Occupational Therapy Practices - Iowa Association of Homes ...

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Level IILevel IIILevel IVLevel VTwo groups, nonrandomized studies (e.g., cohort, case-control)One group, nonrandomized (e.g., before and after, pretest and posttest)Descriptive studies that include analysis of outcomes (e.g., single-subject design, case series)Case reports and expert opinion that include narrative literature reviews and consensus statementsNote: 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, 71–72.Methods Used to Analyze the EvidenceReview of Published Meta-AnalysesSystematic Review with Evidence TablesDescription of the Methods Used to Analyze the EvidenceThe two teams working on each focused question reviewed the articles according to their quality (scientific rigor andlack of bias) and levels of evidence. Each article included in the review was then abstracted using an evidence tablethat provides a summary of the methods and findings of the article, an appraisal of the strengths and weaknesses ofthe study on the basis of the design, methodology, and implications for occupational therapy. Review authors alsocompleted a Critically Appraised Topic (CAT), a summary and appraisal of the key findings, clinical bottom line, andimplications for occupational therapy of the articles included in the review for each question. Review authors alsocompleted Critically Appraised Papers for all articles included in the perception and routines reviews and the Level I, II,and III articles for the occupation review. American Occupational Therapy Association (AOTA) staff and the Evidence-Based Practice Project consultant reviewed the evidence tables and CATs to ensure quality control.Limitations of selected studies incorporated in the review include small sample size, lack of power analysis, and limiteddetail regarding recruitment of participants. In several cases, the study group was heterogeneous and may not havebeen representative of the population with dementia. Depending on the level of evidence, there may have been a lackof randomization, lack of control group, and limited statistical reporting. In many cases, the studies included both alimited description of the outcome measure and explanation of the psychometric properties of the measures. In somecases, the outcome measures were subjective, and there was limited follow-up of the intervention. It is difficult toseparate the effects of a single intervention that is part of a multimodal intervention. In addition, adverse effects of anintervention may not have been included, and some studies did not control for confounders in the analysis. Several ofthe qualitative studies were limited by the amount of information provided about the data collection and analyticprocedures. Because several were published before 2001, the review author indicated that this may be a reflection offewer demands related to trustworthiness and credibility as part of a general limited understanding of qualitativeresearch in older literature.Methods Used to Formulate the RecommendationsExpert ConsensusDescription of Methods Used to Formulate the RecommendationsNot statedRating Scheme for the Strength of the RecommendationsStrength of RecommendationsA—Strongly recommend that occupational therapy practitioners routinely provide the intervention to eligible clients.Good evidence was found that the intervention improves important outcomes and concludes that benefits substantiallyoutweigh harm.B—Recommend that occupational therapy practitioners routinely provide the intervention to eligible clients. At leastfair evidence was found that the intervention improves important outcomes and concludes that benefits outweigh harm.C—No recommendation is made for or against routine provision of the intervention by occupational therapypractitioners. At least fair evidence was found that the intervention can improve outcomes but concludes that thebalance of the benefits and harm is too close to justify a general recommendation.D—Recommend that occupational therapy practitioners do not provide the intervention to eligible clients. At least fairevidence was found that the intervention is ineffective or that harm outweighs benefits.I—Insufficient evidence to recommend for or against routinely providing the intervention. Evidence that theintervention is effective is lacking, of poor quality, or conflicting and the balance of benefits and harm cannot bedetermined.Note: Recommendation criteria are based on standard language developed by the Agency for Healthcare Research and Quality (2009).Cost AnalysisThe guideline developers reviewed published cost analyses.Method of Guideline ValidationPeer ReviewDescription of Method of Guideline ValidationContent experts reviewed this guideline.RecommendationsMajor RecommendationsReferralIn the early stages of Alzheimer's disease, referral to occupational therapy is appropriate when an individual exhibits adecline or impairment in performance of functional activities because of problems with thinking, memory, or executivefunction. The individual may report general memory or communication difficulties to a health care provider, but often afamily member is the one who raises concerns about occupational performance in instrumental activities of daily living(IADLs) and hazardous activities such as cooking on a stovetop, operating machinery, or getting lost when driving.These concerns are frequently echoed by adult children, employers, friends, and community members. In the early
RecommendationsMajor RecommendationsReferralIn the early stages of Alzheimer's disease, referral to occupational therapy is appropriate when an individual exhibits adecline or impairment in performance of functional activities because of problems with thinking, memory, or executivefunction. The individual may report general memory or communication difficulties to a health care provider, but often afamily member is the one who raises concerns about occupational performance in instrumental activities of daily living(IADLs) and hazardous activities such as cooking on a stovetop, operating machinery, or getting lost when driving.These concerns are frequently echoed by adult children, employers, friends, and community members. In the earlystages of the disease, a referral is indicated if cognitive limitations are barriers to participation in daily living skills,social activities, leisure interests, or work and volunteer activities. In the middle stages of the disease, additionalindications for referrals may be to determine service needs such as home health assistance, memory care or dayservice programs, or caregiver respite support. In later stages of the disease, occupational therapy is referred toresolve barriers to performance in self-care or to manage challenging behaviors such as agitation, aggression,disruptive vocalizations, wandering, altered sleep–wake cycles, catastrophic reactions, or frustrations related tocommunication problems.Referrals may be initiated by a client or a family member or may come from a physician (geriatrician, geropsychiatrist,neurologist, family practitioner), nurse (nurse practitioner, public health nurse), neuropsychologist, or social worker.The referral may indicate a specific purpose for the occupational therapy evaluation, such as cognitive performancetesting for diagnostic information (for the physician, the presence of cognitive deficits that affect functionalperformance may discriminate mild cognitive impairment from dementia; a physician would use this information indiagnosing) or be a general order for an evaluation and intervention. For some clients, their first encounter withoccupational therapy is in rehabilitation in a transitional or subacute care unit after a precipitating event, such as a fallor illness. A cognitive functional screening as part of an occupational therapy evaluation may serve as a referral forfurther cognitive assessment. Some specialty memory disorder clinics that use a team approach have a standingreferral for clients that includes occupational therapy evaluation as an integral part of a comprehensive assessment fordementia.EvaluationThe occupational therapy evaluation is conducted with the client, caregiver or family member, or health care proxy tofacilitate an accurate exchange of information. Questions should be directed toward the client, allowing the client totake an active and central role in the interview process. Others present should be encouraged to provide additionalinformation, if appropriate. Information is gathered through an occupational profile (interview), analysis of occupationalperformance (observation), and standardized and nonstandardized assessments. This section of the Guideline outlinesareas for evaluation using the Occupational Therapy Practice Framework (see "Availability of Companion Documents"field) classification and justifies the rationale as it relates to characteristics of Alzheimer's disease.The occupational therapist obtains client information through the occupational profile to determine barriers tooccupational performance. If cognition is the primary concern limiting participation, a brief cognitive assessment usinga screening tool such as the Large Allen Cognitive Lacing Screen is administered to determine whether a full cognitivefunctional assessment is warranted. Some standardized cognitive functional assessments such as the CognitivePerformance Test (CPT) or the Executive Function Test may require additional training to administer and interpret,reflecting a specialized area of practice.An individual with cognitive deficits may exhibit a decline or impairment in performance of functional activities causedby comorbidities that affect motor and praxis, sensory-perceptual, emotional regulation, cognitive, communication, andsocial skills. One difficulty in assessment with comorbidities is delineating the source of the performance deficit. Withclinical expertise, all factors that limit occupational performance are considered, along with thinking, memory, orexecutive function abilities. These factors need to be considered when selecting valid assessment tools. For instance,verbally based assessments may not be valid when auditory deficits are present, and perceptual tests lose validitywhen visual deficits are evident. Through skilled selection and administration of the assessment and interpretation ofthe results, the occupational therapy evaluation contributes to an individualized intervention plan.Occupational Profile (Family/Caregiver Profile)The occupational profile is a nonstandardized assessment to obtain background information about the client (see Table3 in the original guideline document). It includes demographic information about the client, family members, livingsituation, employment or employment history, education, caregivers or people responsible for care, diagnoses includingmental health diagnoses, resources, and reasons for the referral. Questions about leisure interests, strengths andlimitations to participation in daily activities, and goals of intervention can be included (see Table 4 in the originalguideline document for sample questions). The Canadian Occupational Performance Measure is an evidence-based,standardized tool used to identify occupational performance issues and to prioritize the selection of intervention goalswith client and family input. Client and family goals are obtained to guide the family-centered intervention process.The occupational profile includes the client and family member's description of the cognitive or memory impairmentsthat may affect safety. Through the interview, the occupational therapist gains a sense of the client's self-awarenessof disability. Self-awareness is important in making recommendations about supportive living situations and levels ofassistance needed to remain safe in the home environment. Family members should be asked to describe theirobservation of the client's memory or thinking problems. The client's perception may differ from the family member'sperception, especially in the middle to later stages of the disease, which will influence the strategies for intervention.Observation of the client provides an opportunity to screen for client factors that may guide the appropriate selectionof assessments.An occupational history provides information regarding participation in daily activities. "Describe a typical day" is astandard question. The client will identify activities he or she is able to perform or enjoys doing and may be consideredthe client strengths. Often these activities are habits or routines that are well rehearsed or rote, drawn from long-termor procedural memory. An occupational history includes information about those activities the client used to do but nowfinds challenging. An "interest checklist" can stimulate discussion about activities the client desires to continue andbarriers to participation. Attention to the amount of time the person is engaged in activities is important because ofthe tendency to socially isolate or sleep for lengthy periods during the day or the propensity for occupationaldeprivation (obstructing occupational enjoyment because of disease) in the middle to later stages of the disease.An important part of the occupational profile is to gain information about the physical environment, or living situation,and social environment, or available caregiver support. Key to effective management of the disease is providingenvironmental supports for safety and optimal functioning. Clients with dementia symptoms come to an evaluationfrom a variety of living situations with different levels of support—from living independently in a single family home toresiding in a memory care facility with 24-hour supports in place. Promotion of security is targeted to prevent the sixmost common household injuries: falls and slips, burns, poisoning, cuts, electrocution, and drowning. A home safetyassessment such as the Home Environmental Assessment Protocol or Safety Assessment of Function and theEnvironment for Rehabilitation can highlight necessary adaptations to the home to promote a safe environment andsupport caregiver supervisory responsibilities.A significant factor in managing care throughout the course of the disease is the presence of a caregiver. A study on
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