Download Dana Rei Fukuda Rauckhorst - University of Puget Sound

Dana Rei Fukuda Rauckhorst
University of Puget Sound
December, 2004
Aging In Place: What is Our Role?
Introduction:
“The nation is aging” (AOTA, 2003). By the year 2030, it is predicted that more than 70 million Americans will be over the age of 65;
demographically representing the largest portion of the national population. Projections also state that 95% of these individuals, will continue to live
in the community and home environments as long as possible. As the population of older adults grows, lifespan increases, and needs change,
environmental modification will becomes more of a necessity for individuals desiring to “age in place.” New challenges and opportunities of
services will be presented to health professionals. “Values of autonomy, productivity, engagement, and purpose are all implied by aging in place,
and these values are congruent with the philosophy of occupational therapy” (AOTA, 2003). Determination of an appropriate fit between the
environment and the individual’s ability levels, require the skills and expertise of an occupational therapist. Suitable matches will allow for “aging
well” within a physical context; home environment. Therefore, this report will attempt to reveal the rationale for, involvement and effectiveness of
occupational therapy with aging in place.
Evidence Based Practice Question:
What is the role of occupational therapy in creating, addressing, and promoting contexts for geriatric individual’s home environmental interventions
in order to successfully age in place? Does evidence for effectiveness of the occupational therapy role exist?
Criteria for Evidence Selection:
 Types of Participants:
☻ Adults, specifically geriatric/elderly desiring to age in place
☻ With or without disabilities
☻ Occupational therapists/occupational therapy assistants
 Types of Interventions:
Proactive stance:
☻ Lifestyle Redesign/Well Elderly program
☻ Home assessments/modifications, “user friendly” design criteria
☻ Home safety evaluations/behavioral strategies
☻ Fall prevention
☻ Models of service; alternatives to one-on-one service delivery
☻ Consultation, education, and organizational/group clients
☻ Advocacy: policy and program development
☻ Collaboration with other professions
 Types of Studies :
☻ Randomized Controlled Trials, Cross-Sectional Studies, Case Reports,
☻ Evidence levels: I, III,IV, & V
Table Summarizing the Evidence:
 Evidence for role of OT
References
Study
Level of
Design/
Evidence
Data
Collection
Gallup
CrossLEVEL
Organization.
Sectional
III
(2003)
Study
(Phone
survey)
Trickey, F. et
Case
LEVEL
al. (1993)
Reports
IV
Siebert, C.
(2003)
Literature
Review
LEVEL
IV
Auriemma, D.
et al. (1999)
Literature
Review
LEVEL V
Klein, S. et al.
(1999)
Literature
Review
LEVEL V
Sample Size
Outcome/Intervention
Summary of Results
(Conclusions & Implications)
500 adults age Questions regarding
60 or older
awareness, perception, &
knowledge of OT, &
opinions about importance of
healthcare-related activities
177 elderly
Evaluated/modified housing
clients (mean in relation to individual
= 76.7 y.o.) of functional status (assisted by
3 home care carpenter). Installation of
service
grab bars, shower seats, &
centers
hand-held showers
n/a
Possible occupational
therapy (OT) interventions
include home establishment,
modification and
management, safety
procedures and emergency
responses, communication
device use, performance
patterns, address temporal &
physical context
Psychosocial implications for
OT when dealing with
individuals wishing to AIP
Home inspections,
modifications, & follow-up
inspections
Awareness of the role of OT is low. OT practitioner are
generally perceived correctly, however perspectives
overlap with less well-trained health care workers (not
shared by physical therapists)
898 modifications completed, half modifications made to
bathrooms. These modifications had highest utilization
rates. Average cost of home adaptations = $150.00 per
household.
Aging in place (AIP) is the only feasible option for a
society with 35 million people over age 65 and a
subsequent generation with an 80+ year predicted
lifespan. Although expectation to age in
homes/communities are increasing, potential for
physiological complications still exist (e.g. – aging,
illness, etc.). Therefore, AIP presents opportunities &
challenges for OT to contribute to programs/policies
through facilitation of common OT values (autonomy,
productivity, engagement, purpose).
High societal value on independent living and increased
need for home modifications, yield certain psychosocial
implications for OT practitioners when collaborating
with clients wishing to AIP.
In all home repair and modification programs administered
by the Housing Dept.; Philadelphia Corporation for Aging
(PCA) programs, OTs assist the consumer/programs in
developing useful & proper home modifications. Followup inspections yield useful information on construction
specifications & on the modification process.
 Evidence for effectiveness of OT involvement
Cumming,
R.G. et al.
(1999)
Randomized
Controlled
Trial
LEVEL I
530
subjects
(mean =
77 y.o.)
recruited
before
discharge
from
hospital
Intervention included home
visit/assessment for
environmental hazards &
facilitation of any necessary
home modifications.
36% of subjects in intervention group had at least one fall
compared to 45% of controls (P = .050). The intervention was
effective only among subjects (n = 206) who reported having one
or more falls during the year before recruitment into the study; in
this group; was 0.64 (95% confidence interval, 0.50-0.83). Similar
results attained with survival analysis techniques (proportional &
multiplicative hazards models) & fall rates (mean number of falls
per person per year). About 50% of home modifications were in
place at a 12-month follow-up visit. Modifications by OTs can
prevent falls, but home visits may also affect behavior, allowing
safer living in the home/external environment.
Gitlin, L. et
al. (2001)
Randomized
Controlled
Trial
LEVEL I
Randomized
Controlled
Trial
(Large-scale)
LEVEL I
Five 90 minute home visits
by OTs who provided
education &
physical/social
environmental
modifications.
3 groups: one with
OT/Well Elderly
Treatment Program, one
with social activities, on
with no treatment. OT
group 2 hour per week;
social activity group 2 ¼
hour per week (w/o
professional guidance)
Compared to controls, intervention caregivers reported fewer
declines in patients’ instrumental activities of daily
living/self-care & fewer behavioral problems 3 months posttest. Intervention spouses reported lower incidence of being
upset, women reported enhanced self-efficacy in managing
behaviors/functional dependency (same w/minorities).
Clark, F. et
al. (1997)
171
caregivers
(aged 2392) of
dementia
patients
361
elderly
(ages 6089)
residents
of Los
Angeles
- After nine months, OT intervened group showed significantly
positive differences from other groups. While control group
declined in all eight measured categories of health/well-being, the
OT group advanced in five areas and declined considerably less in
other three areas. The social activities group was synonymous
with the control group
- Group sessions were a cost-effective method of enabling the
participants to maintain a healthier/more independent lifestyle,
however individualization was key to success of OT intervention.
- Adding preventive OT programs for seniors to health plans
could delay reliance on more expensive nursing home care, and
loss of independence
- Shift in OT from reactive to proactive/preventative
Results indicate that OT provides a health advantage for seniors.
Summary of Evidence:
♥ Apparent existence of and need for the role of OT in AIP.
♥ General description of OT role in AIP include:
- home assessment/inspection, visits for safety precautions (e.g. – fall prevention)
- evaluation of “fit” between person’s ability & environment for maximum independence
- physical/social environmental modifications (e.g. - in bathroom, kitchen, hallways/doorways, living room, bedroom, etc.)
- advocacy for programs & policies
- establishing alliances with other disciplines involved with AIP
- developing contexts (physical, social, etc.) for geriatric individuals desiring independent living
♥ Aside from indications/outcomes of efficacy in OT intervention with fall prevention & the Well Elderly Treatment Program, evidence for
effectiveness of OT’s role within the specific domain/contexts of AIP, was lacking. No substantial evidence was found.
Implications for Consumers:
AIP can help:
 maintain social network: aging in place promotes self-sufficiency, encourages cost-saving interdependence between friends & neighbors in
community, offsets social isolation, doesn’t involve costly professional support unless necessary
 limit the negative effects of relocation & dramatic transitions
[Lawler 2001]
Implications for Practitioners:
 Target caregivers & older adults with consumer-oriented message & guidelines about the important role OT can play in maintaining
independence, self-care, & safety
 Develop more robust partnerships with service organizations for the aging & providers at both the national & community-based levels
 Awareness of OT is low, therefore provide OT practitioners with communication tools that make it clear how the specific service being
delivered to clients connects with the larger goal of helping individuals successfully age in place.
[Gallup Organization, 2003]
Implications for Researchers:
 More research is required to determine the effectiveness of occupational therapy intervention and involvement with aging in place.
 Utilization of the newly developing occupational science field should be considered for its ability to supplement the realm of public health
through examination of how daily activities contribute to physical health & well-being
Recommendations for Best Practice:
 Image of OT needs to be defined by training/professional knowledge to be distinguished from other healthcare providers
 Promotion of proactive use of OT to assist with:

Reduction of healthcare cost to families, increase quality of life for independent older Americans, prevent accidents in the home
 This will further serve to define & identify OT personnel as essential & important healthcare professionals having both reactive & proactive
solutions for healthy independent living
 Outreach programs to both the well-elderly & their families should seek to identify OT services with independent living through proactive
offerings of OT services
References:
☺ AARP. (2000). Fixing to stay: A national survey on housing and home modification issues. Retrieved November 20, 2004 from
http://research.aarp.org/il/home_mod.pdf
☺ American Occupational Therapy Association. (2004). AOTA & Rebuilding Together - Strategies for success: Stories from the community. Retrieved
November 30, 2004 from http://www.promoteot.org/AI_Stories.html
☺ Auriemma, D., Faust, S., Sibrian, K., & Jimenez, J. (1999). Home modifications for the elderly: Implications for the occupational therapist. Physical and
Occupational Therapy in Geriatrics, 16, 135-144.
☺ Baum, C. (2002). Creating Partnerships: Constructing our future. Australian Occupational Therapy Journal, 49, 58-62.
☺ Campbell, J., Herge, E. (2000). Challenges to aging in place: The elder adult with MR/DD. Physical & Occupational Therapy in Geriatrics, 18(1), 75-90.
☺ Clark, F., Zemke, R., Jackson, J. (1997). The USC well elderly study. Retrieved November 30, 2004 from
http://www.usc.edu/assets/ot/faculty/research/2.html
☺ Cumming, R., Thomas, M., Szonyi, G., Salkeld, G., O’Neil, E., Westbury, C., & Frampton, G. (1999). Home visits by an occupational therapist for
assessment and modification of environmental hazards: A randomized trial of falls prevention. Journal of the American Geriatrics Society, 12, 1397-1402.
☺ Dishman, D. (n.d.) Inventing Wellness Systems for aging in place. Retrieved December 2, 2004 from
http://www.computer/homepage/0504/dishman/?SMSESSION=NO
☺ Gallup Organization. (2003). Forging connections: A national public awareness survey of occupational therapy’s role in helping independent-living older
adults. [Preliminary report]. Retrieved November 20, 2004 from http://www.promoteot.org/docs/Gallup.pdf
☺ Gitlin, L. (2003). Conducting research on home environments: Lessons learned and new directions. Gerontologist, 43, 628-37.
☺ Gitlin, L., Corcoran, M., Winter, L., Boyce, A., Hauck, W. (2001). A randomized, controlled trial of a home environmental intervention: Effect on
efficacy and upset in caregivers and on daily function of persons with dementia. Gerontologist, 41, 4-14.
☺ Klein, S., Rosage, L., Shaw, G. (1999). The role of occupational therapist in home modification programs at an area agency on aging. Physical &
Occupational Therapy in Geriatrics, 16, 19-37.
☺ Holm, M. (2000). Our mandate for the new millennium: Evidence-based practice [Eleanor Clarke Slagle lecture]. American Journal of Occupational
Therapy, 54, 575-585.
☺ Intel Corporation. (n.d.) Helping the elderly age gracefully at home. Retrieved December 2, 2004 from http://www.intel.com/research/prohealth/csaging_in_place.htm
☺ Jackson, J., Carlson, M., Mandel, D, Zemke, R., & Clark, F. Occupation in lifestyle redesign: The well elderly study occupational therapy program.
American Journal of Occupational Therapy, 52(5), 326-336.
☺ Lawler, K. (2001). Aging in place: Coordinating housing and health care provision for America’s growing elderly population. Retrieved November 20,
2004 from http://www.chrcatlanta.org/docs/aginginplace.pdf
☺ Mynatt, E., Essa, I., & Rogers, W. (n.d.) Increasing the opportunities for aging in place. Retrieved November 20, 2004 from
http://www.cc.gatech.edu/fce/ahri/publications/agingInPlace-cuu2000.pdf
☺ National Reverse Mortgage Lenders Association. (2003). The NRMLA guide to aging in place. [Booklet]. Retrieved November 20, 2004 from
http://www.seniorsafehome.com/Portals/5/consumer_guide_4.pdf
☺ Scott, A., Butin, D., Tewfik, D., Burkhardt, A., Mandel, D., & Nelson, L. (2001). Occupational therapy as a means to wellness with the elderly. Physical
& Occupational Therapy in Geriatrics, 18, 3-22.
☺ Siebert, C. (2003) Aging in place: Implications for occupational therapy. OT Practice, 8, CE1– CE8.
☺ Taira, E., Carlson, J. (2004). Aging in place: Designing, adapting, and enhancing the home environment. Binghamton, NY: Haworth Press.
☺ Trickey, F., Maltais, D., Gosselin, C., & Robitaille, Y. (1993). Adapting older persons’ homes to promote independence. Physical & Occupational
Therapy in Geriatrics, 12(1), 1-14.