Occupational Therapy in Productive Aging: The Top 10 Things Everyone Needs to Know Stephanie Stephenson, MOT, OTR/L AOTA Emerging Leaders Development Program 2011 Definition of Occupation “Ordinary and extraordinary things people do in their day-to- day lives that occupy time, modify the environment, ensure survival, maintain well-being, nurture others, contribute to society, and pass on cultural meanings and through which people develop skills, knowledge, and capacity for doing and fulfilling their potential” (Crepeau et al., 2009, p. 1162). “Activity that is personally meaningful and contextually anchored within older peoples’ everyday lives has the greatest ability to enhance health-related outcomes” (Hay et al., 2002, p.1386). Occupational Therapy in Productive Aging: The Need “By 2030, the number of older Americans will have more than doubled to 70 million, or one in every five Americans” (Ad Hoc Group on Aging, 2007, p. 1). “Occupational therapists facilitate optimal occupational performance and community participation across the full spectrum of ability, from healthy adults actively engaged in their communities to those who are coping with serious physical and mental health conditions in more supported environments like assisted living facilities and nursing homes” (Ad Hoc Group on Aging, 2007, p. 1). Occupational Therapy in Productive Aging Occupational therapy is hands-on and practical We focus on what occupation looks like in real life We collaborate with clients and family to “create a workable plan for everyone involved” (O’Sullivan, 2011 personal communication). Occupational therapists are experts in activity analysis Emphasis on the therapeutic relationship leads to client-centered goal-setting as individuals feel able to share what is meaningful to them What are the demands of the activity? What are the barriers to performing the activity? What skills are required to complete the activity? How does the environment affect participation in the activity? What is the cultural meaning ascribed to the activity? “Occupational therapists can implement and execute broad theoretical ideas; they flesh out what it looks like in a person’s daily life” (Gitlin, 2011, personal communication). Occupational Therapy in Productive Aging: Foundations Holistic and Client-Centered “Occupational therapy practitioners are architects of life.” (Clark, 2011, personal communication) “Occupational therapy goes so far beyond activities of daily living and addresses overall life management, including health promotion and balance within all contexts” (Clark). Occupational therapy practitioners utilize their understanding of the aging process to enable older adults to participate in meaningful activities in their desired environment given their individual abilities and personal attributes. “Occupational therapy practitioners analyze situations from a variety of life points of view” (O’Sullivan, 2011, personal communication). Older adults have unique perspectives on what is considered independent vs what kinds of activities or changes in routine are considered dependent. Occupational therapy practitioners consider each adult individually to understand their perspective on aging and what is meaningful in relation to maintaining independence (Yuen et al., 2007). Impact of Routine “Occupational therapy is the only profession with explicitly focused training on participation in everyday life” (Clark, 2011, personal communication). Is the older adult’s routine productive and health promoting? What we do everyday is what we become. Healthy everyday activity is an insurance policy against decline. (Clark) “Occupational therapy practitioners help older adults maintain independence by incorporating new health routines into old routines” (O’Sullivan, 2011, personal communication). OT in Action: Tina McNulty I remember an experience working with a 61 y.o. who had difficulty with not having enough energy to clean her house and participate in scrapbooking, which was meaningful to her. I performed a time use analysis (i.e. identified what activities she performed at specific times during the day) which showed that she didn’t eat until 4 pm. She had a cognitive impairment that caused her to become distracted and forget to eat. From this finding, we decided on a system of timers which helped her with her eating routine. She still uses this routine which gives her more awareness of time and ultimately more energy because she eats sooner. With increased energy, she is able to care for her daily needs, maintain participation in meaningful activities, and maintain her overall health and well-being. Participation in Occupation Despite Limitations “We don’t have to make the person better to make an impact.” (Toto, 2011, personal communication) “Occupational therapy practitioners help people function with various limitations such as cognitive or physical” (Gitlin, 2011, personal communication). “Occupational therapy practitioners focus on what someone CAN do” (Smith, 2011, personal communication). “Occupational therapy practitioners help people figure out how to bring older adults home even with physical barriers” (Clark, 2011, personal communication). “Our emphasis on [participating in daily activity] translates into living life meaningfully whether well elderly, chronically ill, or recovering from injury” (Scott, 2011, personal communication). The Top 10 Occupational Therapy Interventions that are Cost-Effective and Promote Wellness and Participation 1. Aging in Place and Home Modifications “Occupational therapy practitioners help to transform a home from an enemy to a friend full of security and comfort.” (Smith, 2011, personal communication) “Aging in place does not just ‘happen.’ Aging in place is a process and an outcome” (Siebert, 2007, p. 2). “Aging in place is not simply maintaining residence in a dwelling. It is the acquisition of services, supports, and resources that sustain engagement in valued activities, routines, roles, and relationships within the home and community. So, aging in place also means sustaining participation without having to move” (Siebert, 2007, p. 2). Occupational therapy provides clients with the tools to optimize their home environments relative to individual abilities and promote full participation in daily life activities. Aging in Place and Home Modifications (cont.) “An occupational therapist evaluates balance, coordination, endurance, safety awareness, strength, attention, problem solving, vision, communication, and many other functions while the individual performs daily tasks” (Fagan & Sabata, 2011, p. 1). Occupational therapy practitioners are essential team members to include in collaboration with architects, builders, remodelers, national association of home builders, AARP, Rebuilding Together, etc. (Morris, 2009). “There is no better place to treat or work with older adults than in their own home where they need to be independent; we can make a better impact, see solutions, and facilitate follow through” (Smith, 2011, personal communication). Di Monaco et al (2008) found that increased adherence to home modification recommendations led to decreased risk of falls. 2. Falls Prevention “In 2000, the total direct medical costs of all fall injuries for people 65 and older exceeded $19 billion. By 2020, the annual direct and indirect cost of fall injuries is expected to reach $54.9 billion” (CDC, 2011). “Fear of falling can be both a risk factor for falls and a consequence of falling. Occupational therapists assist older adults to recognize and overcome their fears and problem-solve about how to keep from falling while staying active. Fear of falling can lead to self-limitation in performing activities and tasks that people need to do to remain as independent as possible” (Scheinholtz et al., 2006, p. 2). “A single home visit by an occupational therapist at a median of 20 days after d/c significantly reduced the proportion of fallers from 26% to 8.8%” (Di Monaco et al., 2008, p. 449). OT suggested targeted modifications of the home environment, behavioral changes, and use of assistive devices. Unique Occupational Therapy Intervention for Falls Prevention: Stepping On Stepping On is a small group based educational program facilitated by an occupational therapist Goals include: improve confidence in self to avoid falls and encourage behavioral change to meet the goal of reducing falls Intervention approaches: lower limb balance and strength exercises, coping with visual loss, medication management, environmental and behavioral home safety, and community safety strategies Clemson et al. (2004) demonstrated reduced falls in the intervention group by 31% as a result of the Stepping On program. In addition, the intervention group displayed increased confidence and used more protective behavioral practices. 3. Low Vision and Safety “Occupational therapy practitioners provide older adults with tools to remain safe and independent at home (age in place) despite significant visual impairment.” (Kaldenberg, 2011, personal communication) Tools may include: low vision devices, home modification/adaptation, lighting options, medication management strategies, reading adaptations, etc. Low vision has a psychosocial impact on the older adult, including but not limited to being able to recognize faces or accurately dial the phone number of a friend. Occupational therapy practitioners can assist the older adult to remain in social circles and be active and engaged socially. “In addition to low vision adaptation, occupational therapy practitioners can increase older adult safety by providing recommendations about the home environment, including reducing clutter, refining organizational skills, and strategies to safely live at home following cognitive decline” (Scott, 2011, personal communication). For example, occupational therapy practitioners can ensure that older adults can dial 911 in an emergency. OT in Action: Jen Kaldenberg I worked with a 94 year old artist. She defined herself by being an artist, however, she developed macular degeneration which hindered her ability to participate in this valued occupation. I provided her with environmental adaptations such as increased lighting and low vision devices such as a magnifying glass. As a result, she could return to her art. This actually led to increased participation in self-care as well as a more positive outlook on her daily life. 4. Driving/Community Mobility Comprehensive driving evaluations mean more than continuation/discontinuation of driving, or “pass/fail”; occupational therapy helps older adults transition from driver to rider with the emphasis on the mobility the driving provided, preserving social engagement and an active lifestyle (Schold Davis, 2012, personal communication; Scott, 2011, personal communication). Occupational therapy evaluation and intervention helps older adults retain driving when possible through strategies, adaptive devices, or vehicle modification (Schold Davis). Generalist occupational therapists routinely evaluate the sub-skills indicative of driving risk: vision, cognition, and physical function.The generalist role is important in determining readiness for and success with the most complex of IADLs during on the road driving tests” (Dickerson, 2011, personal communication; Schold Davis). Unique Occupational Therapy Driving Intervention: www.Car-Fit.org CarFit is an educational program that offers older adults the opportunity to understand the design of safety features in their vehicle and the steps required to “make adjustments” to attain optimal person-to-vehicle fit. The CarFit program is a positive and non-judgmental educational opportunity for drivers seated in their vehicle. Each program is encouraged to offer a “Goody Bag” of local educational information including where to find “off the shelf” adaptive devices as well as driving rehabilitation services (what they are and how to find them). All resources support a driver’s choice to drive as long as safely possible. CarFit contributes to driver safety. It is the hope that enhanced awareness and the attainment of optimal person vehicle fit can lead to decreased accidents, injuries, and death. The longer a driver remains accident/injury free the longer he or she drives, reducing the demand for communities or providers such as Medicaid/Medicare to financially support transportation for the older adult (Costa, 2011, personal communication; Schold Davis, personal communication, 2012). OT in Action: Pam Toto I had an experience with a woman with multiple sclerosis. She had a few falls in her apartment. Because of the falls, she was afraid to ride the bus and go in the community. She realized she couldn’t live independently in her apartment if she couldn’t ride the bus. Her family thought she needed to move to assisted living. As her occupational therapist, I assisted her with community mobility and educated her regarding self-management strategies for fatigue and anxiety, advocating for herself by asking the bus driver to wait until she is seated to begin driving, and pacing strategies for riding the bus such as planning bus rides for the time of day when she has the most energy. We rode the bus as part of our occupational therapy sessions, and she was able to implement these strategies, remain independent in her apartment, and decrease the potential for caregiver burden and increased healthcare costs. 5. Social Participation and Social Networking Decreased community mobility can lead to social isolation; occupational therapy practitioners assist older adults with accessing the community in order to promote increased social participation. For example, assisting the older adult to arrange transportation to an activity at the senior center or promoting intergenerational socialization by assisting the adult to volunteer at a local school. Occupational therapy practitioners address access to technology for social participation. Computer training and cell phone training can assist older adults with continued social participation (Sanders et al., 2011). 6. Occupational Therapy and Dementia “In the community, practitioners can assist those with dementia to live in their own homes safely for as long as possible through environmental evaluation and adaptation. Practitioners may also provide wellness programs, such as falls prevention and caregiver educational sessions. They help those with dementia in long-term-care and adult day health settings to retain existing function for as long as possible. Throughout the continuum of care, occupational therapy practitioners intervene both as direct care providers and as consultants” (Robnett, 2012, p. 1). “Although remediation of cognitive performance is not likely, the person may demonstrate improved function through compensation or adaptation” (Robnett, p. 1) “Enhancing function, promoting relationships and social participation, and finding ways for those with dementia to enjoy life are the keys to successful occupational therapy intervention” (Robnett, p. 2). 7. Working with Caregivers “Occupational therapy practitioners can articulate the capacity of an older adult to help family with decisionmaking and daily care.” (Gitlin, 2011, personal communication) “If families were supported in how they can help older people age in place or live with children, there would be less people in residential community situations” (Clark, 2011, personal communication). “Occupational therapy is important in helping family and caregivers understand the importance of meaningful occupations” (Toto, 2011, personal communication). For example, meal preparation may be an important role for an older family member, but the family may feel they are keeping a family member safe by removing the individual’s need to participate in meal preparation. The family may not consider the consequence of eliminating this role or understand how to support the older adult in maintaining their contribution to the family. “Occupational therapy practitioners assist caregivers with maintaining a connection to their own life and valued activities separate from care giving” (O’Sullivan, 2011, personal communication). Unique Occupational Therapy Caregiver Interventions: TAP and COPE Tailored Activity Program – 8 session, 4 month structured occupational therapy intervention that provides dementia clients with activities tailored to their capabilities and trains family caregivers in their use (Gitlin, Hodgson, Jutkowitz, & Pizzi, 2010). It has been shown to reduce the frequency of behavioral occurrences, particularly shadowing and repetitive questioning, and reduce caregiver time providing instrumental care and daily oversight. Care of persons with dementia in their environments (COPE) – nonpharmacologic, biobehavioral approach to support physical function and quality of life for clients with dementia and the well-being of their caregivers (Gitlin, Winter, Dennis, Hodgson, & Hauck, 2010). It targets modifiable environmental stressors. The intervention seeks to re-engage clients in daily activities and increase functionality, thereby alleviating caregiver burden. Improved client functioning especially in instrumental activities of daily living (i.e. meal preparation, shopping, managing finances, etc.), client participation, and caregiver wellbeing and confidence using activities. 8. Wellness and Health Promotion “Until we die, we have amazing capacity to change. It’s not about decline; aging doesn’t necessarily mean you have to live through pain or discomfort.” (Sabel, 2011, personal communication) “Occupational therapy has a preventive role – activity is viewed as a critical element to promote longevity and healthy lifestyles” (Gitlin, 2011, personal communication). The Well Elderly Study demonstrated that a “6-month preventive lifestyle- oriented intervention” had a positive effect on vitality, social function, mental health, life satisfaction, depressive symptomatology, and bodily pain (Clark et al., 2011, p. 4). The Well Elderly Study was based on the hypothesis that participation in occupational can positively impact health and prevent decline. Participants were divided in a treatment group involved in occupation-based treatment and a control group that did no not receive occupational therapy, but participated in social activity groups. Unique Occupational Therapy Wellness Approach: Yoga and Tai Chi Occupational therapy practitioners can use yoga or tai chi as part of a holistic approach to treatment in preparation for or as an adjunct to occupation-based intervention Occupational therapy practitioners need additional training and must demonstrate competency with these interventions in order to incorporate them into a comprehensive occupational therapy program Just as physical agent modalities are used as preparatory or adjunctive to therapy, yoga and tai chi can be used as preparation to enable a client to participate in a valued activity. “Yoga aids in breathing deeper and easier, decreased pain, stress reduction, autonomic responses such as metabolizing sugar better, increased memory, increased attention” (Sabel, 2011, personal communication). Tai Chi improves body awareness so the principles can be applied to everyday occupations such as sitting at a desk, bending down, reaching up, lifting heavy objects, etc. 9. Mental Health Occupational therapy arose as a profession closely linked to psychotherapy in the early 20th century as health professionals recognized the impact of participation in meaningful daily activity on mental and physical health (Crepeau et al., 2009). “Seven million people older than age 65 in the United States live with a diagnosable psychiatric illness. That number is expected to double. Older adults with psychiatric illness have lower quality of medical care, have higher mortality rates than those without psychiatric illness, and are more likely to be placed into nursing homes despite their ability to complete all self-care activities” (Scott & Mahaffey, 2010, p. 98). “Occupational therapists play a key role in understanding behavior and finding ways to intervene that help their clients maintain dignity, participation, and a sense of purpose…regardless of mental status” (Scott & Mahaffey, p. 110). Modification of environment to promote relaxation or reduce stress and agitation Alleviation of depression through participation in meaningful activities OT in Action: JoAnne Wright I worked with a woman with severe rheumatoid arthritis who wanted to be able to continue to crochet, but had significant ulnar drift. I created a splint that would assist with ulnar drift and allow her to perform her activities of daily living (dressing, bathing, etc.) as well as continue to crochet. As a result, she re-engaged in her own self-care and valued occupation of crocheting. This led to a more positive outlook and decreased dependence on a paid caregiver. With her increased participation, she also improved in overall strength and mobility. 10. Chronic Disease Management “The Centers for Disease Control estimated that 25 million or 1 in 10 Americans experience limitations in daily living activities and participation in the community due to a chronic disease” (Bondoc & Siebert, 2012). Occupational therapy interventions assist in: Addressing problems or symptoms associated with specific chronic conditions to sustain current abilities Developing strategies to incorporate energy conservation and activity modification techniques into daily activities to cope with physical demands and reduce fatigue associated with many chronic conditions Learning and incorporating health management tasks into existing habits so they become part of one’s routine Resources AOTA and Aging: Older Driver Resources: http://www.aota.org/About-Occupational-Therapy/Patients-Clients/Adults.aspx http://www.aota.org/older-driver www.carfit.org Falls Prevention: Stepping On: AOTA Resources http://sydney.edu.au/health_sciences/staff/lindy_clemson http://www.dhs.wisconsin.gov/aging/CDSMP/SteppingOn/index.htm#How%20was%20the %20Program%20Developed? http://www.aota.org/Practice/Productive-Aging/Falls.aspx CDC Compendium of Effective Community-based Interventions http://www.cdc.gov/HomeandRecreationalSafety/images/CDCCompendium_030508-a.pdf Thank You! Deborah Yarett Slater, MS, OT/L, FAOTA Laura Collins, AOTA Communications Director JoAnne Wright, PhD, OTR/L, CVLT Donna Costa, DHS, OTR/L, FAOTA Tina McNulty, PhD, OTR/L Richard Sabel, MA, OTR, MPH, GCFP Laura Gitlin, PhD Elin Schold Davis, OTR/L, CDRS Karen Smith, OT, CAPS Florence Clark, PhD, OTR/L, FAOTA Pamela Toto, PhD, OTR/L, BCG, FAOTA Anne Dickerson, PhD, OTR/L, FAOTA Janie Scott, MA, OT/L, FAOTA Jennifer Kaldenberg, MSA, OTR/L, SCLV, FAOTA Ann O’Sullivan, OTR/L, LSW, FAOTA References AOTA Ad Hoc Group on Aging. (2007). The AOTA report to the executive board. Bondoc, S., & Siebert, C. (2012). The role of occupational therapy in chronic disease management: Chronic disease fact sheet. Retrieved May 23, 2012 from http://www.aota.org/Consumers/Professionals/WhatIsOT/PA/Facts/Chronic-DiseaseManagement.aspx?FT=.pdf CarFit. (2011). Program goals and outcomes. Retrieved December 10, 2011, from http://www.car-fit.org/ Centers for Disease Control and Prevention. (2011). Costs of falls among older adults. Retrieved December 10, 2011, from http://www.cdc.gov/homeandrecreationalsafety/falls/fallcost.html Clark, F., Jackson, J., Carlson, M., Chou, C., Cherry, B., Jordan-Marsh, M., et al. (2011). Effectiveness of a lifestyle intervention in promoting the well-being of independently living older people: Results of the Well Elderly 2 randomised controlled trial. Journal of Epidemiology and Community Health. Retrieved on December 10, 2011, from http://jech.bmj.com/content/early/2011/06/01/jech.2009.099754.short Clemson, L. Cumming, R. G., Kendig, H., Swann, M., Heard, R., & Taylor, K. (2004). The effectiveness of a community-based program for reducing the incidence of falls in the elderly: A randomized trial. Journal of the American Geriatrics Society, 52(9), 1487-1494. Crepeau, E., Cohn, E., & Schell, B. (Eds.). (2009).Willard and Spackman’s occupational therapy. Philadelphia: Lippincott Williams & Wilkins. 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