Physical and social environment in the occupational therapeutic intervention process for elderly with Alzheimer’s disease and their caregivers: a systematic review of the literature

Bernardo, Lilian Dias; Raymundo, Taiuani Marquine

doi:10.4322/2526-8910.ctoAO1064

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Review Article • Cad. Bras. Ter. Ocup. 26 (02) • Apr 2018 • https://doi.org/10.4322/2526-8910.ctoAO1064 copy

Physical and social environment in the occupational therapeutic intervention process for elderly with Alzheimer’s disease and their caregivers: a systematic review of the literature

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Introduction:

Alzheimer’s disease has a significant impact on patients and their families. The restriction on participation is understood in its totality only if considered the context and environment in which the activities happen. In occupational therapeutic intervention, the actions aimed to the environment have been effective in engaging the elderly in significant occupations.

Objective:

Analyze the intervention process directed to the physical and social environment of the elderly with Alzheimer’s disease.

Method:

A systematic review was conducted, in a 10-year period (2006-2015), in English, Portuguese, and Spanish. The Web of Science, MEDLINE / PubMed, CINAHL, PsycINFO^®, LILACS, SciELO, OTSeeker, and PEDro databases were used as sources of information. The inclusion criteria were selected for deeper analysis: scientific publications related to Alzheimer’s disease in elderly with the participation of at least one occupational therapist as an author and that considered the environmental interventions, or to discuss occupational therapy in Alzheimer’s disease without restrictions on the stage of the disease.

Results:

A total of 141 articles were found, of which only 9 met the selection criteria. National and international studies have shown close association of these interventions with the patient’s functionality, humor and quality of life of the dyad, better sense of competence among caregivers, less burden of work, and better cost-effectiveness.

Conclusion:

Occupational therapy, through environmental modification and educational actions, promotes improvement in the quality of life of the dyad.

Keywords:
Occupational Therapy; Alzheimer Disease; Aged; Environment; Systematic Review

Information sources	Search Expressions	Result
CINAHL with Full Text (EBSCO)	(“occupational therapy” OR “Occupational therapy/methods”) AND (“Alzheimer” OR “Alzheimer disease” OR “Alzheimer’s disease”) AND (“behavior” OR “environment” OR “cognition” OR “occupation” OR “activities” OR “social support” OR “caregivers”)	86
LILACS	“Alzheimer” [Palavras] and “occupational therapy” [Palavras] OR “Behavior” [Palavras] and “Alzheimer disease” [Palavras] OR “environment” [Palavras] and “Alzheimer disease” [Palavras] OR “caregivers” [Palavras] and “Alzheimer disease” [Palavras]	206
MEDLINE/ PubMed (via National Library of Medicine)	(“occupational therapy” [All Fields] OR “Occupational therapy/methods”[All Fields]) AND (“Alzheimer”[All Fields] OR “Alzheimer disease”[All Fields] OR “Alzheimer’s disease”[All Fields])) AND (“behavior”[All Fields] OR “environment”[All Fields] OR “cognition”[All Fields] OR “occupation”[All Fields] OR “activities”[All Fields] OR “caregivers”[All Fields] OR “social support”[All Fields])	167
OTseeker	(“occupational therapy” OR “Occupational therapy/methods”) AND (“Alzheimer” OR “Alzheimer disease” OR “Alzheimer’s disease”) AND (“behavior” OR “environment” OR “cognition” OR “occupation” OR “activities” OR “social support” OR “caregivers”)	13
PsycINFO	Any Field: “occupational therapy” OR “Occupational therapy/methods” AND Any Field: “Alzheimer” OR “Alzheimer disease” OR “Alzheimer’s disease” AND Any Field: “behavior” OR “environment” OR “cognition” OR “occupation” OR “activities” OR “social support” OR “caregivers”	224
PEDro	“Alzheimer” OR “dementia”	31
Scielo Citation Index	Tópico: (occupational therapy) AND Tópico: (Alzheimer disease) OR Tópico: (behavior) ANDTópico: (Alzheimer disease) OR Tópico: (environment) AND Tópico: (Alzheimer disease) OR Tópico: (caregivers) AND Tópico: (Alzheimer disease)	137
Scopus	TITLE-ABS-KEY (“Occupational Therapy” OR “Occupational therapy/methods”) AND TITLE-ABS-KEY (“behavior” OR “environment” OR “cognition” OR “occupation” OR “activities” OR “social support” OR “CAREGIVERS”) AND TITLE-ABS-KEY (“Alzheimer” OR “Alzheimer disease” OR “Alzheimer’s disease”)	233
Web of Science	Tópico: (“occupational therapy” OR “Occupational therapy/methods”) AND Tópico: (“Alzheimer” OR “Alzheimer disease” OR “Alzheimer’s disease”) AND Tópico: (“behavior” OR “environment” OR “cognition” OR “occupation” OR “activities” OR “social support” OR “caregivers”)	66
Total Article Search		1,163

Nº	AUTHORS	OBJECTIVES	METHODOLOGICAL DESIGN	RESOURCES USED	OUTCOMES	LIMITATIONS OF THE STUDY
01	Graff et al. (2007GRAFF, M. J. L. et al. Effects of community occupational therapy on quality of life, mood, and health status in dementia patients and their caregivers: a randomized controlled trial. Gerontological Society of America, Washington, v. 62, n. 9, p. 1002-1009, 2007.)	To verify that intervention improves mood, quality of life, health status, and sense and control over the lives of these patients and their informal caregivers.	Randomized Clinical Trial. Participants: 135 dyads. In the follow-up: 105 dyads. Intervention group: OT. Control group: without OT. Outcome measures: COPM, OPHI-II, DQoL, GHQ-12, CSD, CES-D, Mastery Scale	Environmental modifications to adapt ADLs. Cognitive and behavioral interventions Caregiver Orientation	1) Patients and caregivers who received OT improved significantly compared to the start of treatment, regarding overall quality of life, health status, and mood. 2) At the follow-up, the results of the intervention group remain better than the control group. 3) Strong association between daily functioning of the patient, mood, and quality of life in the caregivers’ sense of control over life.	It is not possible to conduct a double-blind study (convenience sample). The sample may not be representative of all types of patients in the region.
02	Graff et al. (2008GRAFF, M. J. L. et al. Community occupational therapy for older patients with dementia and their caregivers: cost effectiveness study. BMJ, London, v. 336, n. 7636, p. 134-138, 2008.)	To evaluate the cost-effectiveness of an OT service in the community compared to the usual care for elderly people with dementia and their caregivers.	Randomized Clinical Trial. Participants: 132 dyads. Intervention group: 10 sessions (1 hour) of OT at home for 5 weeks Control group: no OT. Outcome measures: CIRS-G, RMBPC, AMPS, IDDD, Cornell SCQ Depression Scale, CES-D	Environmental modifications to adapt ADL. Cognitive and behavioral interventions Caregiver Orientation Cost-effectiveness: daily expenses	1) Costs to visit doctors and hospitals were the same in the groups. The costs of home care, social work, physiotherapy, day-care use and meal delivery were all lower in the intervention group, as well as hospital admission and in homecare institutions. 2) Average saving of 1,748 euros per dyad of the intervention group, in the period of 3 months.	Not compared to other types of treatment. The sample may not be representative.
03	Chiu et al. (2009CHIU, T. et al. Internet-based caregiver support for chinese canadians taking care of family member with Alzheimer Disease and related dementia. Canadian Journal on Aging, Ontario, v. 28, n. 4, p. 323-336, 2009.)	To explore the reliability and usability of an Internet-based caregiver support service (ICSS), and to evaluate the effect of caregiver participation on health.	Longitudinal descriptive and in-depth interviews Participants: 28 Chinese caregivers living in Canada. Outcome measures: BSFC, RMBPC, CES-D Self Rated Health, MSPSS, PAC, OARS CCS	Use of the online program to guide about dementia	1) Usability of ICSS: Chinese prefer to talk and receive information in Chinese, but send email in English. 2) The elderly had a better perception of competence to care for the elderly, but this was associated with less use of the online program (forgetting the login and password). 3) Perception about care is cultural. 4) Stress relief after online support.	Sample of convenience. Support is not aimed at caregivers who do not speak Mandarin. There was no analysis of the content of the emails.
04	Donovan and Corcoran (2010DONOVAN, M. L.; CORCORAN, M. A. Description of dementia caregivers uplifts and implications for Occupational Therapy. The American Journal of Occupational Therapy, Bethesda, v. 64, n. 4, p. 590-595, 2010.)	Descrever como os cuidadores agem, pensam e conduzem seus cuidados. To describe how caregivers act, think and manage their care.	Type of study: Qualitative research. Participants: 15 informal caregivers.	Educational actions	1) Positive behaviors: simplify and organize routine, exercise or rest, hobbies, humor, engage with family, colleagues and caregivers, support in religion, kipping a conversation.	Secondary data used. It does not have racial diversity in the analyzed group.
05	Oliveira-Assis et al. (2010)OLIVEIRA-ASSIS, L. et al. Evaluation of cognitive technologies in Geriatric Rehabilitation: a case study pilot project. Occupational Therapy International, Madison, v. 17, n. 2, p. 53-63, 2010.	To test the effectiveness of external aid resources. Develop technologies. To evaluate the appropriateness and usefulness of the resources by a group of professional occupational therapists.	Type of study: Case study. Carer’s reports were analyzed. Participants: For product efficacy: 1 dyad. Frequency: 2 × in the week, 50-minute sessions for 4 months. To evaluate the resources: 7 OT specialists in gerontology. Outcome measures: MEEM, Verbal Fluency Test, Clock Test, KI-ADL	Environmental modification: calendar and nameplates of the rooms. Modification of activities: Activity board and routine organizer. For training of the cognitive domains: activity table and Geriatric Software	1) Environmental changes led to an increase in the aspect of time orientation. 2) The caregiver states that the elderly are more communicative and able to keep a conversation. 3) Wife reports qualitative improvements in bathing activities, toilet use and continence (initiative and agility). 4) There was decline in aggressive behavior. 5) In the evaluation of resources: OT point the software as useful, with capacity to adapt and motivate the interest of the patient. 6) Improvement of resources: they are focused on the type of material and the transportation.	It did not include measures of elderly satisfaction and caregiver overload. He did not do the experimental design. Because it is a case study, the data cannot be generalized.
06	Cunha et al. (2011CUNHA, F. C. M. et al. Abordagem funcional e centrada no cliente na reabilitação de idoso com demência de Alzheimer - relato de caso. Revista de Terapia Ocupacional da Universidade de São Paulo, São Paulo, v. 22, n. 2, p. 145-152, 2011.)	Descrever os resultados da intervenção domiciliar de terapia ocupacional associada ao tratamento medicamentoso, em um idoso com DA em fase avançada. To describe the results of home care of occupational therapy associated with drug treatment in an elderly patient with advanced stage of AD.	Type of study: Case study. Participant: an elderly person with advanced AD and his/her caregiver. Frequency: 3 × in the week, for 8 months. Outcome measures: MEEM, Verbal fluency test, Clock test, KI-ADL, COPM, Time Diary	Environmental Modification, Cognitive Stimulation Techniques, Walking, Senior Dance, and Caregiver Education	1) Sustained increase in MEEM (contrary to literature), clock (slight improvement) and verbal fluency (important gain). 2) Maintenance of gains for 5 months after intervention. 3) OT and drug therapy promote a positive impact on the caregiver, reducing the functional dependence of the elderly and promoting the temporary stabilization of the disease, despite the progressive nature of the disease.	To be a case study. Generalization of data cannot occur.
07	Voigt-Radloff et al. (2011)VOIGT-RADLOFF, S. et al. A multicentre RCT on community occupational therapy in Alzheimer’s disease: 10 sessions are not better than one consultation. BMJ Open, London, v. 1, n. 1, p. e000096, 2011.	To compare the benefits and harms of the 10 sessions of Community Occupational Therapy (DATI) program in Dutch patients with AD, and the impact of a consultation session in German health centers (COTC).	Type of study: Randomized clinical trial. Participants: 104 elderly and their caregivers. Intervention group: 54 dyads Frequency: 1 ×, 1 h, 5 wks. Control Group: 50 dyads. Frequency: 1 × for 30 min Follow-up: 6th, 16th, 26th, 52nd week. Outcome measures: IDDD; PRPP, SF-12, Dementia Quality of Life Instrument.	In the Netherlands: adaptation, simplification, caregiver education. Control group (in Germany): one hour consulting with a one-page booklet.	1) The daily functioning of the patients did not present significant changes during the 26 weeks, in neither of the two groups. 2) There was no greater benefit of the DOTC compared to the COTC. 3) In both groups, the need for ADL and IADL assistance remained stable for 6 months after the start of the research. 4) There was no significant difference in quality of life, mood, patient’s inability to perform ADL, sense of competence of the caregiver, daily hours of care and place of residence of the caregiver.	Small sample size that limits the validity of the results. Comparison between two different cultures. Used in Germany the material that was produced by the Netherlands.
08	Piersol, Earland and Herge (2012PIERSOL, C. V.; EARLAND, T. V.; HERGE, E. A. Meeting the needs of caregivers of persons with dementia: an important role for occupational therapy. OT Practice, Bethesda, v. 17, n. 5, p. 8-12, 2012.)	To guide on strategies to deal with Alzheimer’s, showing that changes in the physical and social environment lead to the reduction of behavioral disorders.	Type of study: Case study. Participant: Caregiver, daughter of an elderly woman with AD. Aggressive and resistant patient to perform the activities. Outcome measures: based on the caregiver’s reports.	Modifications in the social environment: conducting communication and how to do it. Routine structuring, use of assistive products	1) Stressful antecedents: give lots of tips, talk all the time, hasten your mother to take a shower, harsh tone in speech 2) After: changes smoothed the morning routine and increased participation of the elderly in self-care activities. 3) The care given to the elderly has become less painful and more manageable.	Single case study
09	Wenborn et al. (2013WENBORN, J. et al. Providing activity for people with dementia in care homes: A cluster randomised controlled trial. International Journal of Geriatric Psychiatry, Londres, v. 28, n. 12, p. 1296-1304, 2013.)	To evaluate the effectiveness of an OT program to train nursing staff in order to make them able to increase the activity and participation in ADL of residents with dementia	Type of study: Randomized clinical trial. Participants: Intervention group: staffs of 80 elderly people received the OT program. Control group: 70 elderly people who received the usual care. Follow-up for 8 weeks and follow-up was done at 4 and 12 weeks post-intervention. Outcome measures: QOL-AD, CAPE-BRS, CBS, CSD, Rating Anxiety in Dementia, CDR, Pool Activity Level Checklist	Educational actions, individual attendance, and evaluation of the physical environment (individual and group).	1) In the intervention group, 2 institutions had poor adherents, 4 fair and 2 good. 2) There was no significant difference in the adherence of staffs in different nursing homes, neither in the study period nor in the follow-up. 3) Even with positive staff feedback, there was no evidence that the intervention group had improvements to increase activity and participation, relative to control. 4) For the staff of the intervention group, they report that the quality of life of the residents with AD decreased when evaluated at the follow-up, in relation to the control group.	Variability of asylum adherence and lack of planning of the administrative sector to make staff available in the program. Not having done with more severe elderly, which decreases the capacity of engagement and social participation.

Universidade Federal de São Carlos, Departamento de Terapia Ocupacional Rodovia Washington Luis, Km 235, Caixa Postal 676, CEP: , 13565-905, São Carlos, SP - Brasil, Tel.: 55-16-3361-8749 - São Carlos - SP - Brazil
E-mail: cadto@ufscar.br

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[1] Corresponding author:
Lilian Dias Bernardo, Universidade Federal do Paraná, Avenida Prefeito Lothário Meissner, 632, Jardim Botânico, CEP 80210-170, Curitiba, PR, Brasil, e-mail: lilian.bernardo@ifrj.edu.br.