Occupational Therapists Use of Cognitive Interventions for Clients with Alzheimer s Disease

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1 RESEARCH ARTICLE Occupational Therapists Use of Cognitive Interventions for Clients with Alzheimer s Disease Alexandra Robert 1 *, Isabelle Gélinas 2 & Barbara Mazer 3 1 Hôpital du Haut-Richelieu, Quebec, Canada 2 School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada 3 School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada; Jewish Rehabilitation Hospital, Goldbloom, Laval, Quebec, Canada Abstract The aim of this study was to establish a profile of occupational therapy practice for cognitive interventions for clients with Alzheimer s disease (AD) in an urban setting. Seventy-four occupational therapists working with older adults with AD in diverse settings in the city of Montreal were randomly selected and were sent a self-administered questionnaire by mail. Sixty-five (87.8%) therapists responded. Findings indicated that 52.3% of occupational therapists are performing cognitive interventions with persons with AD. Of those, 82.4% report using cognitive rehabilitation, 61.8% using cognitive stimulation and 50.0% using cognitive training. Intervention use varied across settings and differed according to severity of AD. The sessions are usually provided individually and often include the client s caregiver. Generalizability of the results is limited to urban areas, and possible differences in service provision should be taken into consideration. Further research is needed to measure the effectiveness of these interventions provided by occupational therapists and to compare occupational therapy practices in urban and rural areas. Copyright 2009 John Wiley & Sons, Ltd. Keywords Alzheimer s disease; cognitive interventions; geriatric occupational therapy *Correspondence Alexandra Robert, Hôpital du Haut-Richelieu, 920 boul. Séminaire Nord, St-Jean-sur-Richelieu, Quebec, J3A 1B7, Canada. alexandra.robert@mail.mcgill.ca Published online 17 August 2009 in Wiley InterScience ( DOI: /oti.283 Introduction It is estimated that the prevalence of individuals with dementia worldwide is approximately 24 million, and with the aging of the population, this number is projected to double every 20 years (Qiu et al., 2007). Alzheimer s disease (AD), which accounts for 60% of all dementias, is a degenerative disease which leads to progressive cognitive deterioration (Bier et al., 2006; Kalaria et al., 2008). In early-stage AD, memory deficits are the most important problems due to their impact on multiple areas of daily life. However, some subcomponents of memory are more typically affected, while others remain relatively intact (Clare et al., 2003). Specifically, early in the disease, deficits are mainly in episodic memory, the memory of personal life events, while procedural memory, the use of previous experiences without conscious awareness, and semantic memory, the long-term memory for general world knowledge, are preserved or are only slightly affected (Zanetti et al., 2001; Clare and Woods, 2004). Therefore, people with early AD, despite significant memory problems, still have the potential to learn and retain information and skills through cognitive interventions 10 Occup. Ther. Int. 17 (2010) John Wiley & Sons, Ltd.

2 Robert et al. Cognitive Interventions for Clients with Alzheimer s Disease by targeting the specific subcomponents of memory which are relatively preserved (De Vreese et al., 2001; Clare and Woods, 2004). In a review of the literature, Clare and Woods (2004) proposed three main types of cognitive interventions for individuals with AD: cognitive stimulation, cognitive rehabilitation and cognitive training. This classification was selected for this study as all types of cognitive interventions can be included in these three broad categories. Moderate effect sizes were found overall for all types of cognitive intervention with clients with AD on learning, memory, executive functions, global cognition, depression, general functioning and on activities of daily living (ADL), the latter receiving the greatest benefit emphasizing the role of occupational therapists in this domain (Sitzer et al., 2006). Cognitive stimulation consists of participation in group activities (such as occupationally-based activities) and discussions to improve global cognition and social functioning (Clare and Woods, 2004). The rationale is that cognitive functions interact with each other, and focusing intervention on more than one function will more likely enhance global cognitive functioning (Clare and Woods, 2004). Procedural memory function contributes to the clients participation in activities. Different modalities have been proposed to provide cognitive stimulation, including reminiscence therapy (i.e., discussion of past experiences with prompts; Woods et al., 2005), validation therapy (i.e., recognition of individual experience; Neal and Briggs, 2003) and reality orientation (i.e., presentation of orientation information; Spector et al., 2000). Although there is limited evidence, there appears to be some positive effects of stimulation intervention for people diagnosed with dementia, particularly on global cognition, behaviour and mood (Bach et al., 1995; Neal and Briggs, 2003). For instance, a systematic review conducted by Woods et al. (2005) evaluated the effectiveness of reminiscence therapy for older adults diagnosed with dementia, cognitive impairment and organic brain syndrome, and demonstrated that reminiscence therapy was associated with significant improvement in behaviour (p = 0.004), cognition (p = 0.02) and depression (p = ). Cognitive rehabilitation is an individualized treatment approach to improve functioning in the everyday context (Clare and Woods, 2004). It is appropriate for people with early-stage AD who have some preserved aspects of memory, and who can develop compensatory strategies for the memory areas that are more affected (Clare and Woods, 2004). These strategies include memory aids such as calendars, diaries, agendas and electronic devices (De Vreese et al., 2001). Residual semantic memory is required to be able to integrate these strategies. Interventions are client-centred and target everyday situations that are relevant to the individual, an approach which is central to occupational therapy (Clare and Woods, 2004). Although there are few studies that have evaluated the effectiveness of cognitive rehabilitation (Clare et al., 2003), these studies suggest some positive effects. For example, individuals with early-stage dementia can learn or re-learn personally meaningful information, maintain it over time and apply it in everyday life (Clare et al., 2003; Clare and Woods, 2004). Cognitive training is a remedial treatment approach that focuses on specific cognitive functions that are trained using a set of tasks (Clare and Woods, 2004). Different strategies are taught and practised through exercises with the rationale being that regular practise of a task requiring a particular cognitive function can maintain or improve functioning in that domain (Clare and Woods, 2004). This is a remedial approach that emphasizes reducing the underlying impairment and slowing the progression of AD (Clare and Woods, 2004). Strategies include spaced retrieval (i.e. retrieval of information with increasing time delays), vanishing cues, errorless method, face name association, interactive/visual imagery, homework exercises, categorization, verbal elaboration and concentration/overt repetition. Some of these strategies provide support in encoding and retrieval of information in order to improve memory functions such as episodic memory (De Vreese et al., 2001). These strategies can be applied within the occupational therapy intervention plan to optimize participation in daily occupations. A systematic review of the effectiveness of cognitive training targeting memory deficits for people with early-stage AD or vascular dementia included six randomized controlled trials (Clare et al., 2003), and although these studies had methodological limitations, no statistically significant differences were found. According to the Canadian Model of Occupational Performance (Canadian Association of Occupational Therapists, 2002), occupational therapy practice is centred on the interaction between the person, his/her occupation and the environment. One area that must be considered by occupational therapists regarding the person is cognition (Canadian Association of Occup. Ther. Int. 17 (2010) John Wiley & Sons, Ltd. 11

3 Cognitive Interventions for Clients with Alzheimer s Disease Robert et al. Occupational Therapists, 2002). Indeed, position statements by the American Occupational Therapy Association (1991; 1999) state that there is a role for occupational therapists working with clients who have cognitive impairments: building on the abilities of these clients to maximize their performance in daily living tasks. Several studies in the literature discuss occupational therapists use of cognitive rehabilitation for clients with traumatic brain injury and cerebrovascular accident; however, few have reported on their role with clients with dementia. Cognitive interventions, though, can easily be integrated into occupational therapy practice with this population (Bier et al., 2006). Examples reported in the literature include an occupational therapy cognitive stimulation programme for stimulating occupational activities in people with dementia by Borell et al. (1994) and an intervention of cognitive training of ADLs by Zanetti et al. (2001). Even though some positive benefits of cognitive interventions have been found in clients with dementia, the use of these interventions in occupational therapy with this clientele is unknown. One way to determine whether evidence from research is being translated into practice is to complete a survey of occupational therapy practice. Moreover, with the professional autonomy offered to occupational therapists in practice, many different approaches can be applied with this clientele. It is therefore important to better understand which cognitive interventions are being used clinically by occupational therapists. Having a profile of occupational therapy practice will allow comparison of clinical practice with current evidence-based knowledge, and accordingly, will provide guidelines for the improvement of professional practice (Stringer, 2003). Thus, the global objective of this study was to establish a profile of the occupational therapy practice with regard to provision of cognitive interventions (cognitive stimulation, cognitive rehabilitation and cognitive training) for clients with AD in Montreal. Specific objectives were to determine the types of cognitive interventions performed by occupational therapists, describe the methods of administration of cognitive interventions and identify factors (therapist, environment and client factors) influencing the use of cognitive interventions. Methods This was a descriptive cross-sectional study of occupational therapy practice with regard to cognitive interventions for clients with AD. A survey methodology using a self-administered questionnaire was used. Approval of the institutional Ethics Committee was obtained prior to the implementation of the study. Participants The population includes occupational therapists working with older adults with AD in the city of Montreal. To be eligible for participation, occupational therapists had to be a member of the Ordre des Ergothérapeutes du Québec (OEQ; Ordre des Ergothérapeutes du Québec, 2006), treat clients with AD and work in only one setting: either a day centre, community health centre, rehabilitation centre, acute care hospital or long-term care centre. The sampling frame was obtained through the OEQ directory available on their web site. Stratification according to type of setting was done to gather an adequate representation of occupational therapists working with people with AD. According to the information on the OEQ list for the region of Montreal, there were 32 occupational therapists working in day centres, 149 in community centres, 121 in rehabilitation centres, 97 in acute care hospitals and 106 in long-term care centres, all working with a geriatric clientele, for a total of 505 occupational therapists (Ordre des Ergothérapeutes du Québec, 2006). Twentyseven occupational therapists who were working in two different settings were removed from the sample as it would have given them a greater chance of being selected, and their responses could not be associated with any one setting. Initially, 15 participants in each type of setting were randomly selected for a total of 75 participants. The final sample included 74 participants: 11 from rehabilitation centres, 14 from day centres, 15 from community centres, 15 from acute care hospitals and 19 from long-term care centres. Data collection Data were collected through a self-administered questionnaire. The questionnaire was developed based on evidence from the literature, and was then reviewed by two expert occupational therapists and two experts in survey methodology to establish face validity and clarity of the questionnaire (Dillman, 2007). A pilot test was conducted with four occupational therapists to verify the clarity of the questionnaire. Definitions for the three types of cognitive interventions targeted by the survey were provided. Furthermore, participants were 12 Occup. Ther. Int. 17 (2010) John Wiley & Sons, Ltd.

4 Robert et al. Cognitive Interventions for Clients with Alzheimer s Disease given the opportunity to add other types of cognitive interventions when responding to the survey. The variables measured are divided into three main categories related to the objectives of the study: (1) the types of cognitive interventions performed by occupational therapists (i.e., cognitive stimulation, cognitive rehabilitation and cognitive training); (2) the methods of administration of cognitive interventions; and (3) the factors influencing the use of cognitive interventions (i.e., therapist, environment and client factors). Severity of the disease was categorized according to scores on the Mini-Mental State Exam (MMSE), a widely used test in clinical practice (Tombaugh and McIntyre, 1992). Mild AD was defined as a score on the MMSE of 18/30, moderate AD as MMSE 11 to 17/30 and severe AD as MMSE 10/30. The questionnaire and a cover letter along with a stamped return envelope were sent to the selected occupational therapists by mail. A reminder postcard was sent to non-respondents 2 3 weeks later. The authors became aware, early in the study, of eligibility problems (e.g., occupational therapist working with older adults but not seeing clients with AD). Subsequently, all selected occupational therapists were called to verify their eligibility. Non-eligible participants were replaced by new ones using the same procedure described previously, with the addition of a phone call made to verify eligibility prior to mailing the questionnaire. Data analysis Descriptive statistics were calculated including means, percentages and frequencies. Also, comparisons were made between the use of cognitive interventions and factors potentially influencing the use of such interventions, using Fischer s Exact Tests because some cells had expected counts less than five. The profile of occupational therapy practice regarding cognitive interventions was analysed for the group as a whole as well as according to the type of setting where the interventions were provided. Results Of the 74 surveys sent, 65 were completed, representing a high response rate of 87.8%. The socio-demographic characteristics of the participants are presented in Table 1. All participants had baccalaureate as their highest Table 1. Demographic characteristics of occupational therapists Demographic characteristics Total (n = 65) Rehabilitation (n = 9) Acute care (n = 14) Community (n = 14) Long-term care (n = 16) Day center (n = 12) Gender Female 61 (93.8) 9 (100.0) 14 (100.0) 14 (100.0) 15 (93.8) 9 (75.0) Male 4 (6.2) (6.2) 3 (25.0) Age (30.8) 4 (44.4) 8 (57.1) 2 (14.3) 5 (31.2) 1 (8.3) (33.8) 4 (44.4) 5 (35.7) 4 (28.6) 7 (43.8) 2 (16.7) (23.1) 1 (11.1) 0 4 (28.6) 3 (18.8) 7 (58.3) 50 and more 8 (12.3) 0 1 (7.1) 4 (28.6) 1 (6.2) 2 (16.7) Work status Full time 45 (69.2) 6 (66.7) 10 (71.4) 8 (57.1) 12 (75.0) 9 (75.0) Part time 20 (30.8) 3 (33.3) 4 (28.6) 6 (42.9) 4 (25.0) 3 (25.0) Years of experience with elderly clientele <1 1 (1.5) 0 1 (7.1) (35.4) 6 (66.7) 10 (71.4) 2 (14.3) 4 (25.0) 1 (8.3) (7.7) (28.6) 1 (6.2) 0 >10 36 (55.4) 3 (33.3) 3 (21.4) 8 (57.1) 11 (68.8) 11 (91.7) Proportion of clients with Alzheimer s disease (n = 64)* 0 25% 39 (60.9) 6 (66.7) 9 (64.3) 12 (85.7) 4 (25.0) 9 (75.0) 26 50% 16 (25.0) 2 (22.2) 2 (14.3) 2 (14.3) 7 (43.8) 3 (25.0) 51 75% 7 (10.9) 1 (11.1) 2 (14.3) 0 4 (25.0) % 2 (3.1) 0 1 (7.1) 0 1 (6.2) 0 *One missing data in long-term care. Occup. Ther. Int. 17 (2010) John Wiley & Sons, Ltd. 13

5 Cognitive Interventions for Clients with Alzheimer s Disease Robert et al. level of education and were working mainly as a clinician. Types of cognitive interventions Fifty-two percent (n = 34) of respondents reported that they perform cognitive interventions with clients with AD. Those not using these interventions work primarily in acute care and long-term care centres. Of the 34 users of cognitive interventions, 28 (82.4%) used cognitive rehabilitation, 21 (61.8%) used cognitive stimulation and 17 (50.0%) used cognitive training. Twenty-four of those that use cognitive interventions (72.7%) responded that cognitive interventions were used 25% of the time. Therefore, only a small portion of clinician time is devoted to cognitive intervention. Of the 34 therapists who report using cognitive intervention, 32.4% used only one form, 32.4% used two and 32.4% used three types of cognitive interventions (data missing n = 1). When clinical practice is examined according to setting, differences in the use of cognitive interventions are noted (see Figure 1). Of the 34 users, all the occupational therapists in rehabilitation centres and day centres were using cognitive rehabilitation, whereas occupational therapists working in long-term care facilities did not perform any cognitive training. Also, occupational therapists in community centres were using more cognitive training than cognitive stimulation (87.5% vs 25.0%), while occupational therapists in day centres were using more cognitive stimulation and rehabilitation compared with cognitive training (87.5% and 100.0% vs 50.0%). Methods of administration The length of each session varied between 15 and 60 minutes. The frequency of intervention ranged from two to four times a week to an occasional basis. Cognitive stimulation and rehabilitation were more likely to be offered two to four times a week, whereas the frequency of sessions for cognitive training was more variable. The duration of intervention was most commonly 1 3 months. Moreover, sessions were typically individual (mean = 81.5%, standard deviation [SD] = 35.0) and were only rarely offered in groups (mean = 12.9%, SD = 29.5). Eighty-four percent of users reported that they involve the clients caregivers in the intervention, either assisting during the session, helping clients with their homework or implementing the recommendations at home. Several therapeutic modalities were used for each type of intervention and are presented in Table 2. The most common therapeutic modalities/activities were paper and pencil activities, games, ADLs and instrumental activities of daily living (IADLs). Factors influencing the use of cognitive interventions Therapist, client, and environment factors that may influence the use of cognitive interventions were examined. Of these, age of therapist (p = 0.09) and the number of years of experience (p = 0.93) working with an older clientele were not significantly associated with the use of cognitive interventions. Moreover, the majority of occupational therapists in every age category were providing cognitive rehabilitation, and use of cognitive stimulation and cognitive training were similar across the age categories (see Table 3). Differences in the use of cognitive interventions between mild, moderate and severe AD were found; 85.7 to 94.1% of therapists reported treating clients with mild AD using cognitive interventions, and only 5.9 to 14.3% of therapists reported treating clients with severe AD with these interventions. Clients with moderate AD most frequently received cognitive stimulation and rehabilitation. The factor most commonly involved in the decision of a type of intervention is clinical experience (90.9%; see Table 4) % Cognitive stimulation Cognitive rehabilitation Cognitive training Any type of cognitive intervention Rehabilitation center Acute care center Community center Long term care center Day center Figure 1 Type of cognitive interventions performed according to settings 14 Occup. Ther. Int. 17 (2010) John Wiley & Sons, Ltd.

6 Robert et al. Cognitive Interventions for Clients with Alzheimer s Disease Table 2. Therapeutic modalities used according to the type of cognitive intervention Therapeutic modalities Cognitive stimulation (n = 21) Cognitive rehabilitation (n = 28) Cognitive training (n = 17) Most of the time Sometimes Never Most of the time Sometimes Never Most of the time Sometimes Never Paper and pencil 44.4% 38.9% 16.7% 37.1% 33.3% 29.6% 33.3% 46.7% 20.0% Games 50.0% 35.0% 15.0% 30.8% 26.9% 42.3% 33.3% 26.7% 40.0% Computer program 5.9% 29.4% 64.7% 8.0% 12.0% 80.0% 14.3% 14.3% 71.4% Activities of daily living 50.0% 38.9% 11.1% 52.0% 32.0% 16.0% 42.9% 35.7% 21.4% Instrumental activities of daily living 35.0% 40.0% 25.0% 40.0% 40.0% 20.0% 40.0% 46.7% 13.3% Leisure activities 33.3% 33.3% 33.3% 27.3% 54.5% 18.2% 26.7% 40.0% 33.3% Environmental adaptations N/A N/A N/A 81.5% 18.5% 0.0% N/A N/A N/A Memory aid N/A N/A N/A 78.6% 17.8% 3.6% N/A N/A N/A Table 3. Factors influencing the use of the different types of cognitive interventions (n = 34) Types of intervention* Severity of disease Age of occupational therapist (years) Experience with elderly clientele (years) Mild Moderate Severe 20 to 29 (n = 12) 30 to 39 (n = 9) 40 to 49 (n = 11) 50 (n = 2) 5 (n = 13) 6 to 10 (n = 3) >10 (n = 18) Cognitive stimulation 18 (85.7) 12 (57.1) 3 (14.3) 9 (75.0) 6 (66.7) 6 (54.5) 0 9 (69.2) 2 (66.7) 10 (55.6) Cognitive rehabilitation 26 (92.9) 13 (46.4) 3 (10.7) 9 (75.0) 8 (88.9) 9 (81.8) 2 (100.0) 11 (84.6) 2 (66.7) 15 (83.3) Cognitive training 16 (94.1) 5 (29.4) 1 (5.9) 6 (50.0) 5 (55.6) 5 (45.5) 1 (50.0) 7 (53.8) 2 (66.7) 8 (44.4) *May be 1 response. Table 4. Factors involved in choosing a type of intervention (n = 34) Factors Clinical experience 30 (90.9) Colleague and/or practice setting 21 (63.6) Continued education 22 (66.7) University education 18 (54.6) Scientific literature 13 (39.4) Internet 6 (18.2) Other 1 (3.1) Most participants acknowledged barriers to providing cognitive interventions. In fact, there were only 4 participants who stated that they experience no barriers. The main barriers identified were lack of time and not being part of the mandate of the establishment, where for example, the mandate of the occupational therapists may be to focus on assessment and referral to outside resources for intervention (see Figure 2). Discussion The findings indicate that approximately half of the occupational therapists working with clients with AD were performing cognitive interventions. Cognitive stimulation, cognitive rehabilitation and cognitive training are all offered by occupational therapists with this clientele. Cognitive rehabilitation was the type of intervention offered most frequently. This can be explained by the fact that cognitive rehabilitation, by definition, is closely related to the core concepts of the profession of occupational therapy in terms of clientcentred approach and maximizing occupational performance (Canadian Association of Occupational Therapists, 2002). The use of cognitive interventions varies according to setting. A large proportion of occupational therapists who were not using any type of cognitive intervention (i.e., 47.7%) were found in acute care and long-term care centres. It is understandable that occupational therapists in acute care are less likely to use cognitive interventions, as services in this fast-paced setting are mostly composed of evaluation, and very rarely of treatment (Wressle et al., 2006). In long-term care, cognitive rehabilitation was surprisingly used more often than cognitive stimulation. Because of the characteristics of residents in this type of setting where severe cognitive impairments is more prevalent, it was Occup. Ther. Int. 17 (2010) John Wiley & Sons, Ltd. 15

7 Cognitive Interventions for Clients with Alzheimer s Disease Robert et al. % No barrier Not the mandate of the establishment Lack of time Lack of resources (material and/or financial) Perception of low efficacy Inappropriate clientele Other 0 Type of barriers Figure 2 Barriers in performing cognitive interventions (n = 34) expected that cognitive stimulation would be the type of intervention accomplished more frequently as it requires less specific residual cognitive abilities. However, this study does not take into account interventions by professionals other than occupational therapists. Occupational therapy practice patterns vary between settings along the continuum of care. A functional approach to cognitive rehabilitation was more commonly adopted in long-term care centres, while community centres and rehabilitation settings implemented a more remedial approach using cognitive training. This is consistent with Lee et al. (2001) who stated that clients can receive cognitive rehabilitation in different settings along the continuum of care, varying from a remedial approach to a functional one, depending on the stage of the client. There is however no evidence to date on the effectiveness of specific cognitive interventions according to the type of setting. Methods of administration Although evidence-based guidelines for the specific methods of providing cognitive interventions are lacking, the literature provides some information on the effectiveness of cognitive interventions which may be compared with the current findings. The length of cognitive intervention sessions reported in this study is slightly shorter than that described in the literature where treatment sessions are most often 1 hour (Bach et al., 1995; Zanetti et al., 2001; Clare et al., 2003). No significant differences were observed in the length of sessions between the types of intervention, although in the literature, length of cognitive stimulation sessions are usually shorter than cognitive rehabilitation and training sessions, lasting approximately 30 minutes per session (Spector et al., 2000; Neal and Briggs, 2003). Also, cognitive interventions were generally offered on a less frequent basis in clinical practice within this sample of therapists, compared with the frequency in the literature where sessions are offered from one to five times per week (Spector et al., 2000; Zanetti et al., 2001; Cahn-Weiner et al., 2003; Neal and Briggs, 2003). This is possibly related to the lack of time expressed by therapists. Moreover, the majority of occupational therapists provided cognitive interventions for a period of 1 3 months, shorter than the up to 1 year reported in the literature. This discrepancy could possibly be due to the reduction in the length of stays in the current Canadian health-care system. Two of the most common modalities used by therapists are ADLs and IADLs, as they are more occupational therapy oriented. Paper and pencil activities were another common modality, and are consistent with therapeutic modalities most frequently used in cognitive rehabilitation for clients with traumatic brain injury (Blundon and Smits, 2000). Cognitive stimulation methods such as reminiscence therapy (Woods et al., 2005), reality orientation (Spector et al., 2000) and validation therapy (Neal and Briggs, 2003) were used only by a small proportion of respondents. These methods are usually offered in groups, and the infrequent use of groups in this sample may explain the low utilization of these cognitive stimulation methods. Factors influencing the use of cognitive interventions Several factors having a potential influence on the use of cognitive interventions were examined. The most 16 Occup. Ther. Int. 17 (2010) John Wiley & Sons, Ltd.

8 Robert et al. Cognitive Interventions for Clients with Alzheimer s Disease common factor involved in the selection of a type of intervention was clinical experience. This suggests that occupational therapists are more likely to modify their practice if they experience a new method by themselves. This is important to consider when looking at ways to facilitate knowledge transfer from research to clinical practice. Regarding barriers to performing cognitive interventions, only one participant reported that it is inappropriate to provide such intervention to clients with AD. Thus, occupational therapists are aware of the potential of AD clients and the benefits that can result from cognitive interventions. Nevertheless, cognitive interventions did not seem to be prioritized by therapists and establishments. Moreover, findings from the study suggest that clients with mild AD, and to a lesser extent, clients with moderate AD, were more likely to receive the different types of cognitive interventions than clients with severe AD. This is consistent with the literature which indicates that cognitive interventions can mostly benefit clients in the early stage of AD (De Vreese et al., 2001; Koltai et al., 2001; Zanetti et al., 2001; Clare et al., 2003; Clare and Woods, 2004). This study provides an overview of the current clinical practice of occupational therapists regarding cognitive interventions with clients with AD in Montreal, Quebec. In light of the findings from this study and the knowledge currently available from the literature, suggestions for improving the quality and efficiency of clinical practice may be proposed and investigated to determine effectiveness. There is value in offering cognitive stimulation in long-term care centres in order to enhance global cognitive and social functioning, as well as the quality of life of residents (Woods et al., 2006). Also, cognitive stimulation sessions could be shorter in length (sessions of approximately 30 minutes) but over a longer duration in order to maintain positive impact (Spector et al., 2000; Clare et al., 2003; Neal and Briggs, 2003; Olazaran et al., 2004). Given the limited resources and time expressed by therapists, group intervention is a potential approach to provide services more efficiently. Therefore, occupational therapists may provide more group sessions, particularly for cognitive stimulation, as this type of intervention consists primarily of participation in group activities and discussion (Clare and Woods, 2004). Moreover, including caregivers should be a central component of cognitive interventions. Their participation can help customize the sessions according to the clients needs, increase the time available for cognitive interventions by leading home programmes and facilitate knowledge transfer into the daily lives of the clients by implementing the recommendations (Davis et al., 2001; Koltai et al., 2001). Furthermore, although the effectiveness of cognitive training has not been clearly established, there is some evidence suggesting that it has potential benefits with this population. Thus, occupational therapists could integrate cognitive training in their clinical practice, familiarize themselves with the various techniques of this approach, with the understanding that further study is necessary. Limitations It is important to note that the survey was conducted in one specific urban area in Canada. Possible differences in service provision should be taken into consideration when interpreting the results for other urban areas. Nevertheless, a variety of settings across the spectrum of health care were represented, providing information applicable to those working with clients with AD along the continuum of care. Also, the factors associated with provision of services may be applicable to other centres as well. Recommendations for further research Further research is needed to monitor clinical practice along with the development of evidence-based knowledge and to expand the survey of practice patterns internationally. This will allow comparison of occupational therapy practices across areas (urban and rural) as well as countries. Finally, more research is needed to determine the effectiveness of the cognitive interventions with clients in early-stage AD delivered by occupational therapists. Conclusion This survey of occupational therapy practice related to the provision of cognitive interventions for clients with AD found that approximately 50% of the occupational therapists reported using cognitive interventions. They offer various types of interventions, with differences depending on the work setting. Moreover, occupational therapists have both the theoretical background and the skills needed to provide cognitive interventions (American Occupational Therapy Association, 1999). Occup. Ther. Int. 17 (2010) John Wiley & Sons, Ltd. 17

9 Cognitive Interventions for Clients with Alzheimer s Disease Robert et al. Their holistic view of the person, including his/her occupation and environment, which is central in occupational therapy, can make an important contribution to the treatment of cognitive impairments. Thus, cognitive interventions could be integrated into the clinical practice of occupational therapists along the continuum of care of clients with AD. Acknowledgements The authors would like to thank all the occupational therapists who willingly responded to the questionnaire and demonstrated their commitment in the development of their profession. The research project was undertaken as a requirement for a Master s degree in Rehabilitation Sciences from McGill University. REFERENCES American Occupational Therapy Association (1991). Statement: occupational therapy services management of persons with cognitive impairments. The American Journal of Occupational Therapy 45(12): American Occupational Therapy Association (1999). Management of occupational therapy services for persons with cognitive impairments (statement). The American Journal of Occupational Therapy 53(6): Bach D, Bach M, Böhmer F, Frühwald T, Grilc B (1995). Reactivating occupational therapy: a method to improve cognitive performance in geriatric patients. Age and Ageing 24(3): Bier N, Desrosiers J, Gagnon L (2006). Prise en charge cognitive de la mémoire dans le vieillissement normal, les troubles cognitifs légers et la démence de type Alzheimer. The Canadian Journal of Occupational Therapy 73(1): Borell L, Gustavsson A, Sandman P-O, Kielhofner G, Hasselkus BR (1994). Occupational programming in a day hospital for patients with dementia. Occupational Therapy Journal of Research 14(4): Blundon G, Smits E (2000). Cognitive rehabilitation: a pilot survey of therapeutic modalities used by Canadian occupational therapists with survivors of traumatic brain injury. The Canadian Journal of Occupational Therapy 67(3): Cahn-Weiner DA, Malloy PF, Rebok GW, Ott BR (2003). Results of a randomized placebo-controlled study of memory training for mildly impaired Alzheimer s disease patients. Applied Neuropsychology 10(4): Canadian Association of Occupational Therapists. (2002). Enabling Occupation: An Occupational Therapy Perspective (revised edition). Ottawa, Canada: CAOT Publications. Clare L, Woods RT, Moniz Cook ED, Orrell M, Spector A (2003). Cognitive rehabilitation and cognitive training for early-stage Alzheimer s disease and vascular dementia. The Cochrane Database of Systematic Reviews 4: DOI: / CD Clare L, Woods RT (2004). Cognitive training and cognitive rehabilitation for people with early-stage Alzheimer s disease: a review. Neuropsychological Rehabilitation 14(4): Davis RN, Massman PJ, Doody RS (2001). Cognitive intervention in Alzheimer disease: a randomized placebocontrolled study. Alzheimer Disease and Associated Disorders 15(1): 1 9. De Vreese LP, Neri M, Fioravanti M, Belloi L, Zanetti O (2001). Memory rehabilitation in Alzheimer s disease: a review of progress. International Journal of Geriatric Psychiatry 16: Dillman DA (2007). Mail and internet surveys: the tailored design method 2007 update with new internet, visual, and mixed-mode guide (2nd edn). New York: John Wiley and Sons, Inc. Kalaria RN, Maestre GE, Arizaga R, Friedland RP, Galasko D, Hall K, Luchsinger JA, Ogunnivi A, Perry EK, Potocnik F, Prince M, Stewart R, Wimo A, Zhang ZX, Antuono P, World Federation of Neurololgy Dementia Research Group (2008). Alzheimer s disease and vascular dementia in developing countries: prevalence, management, and risk factors. Lancet Neurology 7(9): Koltai DC, Welsh-Bohmer KA, Schmechel DE. (2001). Influence of anosognosia on treatment outcome among dementia patients. Neuropsychological Rehabilitation 11(3/4): Lee SS, Powell NJ, Esdaile S (2001). A functional model of cognitive rehabilitation in occupational therapy. The Canadian Journal of Occupational Therapy 68(1): Neal M, Briggs M (2003). Validation therapy for dementia. The Cochrane Database of Systematic Reviews 3: DOI: / CD Olazaran J, Muniz R, Reisberg B, Pena-Casanova J, Del Ser T, Cruz-Jentoft AJ, Serrano P, Navarro E, Garcia de La Rocha ML, Frank A, Galiano M, Fernandez-Bullido Y, Serra JA, Gonzalez-Salvador MT, Sevilla C (2004). Benefits of cognitive-motor intervention in MCI and mild to moderate Alzheimer disease. Neurology 63: Ordre des Ergothérapeutes du Québec (2006). Membership directory. (Available at: org/francais/membre/rep.asp) (Accessed 25 October 2006). 18 Occup. Ther. Int. 17 (2010) John Wiley & Sons, Ltd.

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