Dementia and the Occupational Therapist

OTs work holistically with individuals with dementia to achieve the highest quality of life for the patient.

Dementia is a neurocognitive disorder (NCD) that affects millions of people in the United States (American Psychiatric Association [APA], 2013). According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5, 2013) criteria for NCDs are based upon five domains. Both minor and major NCD fall into these domains.

• Complex attention: Sustained (over time), selective (filtered), divided (multiple), processing speed
• Executive function: Planning, decision making, working memory (or immediate memory; holding and manipulating information), feedback and error correction, overriding habits and inhibition, mental flexibility (shifting between concepts)
• Learning and memory: Recent memory, long-term memory
• Language: Expressive and receptive
• Perceptual motor: Visuoconstructional, motor, praxis
• Social cognition: Recognition of emotions, theory of mind

Recommended course: Dementia Care Practice Recommendations: Clinical Practices to Ensure Compliance Requirements

Minor and major NCD

The DSM-5 defines a minor NCD as known cognitive deficits not attributed to other mental disorders, such as delirium or depression. These are not sufficient to impact independence in activities of daily living (e.g., self-care tasks, medicine management, driving etc.) or instrumental activities of daily living (e.g., cooking, cleaning, finances etc.).

During a formal diagnostic assessment, a person with mild NCD would score one to two standard deviations below the norm.

A major NCD describes a substantial functional cognitive decline and performance on diagnostic assessments as two or more standard deviations below the norm. A decrease in occupational performance levels evidences a major NCD. This requires progressive assistance.

Measuring cognitive decline

Common standardized tools healthcare providers use include:

• Occupational therapists to investigate changes in cognition include the Short Test of Mental Status (STMS)
• Montreal Cognitive Assessment (MoCA)
• Mini-Mental State Examination (MMSE)
• Short Blessed Test
• The Saint Louis University Mental Status (SLUM) examination
• Allen Cognitive Level (ACL) Screen
• Cognitive Assessment of Minnesota
• Confusion Assessment Method for the ICU (CAM-ICU)

A prominent difference between mild and major NCD is the level of decline in functional cognition and its impact on daily performance. Dementia is considered to be a major NCD according to the DSM-5.

Dementia vs. normal aging

It is imperative to distinguish dementia from normal age-related brain changes and dementia-like symptoms. Other medical conditions such as thyroid irregularity, depression, vitamin deficiencies, and normal pressure hydrocephalus often present with dementia-like symptoms such as decreased functional cognition. Yet these symptoms are reversible, unlike dementia.

Medical conditions like these, or other precipitating factors such as an infection (like a urinary tract infection or sepsis) can often present with a sudden onset of cognitive deficits. This is caused by inflammation in the body and disturbances in blood/oxygen flow to the brain.

However, unlike dementia or major NCD, the cognitive decline associated with delirium is short-term and reversible. In cases of a UTI, the infection clears up after the patient begins antibiotics, and the cognitive deficits usually resolve quickly.

The DMS-5 describes delirium as a disruption in attention and awareness. A patient might present with confusion, agitation and disorientation. Symptoms of delirium can even vary throughout the day. They fall into several categories:

• Hyperactive (restlessness, agitation, irritability, etc.)
• Hypoactive (poor arousal, withdrawn, etc.)
• Mixed delirium, meaning that they can show symptoms of both hyper and hypo and may fluctuate randomly between the two types

Types of dementia

Although Alzheimer’s disease is the most frequent cause of dementia (accounting for 60-80% of all cases), according to the National Institute on Aging, there are other types of dementia. These include frontotemporal dementia, Lewy Body Dementia, and Vascular Dementia.

There are also other progressive medical conditions that can portray dementia-like symptoms such as Parkinson’s Disease dementia, Huntington’s Disease dementia, Korsakoff Syndrome, and Normal Pressure Hydrocephalous.

Alzheimer’s disease

Alzheimer’s is a major degenerative brain disease caused by complex brain changes following cell damage. It leads to dementia symptoms that slowly worsen over time. The Alzheimer’s Association describes the progression of Alzheimer’s dementia by three stages:

• Early or mild
• Middle or moderate
• Late or severe

In the early stages, a person can still function independently. They may begin to show some decline, only noticeable by close friends or family. This may include trouble finding words, misplacing objects, trouble with executive functioning, getting lost during normal routes etc.

The middle or moderate stage of Alzheimer’s occurs when the person has more difficulty with daily tasks and needs greater assistance. They may experience confusion, forgetfulness, have changes in mood or behavior, and have changes in sleep patterns.

In late-stage Alzheimer’s disease (severe), a person requires 24/7 assistance with all areas of occupational performance. Eventually they lose the ability to walk, talk, swallow, and even control their breathing.

Recommended course: Alzheimer’s Disease and Related Disorders in Occupational Therapy Practice, 3rd edition

Caring for dementia patients

In 2018, the Alzheimer’s Association published Dementia Care Practice Recommendations to review the evidence for best practice and quality of care. These recommendations include:

• Person-centered care
• Early detection and diagnosis
• Assessment and care planning
• Medical management
• Care partner information, education, and support
• Management of behavioral and psychological symptoms and activities of daily living
• Appropriate staff ratios and training in care facilities
• Creation of dignified and therapeutic environments
• Service coordination and ease with transitions throughout the continuum of care

The role of the occupational therapist

The occupational therapy practitioner is integrated throughout these recommendations. OTs work holistically with individuals and their families to achieve the highest quality of life for the patient.
In the early stages of dementia, occupational therapists can implement compensatory training to help a person maintain independence. Such training may involve the use of schedules, environmental modifications such as labels and signage, and training on apps on via smart devices, and other memory aids. 

In the middle to late stages of dementia, occupational therapists can provide family and caregiver training on how to use verbal and visual cues, provide partial or full assistance to daily tasks including safe functional transfers and proper positioning to prevent joint contractures and skin breakdown.
The American Occupational Therapy Association (AOTA) also has published practice guidelines, titled Occupational Therapy Practice Guidelines for Adults with Alzheimer’s Disease and Related Major Neurocognitive Disorders, available via the AOTA website.

For additional information, please check out the following resources:
Alzheimer’s Association
National Institute on Aging

This article was written by Elizabeth D. DeIuliis, OTD, OTR/L, CLA, FNAP.