Whether you work as an occupational therapist or COTA in home health, outpatient rehab, assisted living, or in a skilled nursing facility, you will encounter patients with a dementia diagnosis. If you work with primarily older adults, this might even be the majority of your patients.
In this post, I want to provide you with meaningful and functional ideas to work on with your dementia patients. I’m sad to say I still sometimes see occupational therapists in the older adults setting literally just standing the patient up and instructing them to put pegs in a foam board with no rhyme or reason.
This is not functional nor meaningful and a waste of Medicare and patient dollars as well as the patient’s therapy. I hope this post gives you more ideas than the usual arm bike or peg board.
This post is broken out by the stages of dementia:
For more in-depth information on all of the stages of Alzheimer’s (the most common form of dementia), check out the Alzheimer’s Association website.
Challenges to Keep in Mind
I absolutely love working with patients with dementia. While it’s very rewarding and humbling, working with this diagnosis can be more difficult than working with younger adults.
Your patients with dementia may not 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 usually have better outcomes.
One of the hardest parts about treating dementia is that you will 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 understand and remember much more of what you teach them about ADL retraining.
An individual with a cognitive impairment, however, will not likely 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 OT 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 currently 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; Pool, 2002).
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.
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.
This is probably my biggest frustration working with this stage.
I see this time and time again in nursing facilities where caregivers are not coaching the person to do self-care tasks themselves (with supervision).
The reasons may be a legitimate lack of time or simply a lack of education.
After taking a continuing education course on ADL’s and dementia, 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 (aside from balance retraining and functional mobility). I also am sure to explain to all caregivers 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.
It really wasn’t until I was working with dementia for about six months before I started really researching the evidence and switched my focus from exercise to self-care tasks.
Performing basic ADL retraining (toileting, dressing, self-feeding, for eaxmple) with your patient will also certainly be more meaningful than giving them a puzzle or clothespin task.
When providing ADL retraining with dementia, you might include increased verbal or visual cues, demonstration, physical guidance, partial physical assistance and problem solving to improve the outcome (Beck et al., 1997).
Completing self-care tasks in your patient’s own personal living area is also more beneficial than doing simulated activities in the gym.
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 will be dependent in all 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, 2012).
Caregivers may be experiencing increased stress, depression, and exhaustion in this stage. Support groups 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, OT’s 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. Storming in and talking “at” the family making them feel like you think you know more than them will definitely 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 know more about the patient than you do.
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 may not 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 agitation.
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, you can ask 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. I find myself doing this if I’m feeling uneasy.
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 nuggets.
And as always, let me know in the comments below any great tips and tricks that help you when treating individuals with dementia.