Evidence
Alert

Occupational therapy at home may benefit people with dementia and their carers

Multiple occupational therapy sessions, provided in a person with dementia’s own home, improve their ability to carry out daily activities, compared with usual care. Improvements are also seen in behavioural and psychological symptoms and their quality of life. In addition, carers report feeling less distress, and a better quality of life.

This study was a systematic review of trials where an average of eight one-hour sessions of occupational therapy was compared with usual care or minimal extra support. The benefits to daily life were measured after three or six months.

This study shows positive outcomes, but the evidence is only of low to moderate reliability. There are also questions left unanswered, including how long the effects of the occupational therapy sessions last, and whether alternative, perhaps cheaper, ways of supporting people would also be effective.

 

Why was this study needed?

Dementia describes a range of symptoms that are associated with an ongoing decline in brain functions. Symptoms can include memory loss, changes in behaviour, and problems carrying out everyday activities such as washing and dressing. There are about 850,000 people living with dementia in the UK. Most of these people live at home and are cared for by family members. However, being a carer can result in increased physical and mental health problems, and reduced quality of life.

Occupational therapy (OT) aims to help people manage their activities within both their capabilities and environment. Previous studies have suggested that OT has the potential to improve outcomes for people with dementia, but those studies have not focused on OT in particular settings, or on outcomes for family carers. This study aimed to evaluate the effect of OT provided at home for people with dementia and their family carers.

 

What did this study do?

This systematic review pooled the results of 15 randomised controlled trials, which included 2,063 people with dementia, and their family carers, though actual meta-analyses only used much smaller numbers. Most participants had moderate dementia and needed help with some activities of daily living. The trials compared OT at home with usual care or an attention control (these were mainly up to three phone calls but not equivalent in time to the intervention). On average, participants received eight occupational therapy sessions, lasting between 1 and 1.5 hours. Interventions aimed to improve the person with dementia’s involvement in daily activities, and/or manage their behavioural and psychological symptoms.

One of the included trials took place in Wales and most were carried out in the US. All the trials were at risk of performance bias, as participants and therapists knew their trial groups, and outcomes were self-reported. Publication bias was not assessed.

 

What did it find?

  • Occupational therapy was more effective than usual care or attention control for improving overall activities of daily living for people with dementia (standardised mean difference [SMD] 0.61, 95% confidence interval [CI] 0.16 to 1.05; five trials, 644 participants; low-quality evidence).
  • There were fewer behavioural or psychological symptoms in people with dementia in the OT group, compared with usual care or attention control (SMD -0.32, 95% CI -0.57 to -0.08; six studies, 695 participants; moderate-quality evidence).
  • OT resulted in a better quality of life for people with dementia than for people in the control groups (SMD 0.76, 95% CI 0.28 to 1.24; 6 studies, 470 participants; low-quality evidence).
  • The effect on the family carers was more mixed. There was no difference between the groups for carer depression immediately after the intervention, or for carer burden. However, carers reported fewer hours doing things for the person with dementia (SMD -0.33, 95% CI -0.58 to -0.07; 3 studies, low-quality evidence).
  • Carers in the OT groups also reported less distress or upset with the behaviours or psychological symptoms of the person with dementia (SMD -0.23, 95% CI -0.42 to -0.05; six studies, 846 participants; moderate-quality evidence). In addition, there was some improvement to carers’ quality of life following the OT intervention (SMD 0.99, 95% CI 0.66 to 1.33; 2 studies, 162 participants; moderate-quality evidence).

 

What does current guidance say on this issue?

NICE published a guideline in 2018 on assessing, managing and supporting people living with dementia and their carers. It has a section about interventions to promote cognition, independence and well-being. It recommends considering cognitive rehabilitation or occupational therapy to support functional ability in people living with mild to moderate dementia.

NICE defines cognitive rehabilitation as identifying functional goals that are relevant to the person living with dementia, and working with them and their family members or carers to achieve these. The guidance doesn’t specify where this should take place.

 

What are the implications?

The results of this study suggest that providing OT at home has benefits for people with dementia and their carers. However, there is no economic evaluation included in the study and no long-term outcomes. It is unclear whether OT is beneficial over just the additional 8–12 hours of support in the home. There are obvious costs and capacity issues involved with providing an extended OT service which would be a barrier to changes in practice. Further research is needed to establish the most cost-effective model of care for people with dementia in their own homes.

 

Citation and Funding

Bennett S, Laver K, Voigt-Radloff S et al. Occupational therapy for people with dementia and their family carers provided at home: a systematic review and meta-analysis. BMJ Open. 2019;9:e026308.

The study was partially supported by The University of Queensland, Australia (grant number 2007000387).

 

Bibliography

NHS website. Alzheimer’s disease. London: Department of Health and Social Care; 2018.

NHS website. Vascular dementia. London: Department of Health and Social Care; 2017.

NICE. Dementia: assessment, management and support for people living with dementia and their carers. NG97. London: National Institute for Health and Care Excellence; 2018.

Wittenberg R, Hu B, Barraza-Araiza L and Rehill A. Projections of older people with dementia and costs of dementia care in the United Kingdom, 2019-2040. CPEC Working Paper 5. London: The London School of Economics and Political Science; 2019.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

 

Commentaries

Expert commentary

This rigorous systematic review and meta-analysis found 15 randomised trials with 2,063 participants of 8–12 hours of family carer training to simplify activities, use compensatory strategies, and environmental modification to make changes in the home. In addition, stress management and education about dementia were included. Studies were very low to medium quality. The results were positive and the person with dementia’s function, quality of life and neuropsychiatric symptoms improved but not carer depression.

People who were not occupational therapists could deliver the intervention. There was no cost-effectiveness or long-term data. Interventions that are occupational therapist/nurse supervised (not delivered) are more often cost-effective and practical to roll out. This evidence seems essential now to guide UK implementation.

Gill Livingston, Professor of Psychiatry of Older People, Division of Psychiatry, University College London

The commentator declares no conflicting interests

Expert commentary

Two questions arise from this study: first, can occupational therapy realistically be offered to everyone – are there enough occupational therapists to provide a median of eight hours' input? Second, does it have to be an occupational therapist or is input from other professionals as useful?

Maybe what matters is providing a reasonable amount of meaningful support so that people can adjust to the impact of dementia on their lives. We should pay much more attention to this rather than just handing out leaflets and hoping for the best. In practice, too, occupational therapists are great at providing really useful assessments, for instance, when we want to know how much functional limitation there is. It’s often better than doing too much cognitive testing, as it’s more relevant to everyday life.

Tom Dening, Professor of Dementia Research, Faculty of Medicine and Health Sciences, School of Medicine, University of Nottingham  

The commentator declares no conflicting interests