The effectiveness of occupational therapy for persons with moderate and severe dementia.

An occupational therapy tailored for persons concerned with moderate to severe dementia is effective. Occupational therapy applies in a targeted manner activities as therapeutic measure. Aim is a high quality of life in everyday life - also without drugs. Mental capacity and independence in daily routine shall be maintained as long as possible. Occupational therapy can be more cost-effective than medical treatment because it reduces the nursing expenditures.

Summary

Health political background

It is predicted that the number of persons with dementia of currently around 1.45 million is expected to double until the year 2050. Due to this development and the problems caused by this disease for affected persons, their families, caregivers and physicians as well as for the therapeutic professions the treatment of dementia and in particular the care for persons with moderate and severe dementia is a major human, socio and health political challenge. At present, national and international guidelines recommend – with some limitations – the use of occupational therapy for the treatment of dementia.

Scientific background

Dementia as a term for complex disease symptoms proceeds as chronic or progressive disease of the brain with dysfunction of cortical functions. The aim of occupational therapy is to strengthen persons with dementia in the fields of self-care, productivity and leisure/rest. This enables persons with dementia to increase their functional ability in activities of daily living (ADL), their social participation and their quality of life and life satisfaction.

Occupational therapy is defined by the German remedies directive as means of psycho-functional treatment, brain performance training and neuro-psychological oriented treatment, sensorimotor-perceptive and motor-functional treatment.

Research questions

The clinical question of this report deals with the comparative evaluation of the efficacy of occupation therapy in the treatment of persons with moderate to severe dementia. The report also deals with the question if the progression of the disease in persons with moderate dementia can be slowed down by occupational therapy.

The economic view of the use of occupational therapy arises the questions how cost-effective occupational therapy is in the treatment of persons with moderate and severe dementia.

One more question is to what extent the quality of life for persons with moderate and severe dementia will be improved by occupational therapy.

Methods

The aim of this health technology assessment (HTA)-report is to assess the effectiveness of occupational therapy on the care for patients with moderate to severe dementia. For this purpose a literature research has been conducted between March and November 2012 in 32 electronic databases (e. g. MEDLINE, Cochrane, EMBASE) and additionally in the database CINAHL, complemented by hand search. The search words “dementia” and “occupational therapy” as well as their language equivalents and individual therapeutic methods in German and English were linked. The search was extended worldwide to all publications which has been published since 2007. This period was chosen in order to update the results of various reviews from 2007.

The studies were separately selected by two researchers in consideration of defined in- and exclusion criteria.

Medical results

Eleven medical studies were selected for the report. Due to their study design (five reviews, six randomised controlled trials [RCT]) the publications have a high level of evidence. When analysing the results it must however be considered that nine of the eleven studies have a high risk of bias. The studies are very heterogeneous concerning the demography of the study population, the design and the interventions. A differentiated analysis of the efficacy of interventions on moderate and severe dementia is lacking in most studies. Nine studies prove the efficacy of the use of occupational therapy. Two studies show ambiguous results or no significant therapeutic success.

Only four of the available studies focus specifically on moderate and severe dementia. Follow-up between six and twelve weeks or at most after six months were conducted in the majority of the studies. The indicated periods are too short to assess the grade of reduction of the disease progression.

The studies present results about the effectiveness of cognitive and sensory stimulation, physical training, validation, interventions to improve ADL and the milieu as well as the counselling of family members and caregivers. Multi-component programmes of occupational therapy which combine different interventions and integrate family members and caregivers are attributed to be effective.

Cognitive interventions in small groups are effective for persons with mild and moderate dementia. The follow-up after six months in a study looking at an early stage of Alzheimer shows remaining cognitive efficacy. In the advanced stage of dementia cognitive interventions show only small effects. Sensory stimulation shows effects in all three stages of dementia on different parameters such as behaviour. Functional and skill training with regard to individual functions and integrated in different activities is effective for persons with dementia (without precise classification of degrees of severity. Small and insufficient effect sizes are measured for the effect of validation on behaviour. A structured activity-based concept and counseling of patients’ families show positive effects on persons with dementia. Another study states a long-term effect on the basis of interviews with family members. They were interviewed about the quality of the performance of ADL after 52 weeks. However this study does not apply exactly for the requested target group but for persons with mild to moderate dementia.

Economic results

Two of three economic studies prove the cost-effectiveness of occupational therapy. Furthermore, one review points out that occupational therapy can delay institutionalization for 1.5 years. One study which considers the required stage of moderate to severe dementia, shows that a structured occupational therapy programme has low costs due to the time savings among the family caregivers. Therefore it is more cost-effective than a professional caregiver. One study which contains mild to moderate cases also shows in comparison that the costs for occupational therapy interventions are lower. Occupational therapy cut costs which would otherwise arise by medical, nursing and family care.

Ethical results

Ethical and social questions regarding closeness and distance between therapists and patients or the limits of therapeutic intervention have not been targeted by the studies. The main result of the studies is that occupational therapy improves the quality of life of persons with dementia.

Discussion

Only four reviews and two studies focus specifically on the use of occupational therapy on moderate and severe dementia, the other studies contain study populations with mild and moderate dementia. In most cases there is no differentiated analysis of the results regarding the individual stages of dementia. Therefore it is difficult to assess the effects of the interventions. Eleven of 14 studies prove the efficacy of occupational therapy. One limitation that needs to be mentioned is that the missing differentiation of individual stages of dementia in moderate and severe dementia is a general deficit of the studies.

Conclusion

The available studies are insufficient concerning the analysis of the efficacy of interventions for persons with moderate and severe dementia. On the whole there is a clear trend that occupational therapy shows efficacy on the quality of life and the affects of patients and their families if the therapy is carried out with structured and client-centered interventions.

The conduction of further studies is recommended. They should diagnose dementia by the available psychometric tools which allow a clear classification of the severity of dementia. Furthermore it seems to be useful to concentrate on single research questions to precisely described interventions with standardized procedures.

Despite the deficiencies in the studies occupational therapy can be recommended – in the frame of the mentioned limitations – as means for the improvement of symptoms of moderate/severe dementia. Moreover, occupational therapy is a cost-effective form of treatment compared with drug therapy or increased medical and nursing care.

Notes

Competing interests

The authors declare that they have no competing interests.

INAHTA Checklist

Checklist for HTA related documents (Attachment 1).

Erratum

The article was first published with the English title: "Effectiveness of ergotherapy for patients with moderate to severe dementia". "Ergotherapy" has been replaced by "occupational therapy" in abstract and keyword.