Evidence Based Practice: Alzheimers Disease

Elizabeth Clinch and Carla Sawanec

Utica College

Introduction
Alzheimer's Disease (AD) is a severe progressive disease most commonly diagnosed in
older adults. This, however, is a form of dementia and is not a natural progression of the aging
process. There are three stages of AD; mild, moderate and severe. Mild or beginning stages is
the transition to AD from typical function, individuals or people around them specifically notice
a change in cognitive decline, forgetfulness, and an inability to find words during conversation.
An increase in supervision may be deemed necessary to ensure their safety from wandering and
elopement. During the moderate stage, the person may experience severe inability to control
their emotions as well as situations that are confusing and overwhelming, activities of daily
living (ADLs) are affected. The severe stage is accompanied by personality changes and drastic
motor impairments which usually result in dependence on a caregiver. AD ultimately has
irreversible impacts on the person, leading to total loss of function and death (Radomski &
Latham, 2014).

Summaries
Verbal Cueing and Environmental Modifications: Strategies to Improve Engagement in
Occupations in Persons with Alzheimer Disease
Purpose: Chard, Liu and Mulholland (2009) developed this study to explore the
effectiveness of using environmental modifications and caregiver training during occupational
therapy sessions to increase occupational performance during ADL for individuals living with
AD and other mild cognitive disorders.
Level of Evidence: Per Tomlin and Borgetto (2011), researchers used one group during
this nonrandomized therefore it is a level 3. Researchers of this qualitative exploratory study

also used convenience sampling to form the group of participants while implementing a before
and after design.
Procedures and Methods: There were 15 residents at the assisted-living facility that had a
diagnosis of AD although; only 5 out of the 15 met the inclusion criteria of sufficient
communication skills and family member involvement to be included in the study. These 5
participants were all females between the ages of 7089 years, living at the facility for 324
months and required moderate to maximum assistance with ADLs. The instrument used for the
study was the Assessment of Motor and Process Skills (AMPS). It is a performance skill
evaluation that involves direct observation of 16 motor and 20 process actions performed during
ADL including effort, efficiency, independence as well as safety (Chard et al., 2009).
Before administering the AMPS, researchers performed individual interviews to get a
sense of which ADLs were important to the participants. The caregivers or "Assisted Living
Workers" that worked in the facility were present to confirm their answers. They each reported
two baseline ADL tasks and two post-intervention ADL tasks in which they were evaluated using
the AMPS (e.g. making a PB&J sandwich, hand washing dishes, folding laundry, etc.).
Caregivers of each resident received one session of training with the researcher one on one. The
interventions taught were verbal cues through prompts and circumlocution or talking around the
problem, verbal reinforcements using positivity during the activity and modifications to
environments by labeling drawers, clearing clutter and setting up workstations, etc. For 2 weeks
caregivers used these techniques while the participant completed their ADL. All data was
gathered and analyzed by the AMPS and AMPS computer software (Chard et al., 2009).
Results and Findings: When caregivers used these interventions rather than completing
the entire activity for them results suggested that all five participants had significant changes in

their ADL process skills. Chard et al. (2009) also stated that two of them has significant changes
in motor skills during their ADL, one of them meeting the clinically meaningful category.
Critical appraisal: One of the researchers was AMPS certified and observed the
participants in their natural environments performing their ADL activities. Evaluators were the
same for each participant at baseline and post intervention AMPS evaluations. A future study
could benefit from a larger sample size to evaluate the effects of caregiver training when it
comes to working with patients who have AD (Chard et al., 2009).

Improving Quality of Life for Persons with Alzheimers Disease and Their Family
Caregivers: Brief Occupational Therapy Intervention.
Purpose: Dooley and Hinojosa (2004) stated that the purpose of their study was to
research whether the Assessment of Instrumental Function (AIF) shows an improvement in the
quality of life for people with AD living in the community. They also set out to see if their
occupational therapy recommendations decreased caregiver burden.
Level of Evidence: This qualitative research study was made up of two randomized
groups and had a pretest-posttest control design. According to Tomlin and Borgetto (2011), this
study is a level 2.
Procedures and Methods: This study was made up of 40 men and women participants
with AD as well as their 40 caregivers. Participants were evaluated using the AIF, Zarit Burden
Interview, the Affect and Activity Limitation Alzheimer's Disease Assessment (AAL-AD) and
the Physical Self Maintenance Scale (PSMS). Results from this assessment were used in the
form of recommendations shared with the caregiver and participant with AD. The three main
recommendations were made to the treatment group; environmental modifications to their
physical surroundings, community- based assistance, and various caregiver approaches. Dooley

and Hinojosa (2004) explained that caregiver approaches included, the involvement of the person
with AD during activities, stressing the importance of a daily routine to keep structure and
consistency in the person's life to decrease confusion. Caregivers were also asked to use cueing
in the form of breaking down steps, performing a step at a time, as well as providing gentle
reminders during ADL. The community resources for the caregivers were support groups
offered by the Alzheimer's Association, services that offer delivered meals, OT driving
evaluations and so on to decrease caregiver burden through providing them with viable options.
Assessments were administered a month later after the initial assessment through the
pretest-posttest design. Then caregivers in the treatment group rated the frequency in which they
used the recommendations given to them by the OT. Those caregivers in the control group that
did not receive intervention were mailed the results of the top 5 OT recommendations after they
completed the posttest assessments.
Results and Findings: Results of the study showed that participants with AD that were in
the treatment group had a rise in their independence during ADL, showed more positivity, as
well as their caregivers having a decrease in their burden levels compared to their counterparts in
the control group.
Critical appraisal: Dooley and Hinojosa (2004) clearly stated that they randomly
assigned each pair of participants to either the control group or treatment group directly after the
AIF report was written to avoid any experimenter bias. They stated that this is the first study of
its kind to show a decrease in caregiver burden along with an increase of quality life among
participants with AD.

Managing agitated behaviour in people with Alzheimer's disease: The role of live music

Purpose: Cox, Nowak, and Buettner (2011) conducted a study to investigate whether
exposure to live music could lead to a reduction in agitated behavior in individuals diagnosed
with AD.
Level of Evidence: The researchers used a quasi-experimental, one group, repeated
measures design. According to the AOTA EBP Project (n.d.), this is a level 3 form of evidence
because it nonrandomized, with one group receiving an intervention with a pretest and posttest.
Procedures and Methods: Seven residents of dementia-specific units at a private
residential care facility in Townsville, north Queensland, were selected to participate in this
study. Participants were selected based on physician confirmed probable diagnosis of AD, a
Mini Mental State Exam (MMSE) score less than or equal to 19/30, having no changes in
medication for three months (type, dosage), at least four weeks residing in their current
environment, and no new therapy or intervention that could affect agitated behavior over the past
four weeks. This sample consisted of four females and three males between the ages of 70 and
85 years. Individuals holding an Enduring Power of Attorney were contacted for written
informed consent and were also interviewed to gather information about the participants musical
preference, history, and ethnic origin. This information was used to guide the repertoire of songs
used during the intervention.
Private observation/intervention sessions were carried out three times with each
participant over the course of a four-week period. Each session was carried out on the dementiaspecific unit that the participant resided in and consisted of a 15-minute pre-intervention period,
an 18-minute intervention period (live violin recital performed by the researcher) and a 15minute post-intervention period, during which the participant was video recorded for data
collection. The songs included in the repertoire were either popular or well known, or were

suggested by the participants guardians; the same playlist was used for each participant in each
session.
The researcher and blinded observer watched the videotapes separately, assessing agitated
behavior with the use of the modified Cohen-Mansfield Agitation Inventory and rating scale
(mCMAI). Three behavior features were assessed, the type of behavior, frequency and amount
of time of occurrence during the session. Four subtypes of agitated behaviors were considered,
they included aggressive and nonaggressive demonstrations of physical and verbal behaviors.
Comments and responses to specific songs were also assessed as qualitative aspects, which were
numerically coded.
Results and Findings: Of the total agitated behavior, 90.8% fell under the physically nonaggressive subtype, which was demonstrated by six out of seven participants (Cox, Nowak, &
Buettner, 2011). Physically non-aggressive agitated behaviors included pacing/aimless
wandering; inappropriate dress or disrobing; trying to get to a different place; handling things
inappropriately; performing repetitious mannerisms; and general restlessness (Cox, Nowak, &
Buettner, 2011, p. 521). Results showed a significant decrease in each of these behaviors except
for handling things inappropriately, while there was a decrease in this behavior also it was not
statistically significant. Verbally non-aggressive behaviors accounted for 6.13% of the agitated
behaviors, demonstrated by 4 of the participants, this included negativism and repetitive
sentences or questions. Though these behaviors ceased immediately when the music began, this
decrease was not statistically significant. The only physically aggressive behavior observed was
scratching, which accounted for 1.84% of the agitated behaviors. The least common agitated
behavior demonstrated was verbal aggression which consisted of cursing and accounted for
1.22% of the total agitated behavior; this was directed towards other residents that had wandered

into the intervention area or personal space of the participant (Cox, Nowak, & Buettner, 2011).
There was a significant decrease in the median number of agitated behaviors demonstrated from
pre-intervention observation to intervention and post-intervention observations. These findings
in this study suggest that one-to-one, live musical intervention can reduce agitated behaviors not
only during the intervention, but in the immediate post-intervention period as well.
Critical Appraisal: This study consisted of a small sample of participants who were
recruited via purposive and convenience sampling. This could have led to an inaccurate
representation of agitated behaviors. The measurement instrument, the mCMAI, was developed
for this study, therefore, reliability and validity are not confirmed. There is a possibility for rater
bias in this study. Since the researcher was also the person delivering the musical intervention,
they may have had preconceived bias when they assessed the video recordings. There were
attempts to limit such bias, by randomizing the order in which the recordings were watched and
having another, blinded, investigator observe the recordings separately. It was noted that when
there was a discrepancy between the observers, that of the blinded observer was used, to further
limit the potential for bias.

Profile of Older Adults in Memory Outpatients' Clinic Setting and effectiveness of Novel
Occupational Therapy Intervention in Patients with Mild to Moderate Dementia

Purpose: Kumar, Tiwari, Sreenivas, Kumar Tripathi, and Dey (2013) sought to examine
the effect of a novel occupational therapy intervention programme on cognition, activity of
daily living, physical performance, depression, psychological and behavioral symptom and
quality of life of patients with mild to moderate dementia (p. 298).

Level of Evidence: The researchers chose an experimental pre and post-test, randomized
control group design. This is categorized as a level 1 form of evidence according to the
American Occupational Therapy Association (AOTA EBP Project, n.d.).
Procedures and Methods: This study included 71 participants who were diagnosed with
dementia per the DSM-IV criteria by a geriatrician/clinician. They were required to be 60 years
and above, scoring between an 11 and 23 on the MMSE, having achieved at least 5th standard
educational level (per Indias educational system), with the abilities to read and understand
simple sentences. Those with severe Dementia, depression, severe behavioral or psychological
symptoms, and those with severe medical illness requiring nursing care were excluded from this
study. Participants were randomly assigned to either the experimental group or the control
group, both of which received prescription medication throughout the study.
Ten 70-minute intervention sessions were carried out over the course of the 5-week study
period. Each session consisted of 10 minutes of relaxation, 10 minutes of physical exercise, 15
minutes of personal activities, 20 minutes of cognitive exercise, and 15 minutes of recreational
activity (Kumar et al., 2013). A baseline assessment was completed using the general
Occupational Therapy assessment Performa. Six other standardized scales were used for further
evaluation, including the MMSE, Hindi Geriatric Depression Scale (GDS), Modified Physical
performance test, Bristol ADL Scale, BEHAV-AD and the Hindi WHOQOL-BREF.
Results and Findings: The results of the GDS, BADL, MPPT, and WHOQOL
demonstrate significant improvements in depression, ADL independence, physical performance
and quality of life respectively among the experimental group. Whereas, the control group
demonstrates a significant decrease in the same areas. The results of the MMSE suggest an
increase in cognition among the experimental group and a decrease among the control group,

however the changes did not reach a level of statistical significance. No behavior and
psychological changes were seen in the control group, according to the BEHAV-AD scores,
however, there was a statistically significant improvement among the experimental group. These
findings suggest that individuals diagnosed with AD may experience improved mood,
functionality, physical performance, quality of life, and behavior with implementation of this
novel occupational therapy program consisting of relaxation, physical, cognitive, recreational
and personal activities (Kumar et al., 2013).
Critical appraisal: While the researchers offered a breakdown of the different aspects of
the intervention sessions, they do not offer examples of the types of activities used for each
portion of the the session. It is not noted if each session is the exact same or if there are
differences in sessions among the participants or as the study progresses. There is also no
explanation of who is performing the many assessments and who is carrying out the
interventions sessions, therefore many biases are possible. While this study demonstrates
positive results through implementing this intervention technique, the article is very vague as far
as the methods and procedures are concerned. There is no information acknowledging or
limiting biases throughout this process, therefore, there could be many unknown factors
contributing to these results.

Synthesis
Dooley and Hinojosa (2004) and Chard et al. (2009) suggest that environmental
modifications such as labeling drawers and commonly used objects as well as using adapted
devices to make participation in ADL easier for the person with AD are highly beneficial to their
quality of life. They also found that verbal cueing was an important aspect of increasing the
successfulness of the person's performance. By breaking down steps of the activity, performing

one step at a time along with making sure the person was unoccupied when they participated
allowed caregivers to promote the person's engagement in their ADL. Chard et al. (2009)
suggest that using environmental modification along with caregiver verbal cueing allows patients
with AD to be more successful in ADL activities. Chard et al. (2009) also stated that maintaining
or adapting current occupations would also be beneficial depending on their performance and
level of function. Motor skills should be acknowledged and worked into patients therapy
sessions as well. Kumar et al. (2013), who also examined functionality, suggest that
implementing a novel occupational therapy intervention program can lead to improved ability to
perform ADLs independently. By combining these techniques, environmental modifications,
verbal cuing and novel occupational therapy intervention program, an individual with AD could
potentially demonstrate an greatly improved ability to perform ADLs, maintaining or even
regaining some level of independence.
Cox et al. (2011) examined a very different aspect of AD, involving agitated behaviors.
Their technique of live music could be used during times of increased agitation, such as the later
afternoon hours during which a phenomenon referred to as sun downing typically occurs. While
Kumar et al. (2013) was not specifically focused on agitated behaviors, they did incorporate a
period of relaxation into their novel occupational therapy intervention program. Since agitated
behaviors can be common in individuals with AD, these two methods can be useful in decreasing
agitation, which can also decrease the burden on caregivers if they are educated on effective
mood altering techniques. This relates back to the goals of Chard et al. (2013) and Dolley and
Hinojosa (2004).
Chard et al. (2009), Cox et al. (2011), and Kumar et al. (2013) all focused on individuals
living in either assisted living or long-term care facilities, whereas, Dooley and Hinojosa (2004)

focused on those living in the community. Cox et al. (2011) and Chard et al. (2009) included
very small groups of participants, 7 and 5, respectively. This allowed the researchers to While
Kumar et al. (2013) and Dooley and Hinojosa (2004) both used larger groups for randomized
controlled trials, with pretest/posttest designs.
Implications for Occupational Therapy
Occupational therapists should always consider including recommendations for
caregivers of persons with AD to help them increase their quality of life and occupational
performance. Chard et al. (2009) found that using compensatory strategies during common daily
activities is more beneficial than teaching patients with AD different activities since learning
entirely new information can be confusing and difficult at times. We should always remember
that therapy sessions should be developed individually for each patient to focus on their needs
and interests when it comes to their ADL/IADL. It is also important to take the non-traditional
interventions options into account when working with patients who have AD. Cox, Nowak and
Beuttner (2011) showed us that by integrating music interventions, agitated behaviors including
physical and verbal aggression can be decreased. By using these alternative suggestions
occupational therapists can explore more creative, meaningful and therapeutic activities which
makes our profession unique. Patients experiencing sun downing syndrome may benefit from
relaxing music during their periods of agitation and confusion. Occupational therapists should
consistently take relaxation, physical, cognitive, recreational and personal activities into account
during treatment sessions to improve patients mood, functionality, physical performance, quality
of life, and behavior into account (Kumar, Tiwari, Sreenivas, Kumar, Tripathi, and Dey, 2013).

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