Recovery to Practice (RTP) Weekly Highlights December 22, 2011. To access the RTP Weekly Highlights and other RTP materials please visit: http://www.dsgonline.com/rtp/resources.html

The Role of Occupational Therapy in Adult Cognitive Disorders
by Patricia Cheney, MBA, OTR/L, BCG, and Lisa Rivera, MS, OTR/L
Cognition includes processes such as orientation, attention, perception, problem solving, memory, judgment, language, reasoning, and planning. It is essential for taking in information, synthesizing it, and using it to control behavior. Therefore, a cognitive deficit will have at least some impact on function. Cognitive disorders may be caused by traumatic brain injury (TBI), infection, tumors, stroke, dementias such as Alzheimer's disease, or existing congenital conditions.

Cognitive disorders are a growing problem in the U.S. As people live longer and demographics shift toward an aging population, the incidence of these disorders is accelerating among older adults. In 2010, an estimated 5.3 million people in the U.S. had Alzheimer's disease, and an additional 3.7 to 5.3 million people had other types of dementia,1 most of whom were over 65 years of age.

Among younger adults, cognitive impairment is often caused by injury. Although it is difficult to find statistics for the total number of adults with cognitive impairment, TBI alone accounted for almost 750,000 annual injuries of people between the ages of 15 and 64 from 2002 to 2006.2

Occupational Therapy's Role in Cognitive Rehabilitation
Occupational therapists are experts on determining how cognitive deficits can impact everyday activities, social interactions, and routines. Their knowledge about neurology and neuroanatomy helps them understand the impact of the brain disorder on deficits, administer appropriate tests and measures to identify the extent of cognitive function loss, and determine the extent to which deficits are likely to be remediated or circumvented. Occupational therapists have the skills necessary to assess cognitive aspects of functional activities and design an intervention plan, from acute care to community reintegration.

There is significant evidence that the brain has considerable neuroplasticity, or capacity to redirect pathways and relearn skills, even many years after damage has occurred.3 Occupational therapy practitioners facilitate this process through the use and modification of motivating daily activities and adaptation of the client's environments.

Where Do Occupational Therapy Practitioners Provide Cognitive Rehabilitation?
Occupational therapy services for cognitive impairment are provided in a number of settings:

Acute Care
Typically for individuals with sudden onset, such as cases with stroke or TBI
  • Evaluation of performance ability for safety and independence in self-care activities
  • Preparatory activities to facilitate balance and stability
  • Family and caregiver education
  • Home program may be developed, with client/caregiver training as needed
Rehabilitation Center or Skilled Nursing Facility
Follow-up to acute care intervention when incident is severe
  • Intensive, daily therapy to improve all aspects of functioning
  • Intervention to address attention, problem solving, and perceptual deficits, and to manage impulsive behavior
  • Initial intervention to address basic daily activities, such as eating, bathing, dressing, grooming, and sequencing tasks. If basic skills are achieved, progression to more difficult tasks may include
    • Preparing meals
    • Managing medication
    • Balancing a checkbook/paying bills
    • Organizing daily routines
    • Doing laundry and light housekeeping
    • Responding to an emergency situation, using the telephone, and engaging in socially appropriate behavior
    • Preparing for community re-entry, driving, and workplace assessment as appropriate for the client's level of progress
Outpatient/Home Health Services or Community Reintegration Day Programs
  • Adapt remediation/compensatory strategies as required to support performance in the person's home, workplace, etc.
  • Carryover of cognitive strategies in different environments (workplace, place of worship, grocery store, etc.) and contexts.
When the cognitive disorder has a gradual onset and degenerative course, as is the case with most dementias, the client will usually be seen at home or in a supervised setting such as adult day care, an assisted living facility, an outpatient clinic, or a nursing home. Intervention often involves educating caregivers, adapting the environment, setting up compensatory strategies, and reorganizing and simplifying tasks. These approaches allow the individual to engage in familiar activities to maintain his or her quality of life. Progressive cognitive disorders worsen over time, but with appropriate treatment, clients can remain independent, continuing self-care and other activities well into the disease process.

Occupational therapy practitioners fulfill a vital role for adults with cognitive impairment, helping to facilitate new brain pathways and improve functional skills by adapting activities and retraining. Enabling people to more fully participate in self-care, work, leisure, and community activities enhances their quality of life while reducing the burden on caregivers and societal resources.

Patricia Cheney is the Director of Dementia Services for Fox Rehabilitation in Cherry Hill, N.J. Lisa Rivera is the Supervisor of Occupational Therapy at New York–Presbyterian Hospital. Both are practicing occupational therapists and consultants for the American Occupational Therapy Association.

References
  1. Centers for Disease Control and Prevention. Injury prevention and control: Traumatic brain injury. Retrieved December 2010 from http://www.cdc.gov/traumaticbraininjury/statistics.html.
  2. Faul, M.; L. Xu; M. M. Wald; and V. G. Coronado. (2010). Traumatic brain injury in the United States: emergency department visits, hospitalizations and deaths, 2002–2006. Atlanta, Ga.: Centers for Disease Control and Prevention.
  3. McCombe Waller, S., and J. Whitall. (2004). Fine motor control in adults with chronic hemiparesis: Baseline comparison to non-disabled adults and effects of bilateral arm training. Archives of Rehabilitation and Physical Medicine, 85, 1076–1083.