Occupational Therapy Interventions for Dementia

Whether you work as an occupational therapist or COTA in home health, outpatient, acute care, rehab, or in a long term care facility, you will certainly encounter patients with a dementia diagnosis or co-morbidity. If you work primarily with older adults, this might even be a large percentage of your patients.

In this article, I want to share meaningful and functional occupational therapy interventions for your patients affected by dementia. I was initially inspired to write this post as new grad, after seeing the occasional occupational therapist simply standing their patients with dementia and instructing them to put pegs in a foam board with no functional goal in mind.

Unfortunately this type of intervention can be all too common, which is a disservice to the patient and to our profession. That being said, I hope this post gives you more ideas than the arm bike or peg board! Using functional interventions will also make treatments much more interesting for you as well!

For more on why occupation-based treatments are so great, be sure to check out 10 Reasons Why OTs Should Be Using Occupation-Based Interventions.

This post is organized by the stages of dementia:

• Early Stages of Dementia
• Middle Stage Dementia
• Late Stage Dementia

For more in-depth information on the stages of Alzheimer’s (the most common form of dementia), check out the Alzheimer’s Association website. I also want to note that there are many other forms of dementia, (currently over 100!) according to Alzheimer’s Disease International. To read more about the other most common forms, you can also check out their helpful resource here. 

Challenges to Keep in Mind

While working with people with dementia is very rewarding and humbling, working with this diagnosis can sometimes be more difficult than working with younger adults.

Your patients with dementia may not always recognize you, or understand why you’re trying to do therapy with them.

Patients may become agitated, aggressive, or refuse working with you. It can take you a good amount of time to build a good therapeutic rapport with them.

Once you get to know what works best for them, you can improve the outcome of your session.

One of the hardest parts about treating dementia is that you may not get the same carryover from your interventions that you would get with your patients that do not have dementia.

For example, a patient who is cognitively intact will usually understand and remember much more of what you teach them about ADL retraining.

An individual with a cognitive impairment, however, may not remember what you did in your session or carry-over the information.

Even though there are challenges, you can still provide tremendous value to your patients and their families. The key to treating dementia successfully is to keep your interventions functional and meaningful to the patient.

Interventions for Early Stages of Dementia

An important fact to remember when working with any stage of dementia:

While occupational therapists can’t “fix” a person’s dementia and cognitive performance, we can help improve function through remediation or compensatory strategies.

How do we do this?

For starters, you can interview your patient with measures like the COPM to determine the most meaningful activities for them.

When you’re preparing your patient’s plan of care, you will also want to consider preferences, interests and life histories in order to create meaningful activity plans (Kolanowski et al., 2005).

In the early stages of dementia, your patients will generally still be able to function in daily life pretty well. They may start noticing that they forget simple things like appointments, where they placed their keys, or if they’ve taken their medication.

In this stage, memory aids like calendars, journals, medication reminders, and daily routine schedules can help maintain the person’s independence with higher level ADLs.

To further increase effectiveness of memory aids, evidence shows that combining these aids with caregiver education further improves patient independence outcomes and reduces caregiver stress (Dooley and Hinojosa, 2004).

Your patients or their family members might also notice the individual beginning to need reminders to bathe or eat.

Don’t be afraid to focus your interventions on these less complex tasks if you notice your patient having trouble even though they might appear completely intact cognitively.

Interventions for Middle Stage Dementia

With middle stage dementia, the individual will have even more of a decline in memory and high level cognition.

At this stage, most people begin needing assistance with basic self care tasks like getting to the bathroom in time. They may show decreased sequencing ability and motor planning of basic ADLs.

At this stage, the patient’s caregivers might start jumping in and doing everything for them. With cues and prompting, however, the patient can still physically assist with this, and they should be encouraged to do so.

As OTs, family or caregivers jumping in and doing too much can be one of our biggest frustrations, as it does not allow the patient to continue their routine and may lead to a loss of basic self-care skills.

This may be due a legitimate lack of time or simply a lack of education of the caregivers.

After taking a MedBridge online continuing ed course on ADL’s and dementia (taught by the amazing OT Teepa Snow), I was shocked to learn that once caregivers step in and start doing everything for the patient, the patient loses that automatic skill. The saying, “If you don’t use it, you lose it” really does apply in this case.

Because of this, I focus most of my time working on ADL retraining with the patient (along with balance retraining and functional mobility). I also explain to all caregivers of the benefits of working with the patient to do their own self care as much as possible.

Even if it’s managing clothing and hygiene during toileting, I’ve found this really helps to gain some of that function back. This is a win-win for the patient and caregivers since it reduces the amount of work caregivers have to jump in and do.

Performing basic ADL retraining (toileting, dressing, self-feeding, for example) with your patient will also certainly be more meaningful than giving them a puzzle or clothespin task.

When providing ADL retraining with your patients with dementia, you can include increased verbal or visual cues, demonstration, physical guidance, partial physical assistance and problem solving to improve the outcome (Beck et al., 1997).

Repeating your ADL retraining using the same activity, same sequence, same time, and same place can also help to increase retention.

Completing self-care tasks in your patient’s own personal living area is also more beneficial than doing simulated activities in the gym, when possible.

The more “true to life,” the better!

Interventions for Late Stage Dementia

With late-stage dementia, individuals will be at their final stage of the disease process.

In this stage, they will likely not be oriented to person, place, or time, and are often dependent in all or most self care, including feeding. They will have a severe loss of motor control, and will likely be wheelchair-bound because of this.

Because of the decreased ability to physically perform self-care tasks, you can switch your focus to educating caregivers on safe transfers, contracture management through home exercise programs, proper positioning to avoid skin breakdown and increase comfort, and providing enjoyable sensory stimulation (AOTA).

Caregivers may be experiencing increased stress, depression, and exhaustion with this stage. Support groups (either online or in-person) can really help to have others that are going through the same life stresses.

_______________

Caregiver Education For All Stages of Dementia

Along with working with the patient, occupational therapists also provide caregiver education to family members. Educating your patient’s family members on your interventions to increase carryover is just as important as what you’re doing with the patient.

It’s also important to teach family members how they can reduce their own stress. Family members will benefit from resources and support group information if their loved one is newly diagnosed.

In my experience, I’ve also found that collaborating with the family and staff as a cohesive team makes a big difference. Talking “at” the family making them feel like you think you know more than them will not be as beneficial as taking the collaborative approach.

In reality, caregivers can help you a great deal with providing the best outcomes for your patients since they often know more about the patient than you do, and they can carry over interventions during non-therapy time.

Special Considerations From Personal Experience

While keeping your interventions functional and meaningful, also keep in mind what is most beneficial for that individual client.

If your patient is a male and never did homemaking tasks, asking him to fold clothes or do meal prep won’t be the best intervention.

If your patient refuses to work with you or appears agitated, assess the environment.

• Is there excess stimuli?
• Is it late afternoon and they’re exhausted?

Check in with caregivers about the best times of day to work with the individual. In my experience, the time of day can make a HUGE difference in participation levels.

Also, look at how you’re providing the intervention.

Giving one-step, simple directions is much easier for someone with middle stage dementia to follow. Providing multi-step, complicated instructions is very difficult to follow and can lead to frustration.

If your patient is sexually inappropriate or aggressive, this is almost always due to the disease progression. It’s not because they’re a bad person.

If you’re feeling uncomfortable, I recommend asking someone to accompany you in the room when you’re treating to play it safe. Or, you can treat them in public areas if no one is available.

In Conclusion

To wrap this post up, I just want to finish with a big “Thank you!” to all of you working with this population. It’s not always easy but just know that you’re making a big difference in their lives and in their caregivers’ lives.

If you get overwhelmed on what to do, just remember that providing support, education, and functional, meaningful interventions that are client-centered and focus on the person’s strengths will ensure a successful occupational therapy intervention (Schaber & Lieberman, 2010).

I hope this post helps you get a beginning grasp on how to successfully work with patients with dementia.

To learn more about dementia and the role of occupational therapy, check out the resources below for even more useful information.

And as always, please share in the comments below any great tips and tricks that help you when treating individuals with dementia.

This post was originally published on 6/26/2016 and updated on 1/4/2020 and October 21, 2022.

Additional Resources and References

For more occupational therapy intervention ideas for working with clients with dementia, consider joining the OT Flourish Learning Lab online OT membership (you can get 10% off using our code MYOTSPOT:122)

Dementia and the Role of OT (AOTA)

The Power Of OT Applied To Dementia (Fox Rehab)

Therapeutic Interventions for People With Dementia (National Center for Biotechnology Information)

Three Ways Occupational Therapists Support Dementia Care (AMN Healthcare)

Beck, C., Heacock, P., Mercer S.O., et al. (1997). Improving dressing behaviour in cognitively impaired nursing home residents. Nursing Research. 46:126–132.

Dooley, N.R., Hinojosa, J. (2004). Improving quality of life for persons with Alzheimer’s disease and their family caregivers: brief occupational therapy intervention. The American Journal of Occupational Therapy. 58:561–569

Kolanowski, A.M., Litaker, M., Buettner, L. (2005). Efficacy of theory-based activities for behavioral symptoms of dementia. Nursing Research. 2005;54:219–228

Schaber, P., & Lieberman, D. (2010). Occupational therapy practice guidelines for adults with Alzheimer’s disease and related disorders. Bethesda, MD: AOTA Press.