for Adults Living With Alzheimer’s Disease and Related Neurocognitive Disorders (Smallfield et al., 2024). This evidence helped guide several of the interventions; however, Isabella also used her clinical experience and Emery’s and his nephews’ and niece’s preferences to develop a client-centered intervention plan. They determined that Emery would be seen for skilled occupational therapy services 3×/wk for 6 wk. The interventions were selected to specifically target his anxiety, pain, and cognitive function as well as to promote mood and social engagement. Sessions included a combination of both individual and group modes of therapy. The interventions described in the sections that follow are example interventions that could be implemented to address concerns in other people with dementia and promote improved transitions to an ALF.

Self-Care and Leisure Interventions

Emery participated in individual self-care/leisure interventions 1×/wk for 6 wk, 45 min for each session, to address anxiety and establish a routine because it had become increasingly clear that his anxiety caused him to be reluctant to leave his room and to participate in ADL tasks. Over the 6-wk period, the sessions progressed from participation in preferred activities to activities that provoked higher levels of anxiety for Emery. Isabella did find a Systematic Review Brief (Smallfield et al., 2023) that identified cognitive–behavioral therapy (CBT) as an effective intervention for reducing anxiety in people with dementia. However, in her experience, standard CBT can be difficult to implement with dementia patients because of limitations in cognition, so she used her clinical expertise and reviewed additional literature to help guide her intervention (Kraus et al., 2008). She decided to integrate some elements of CBT strategies into Emery’s self-care routine and to include caregivers in the intervention. Each session started with Emery sharing the level of anxiety he was experiencing, on a scale of 1 to 10. This was followed by instruction on deep-breathing techniques and affirmations that he could use while participating in activities that he felt made his anxiety increase (Kraus et al., 2008). An example of an adapted activity in which he implemented the strategies entailed him playing a game of chess with Isabella while practicing deep-breathing techniques and stating a self-chosen affirmation, such as “There is nothing to be anxious about.” An example of a more anxiety-provoking activity included assisting Emery in his morning bathing routine, during which time Emery received instructions on practicing deep-breathing techniques, with his favorite song, “Don’t Worry, Be Happy,” playing in the background while he was encouraged to sing along. During Weeks 5 and 6, ALF staff were present during the intervention sessions, when available, to receive education on serving in a coaching role to help Emery implement the strategies (Kraus et al., 2008). Emery and Isabella also created a visual weekly schedule that included mealtimes, Emery’s shower days, and activities of interest in the facility to participate in. ALF staff were also provided with a schedule to help ensure consistency. Emery reported that he felt better after most of the sessions and said he was looking forward to implementing the strategies he had learned and getting into a more consistent routine (CPT^® code 97535, Self-Care/Home Management Training, direct, 15 min).

Reminiscence Interventions

To develop a sense of place, Emery participated in individual reminiscence interventions 1×/wk for 6 wk, 45 min for each session, to address cognitive function (Duan et al., 2018; Lee et al., 2022) and to promote enhanced mood and social engagement. Isabella invited his nephews and niece to each of the sessions (each of his nephews attended one session, and his niece attended two sessions). Before the first session, Isabella and Emery had a conversation about how Emery would like his room to be arranged and made a list of items he would like his nephews and niece to bring in from his previous apartment (one of the nephews had rented a storage locker to store the contents of Emery’s apartment until they decided what to do with all the items). After this conversation, Isabella worked with the maintenance crew to rearrange Emery’s room the way he wanted it. She also asked his nephews and niece to bring family photos and any of Emery’s records they could gather to play on the vintage record player in his room during the interventions. During the first treatment session, Emery’s preferred music was played while he and one of his nephews labeled the photos with all known information (i.e., people’s names and ages as well as the location where the photo had been taken). (Emery’s niece and one of his nephews were not present at this first session.) The photos were then placed in a photo album for safekeeping, with a few of Emery’s favorites selected to put in frames around his room. Isabella used this time to ask Emery open-ended questions about the various photos. She used this as an opportunity to model to the nephew and niece the types of questions to ask, along with ensuring that the photo was within Emery’s visual field. Isabella also educated the nephew on how to prompt Emery with information to answer the questions, when needed, but emphasized the importance of allowing Emery enough time to respond before providing prompts. Emery’s preferred music continued to be an important part of subsequent sessions and the photos were again used, in addition to other sensory stimuli, such as smell, taste, and touch, to provoke discussions about past events and memories. Emery’s niece and nephew who were not present at the first session, along with the staff at the facility, were provided with the same education as the nephew was in that session so they could help promote discussions about and stories from Emery’s past. Isabella recommended that these strategies be used before ADL and IADL tasks that tended to provoke increased anxiety for Emery. Emery was an active participant in the reminiscence interventions; he engaged in discussions and shared stories with his nephews, niece, and Isabella. In addition, he felt a sense of pride when sharing his photos with the staff and other residents at the ALF (CPT code 97129, Cognitive Function, direct, initial 15 min, and CPT code 97130, Cognitive Function, direct, each additional 15 min).

Group Music Interventions

Emery participated in a group music and movement intervention 1×/wk for 6 wk, 45 min for each session, to address cognitive function (Dorris et al., 2021; Lee et al., 2022) and pain (Pu et al., 2019) and promote social integration and participation. Isabella surveyed all the group members and their families to create a play list of favorite songs, past and present. Before each session, she choreographed dance moves that went along with the different songs and were within the group members’ physical capabilities. Although the PAINAD was selected to be used as a pre and post measure before the start of the 6 wk and after the final session, Isabella was also interested to see how Emery interpreted his pain before and after each group session. She selected a visual analogue scale (VAS; Hayes & Patterson, 1921) to use with Emery. A few minutes at the start of each session were dedicated to having the members introduce themselves, and a few minutes were provided at the end to allow members to talk to one another. Isabella purposefully sat Emery next to the gentleman whom he sat near in the dining room and with whom he occasionally played chess. Group participants were encouraged to sing along, participate in the choreographed dance moves, or make up their own dance moves, as desired. Emery, along with other participants, was invited to participate in the singing and movements and standing if they could safely tolerate doing so. Musical instruments were also available to participants for use during the group. Emery was an involved member of the group: He consistently sang aloud to the songs he knew, moved to the music, and demonstrated reduced indicators of pain throughout the sessions, as evidenced by his ratings on the VAS before and after each session. At the end of the 6 wk, Emery asked if there were any other music and music groups that were going to be held at the ALF. The recreational therapy team was informed of his interest and began a biweekly group for interested residents (CPT code 97150, Therapeutic Procedures, Group).

Outcomes

At the completion of the 6 wk of occupational therapy interventions, Emery began settling into his newly established routines at the ALF. He became a more active participant in activities offered at the facility and began to sit with one other gentleman during lunch and dinner. Two days a week, Emery and this gentleman stay in the dining area after lunch and play a game of chess. Although Emery continues to require intermittent assistance from staff for reminders with thoroughness with ADLs, he has become more comfortable accepting assistance from the staff. When asked, Emery still reports occasional complaints of pain; however, at the end of the 6 wk his PAINAD score had decreased, indicating an improvement in pain from moderate to mild (Table 2). Emery’s nephews and niece report that they have seen a huge positive difference in their uncle and that he seems to be less anxious, feeling more at home than he had previously. The staff at the ALF have also seen positive changes that are consistent with what the family reports and his results on the RAID. As a part of his maintenance program, Emery continues to participate in the recreation department’s music group. Staff have also been educated on strategies to ensure that Emery continues to perform his dressing and bathing with as much independence as possible while ensuring appropriate clothing and adequate hygiene. In addition, staff at the ALF, as well as Emery’s nephews and niece, have been instructed to remind Emery to use deep breathing and have been provided with a few phrases to use when he appears to become increasingly anxious. Emery was discharged from therapy services; however, Isabella told the staff at the ALF, and his niece and nephews, not to hesitate to reach out if there were any future changes in functional status that indicate he may benefit from additional services.