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Department of Occupational Therapy Faculty
Department of Occupational Therapy
Papers

9-1992

Dementia management: an occupational therapy

home-based intervention for caregivers.
Mary A. Corcoran
Thomas Jefferson University

Laura N. Gitlin
Thomas Jefferson University

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Recommended Citation
Corcoran, Mary A. and Gitlin, Laura N., "Dementia management: an occupational therapy home-
based intervention for caregivers." (1992). Department of Occupational Therapy Faculty Papers. Paper
49.
https://jdc.jefferson.edu/otfp/49

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 ational estimates indicate that 4 million Ameri-
Dementia Management:
An Occupational N cans have Alzheimer disease and that this num-
ber will rise as the older population increases.
Extensive research has documented the profound conse-
quences of Alzheimer disease for the person as well as for
Therapy Home-Based family and friends who continue to prOVide more than
80% of the long-term care and management of the disease
Intervention for process (Pepper Commission, 1990; Select Subcommit-
tce on Aging, 1987). Such daily management issues as
Caregivers wandering, agitation, violence, aggression, and difficul-
ties with self-care activities have been shown to have
dramatic physical and psychological consequences for in-
Mary A. Corcoran, Laura N. Gitlin formal caregivers. This paper presents a home-based oc-
cupational therapy intervention designed to improve
caregiver skill in the management of the behavioral or
Key Words: Alzheimer's disease. caregivers secondal-y symptoms exhibited by a spouse with demen-
tia. The rationale for the intervention, a description of
each therapeutic visit, an innovative documentation
form, and a case to illustrate the intervention process are
This paper describes an occupationaL t.'Jerapv inter- provided. Presented elsewhere are the detailed explana-
vention designed forfmnilv caregivers of persons with
tion of the conceptual components of the intervention
dementia. The intervention, based on the ji'amework
(Corcoran & Gitlin, 1991), the study methods and out-
of a competence-envil'onmentaL press model and the
principle of collaboration, was implemented during 5 comes (Gitlin & Corcoran, 1991a), and a program used to
home visits. Each visit was des~gned to Imilel caregiv- train occupational therapy students in the delivery of the
ing skills through collaboration in identifYing problem intervention (Gitlin & Corcoran, 1991b).
areas. developing and implementing environmentaL
strategies, and modilying management approaches. A
Background
case l.'ignetle illustrates tbe therapeutic proce.I:I· and
outcomes. The theoretical rationale and structure 0/ The intervention presented in this paper addresses three
the intervention and innovative documentation f()1: critical issues that have emerged from caregiver and
evaluation of the theoretic process are aLso presented. health services research: (a) the need for theory-based
treatment approaches, (b) the importance of developing
strategies to manage the behavioral outcomes of Alz-
heimer disease, and (c) the importance of deveJoping
home-based service strategies that reflect the needs of
caregivers.

Needfor Theory-Based Treatment Approaches

Although caregiver interventions have recently proliferat-
ed, they still lack a theoretical base (Gallagher, 1985;
Haley, Brown, & Levine, 1987). Reported interventions
have included stress management, education, group sup-
port programs (Wr1itlatch, Zarit, & von Eye, 1991; 7.arit,
Anthony, & Boutsetts, 1987), personal and group coun-
seling programs (Gallagher, Rappaport, & Benedict,
1985: Lovett & GaJlagher, 1988; ToseJancl, Rossiter, &
Labrecque. 1989), relaxation and meditation (Gendron et
Mary A. Corcoran, PhD. is Assisrant PI'(,fessor, Thomas .leffer- ai, 1986), respite care (Burdz, 1988; Lawton, Brody, &
.,on lJniversirv, Department of Occupational Therapy, UO Saperstein, 1989), and problem-solving groups (Silven et
South 9th Street, Suite 820, Philadelphi3, Pennsvlvani;] 19107. al .. 1986). These interventions have evolved in response
to a body of literature that identifies stress as a major
Laura N. Gitlin, Phi). is A~soci3[e Professor and Rese,trch Coor-
contributor to th<: health and well-being of caregivers.
dinator, Thomas Jefferson University. Department of Occupa-
tional Therapy, Philadelphi3. Pennsylvania. Although these programs provide critical support to care-
givers, they do not reflect the complexity of the experi-
717is arlicte {pas accepledj(Jr publication Apri!.!o. !99.!.
ences and the breadth of issues that caregivers indicate as

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 problematic. Furthermore, research by Dura and Kiecolt- perceptions of need and suPPOrt his or her values and
Glaser (1990) suggests that caregivers who choose not to style of care (Hasselkus, 1988; Levine, Corcoran, & Gitlin,
participate in on-site training and educational programs in press), Treatment strategies that incorporate care-
may differ greatly in their needs and care approaches givers' values and personal goals have been shown to be
from those who require home-based services, Allernalive more efficient and effective for older disabled adults
interventions that are founded in concepts broader than (Chiou & Burnett, 1985; Perlman, 1973; Shelton, Jepp-
stress and that are sensitive to caregivers' concerns are son, & Johnson, 1989),
evidently necessary,

Theoretical Framework
Need to Develop Management Strategies
A competence-environmental press model (Ansello,
Because dementia is irreversible and progressive, care- King, & Taler, 1986; Lawton, 1989b; Lawton & Nahemow,
givers' needs often change and expand over time, Recent 1973) provides the conceptual framework for developing
studies have identified the development of caregivers' the therapeutic strategies within the intervention de-
management abilities as a meaningful approach for ad- scribed below, This model suggests that many behavioral
dressing diverse caregiver needs encountered over time manifestations of dementia may be controlled or mini-
(Clark & Rakowski, 1983; Corbin & Strauss, 1988; Corco- mized by environmental manipulations that lower the
ran & Gitlin, 1991; Crossman, London, & Barry, 1981; press for persons with declining levels of competence,
Gallagher, 1985; Pinkston & Linsk, 1986; Smith, Smith, & Press refers to the external forces of the environment that
Toseland, 1991; Toseland et aI., 1989) Ethnographic re- influence the functioning of a person with a specific level
search has also revealed that caregivers create meaning- of competence, The model suggests that enhancing a
ful, effective solutions to daily care problems, but seek caregiver's ability to modify environmental press may
reinforcement and additional skills to refine their efforts have two consequences, First, it may minimize difficult
(Hasselkus, 1988), These findings underscore the impor- behaviors manifested by the person with dementia, Sec-
tance of helping caregivers develop effective problem- ond, the incorporation of environmental strategies may
solving skills to manage the diverse behavioral manifesta- expand caregiver problem-solving abilities and thus im-
tions of dementia, prove the caregiver's sense of efficacy in managing daily
problems,
Research findings from studies that used theories of
Need for Personalized Interventions
person-environment fit have underscored that the envi-
An extensive body (Jf literature indicates that the emo- ronment can promote or restrict independent behavior
tional, physical, and social consequences of caregiving and positive affect (Barris, Kielhofner, Levine, & NeVille,
differ based on gender, familial relationship, and cultural 1985; Lawton, 1989a; Parma lee & Lawton, 1990; Pynoos,
background (Anthony-Bergstone, Zarit, & Gatz, 1988; Cohen, DaVid, & Bernhardt, 1987), Evidence from studies
Brody, 1981; Hasselkus, 1988; Pruchno, Michaels, & Po- on institutional settings suggests that specially designed
tashnik, 1990; Rodeheaver & Datan, 1988; Sherman, environments may reduce behaviors such as wandering,
Ward, & LaGory, 1988; Wilson, 1990; Young & Kahana, agitation, or restlessness (Corcoran & Barrett, 1987; Hall
1989), These differences influence approaches to manag- & Buckwalter, 1987; Hiatt, 1982; Kiernat, 1982; Levy,
ing care, especially problem-solving skills, use of formal 1987; Paire & Karney, 1984; Parmalee & Lawton, 1990),
and informal suPPOrtS, degree of upset experienced with Environmental strategies to control behavior of the per-
dementia-related behaViors, and sense of personal effica- son with AJzheimer disease have included removing clut-
cy derived from caregiving (Barusch & Spaid, 1989; ter to reduce agitation and promote cue finding, placing
Young & Kahana, 1989), Furthermore, the group educa- clothing out to decrease confusion and promote inde-
tion and counseling format used in most interventions pendent dressing, and simplifying daily tasks to facilitate
may be inappropriate for male caregivers and others from participation (Kiernat, 1986; Levy, 1987) AJthough pub-
diverse cultural backgrounds who traditionally have not lications tell caregivers how to eliminate environmen-
participated in such groups (Barusch & Spaid, 1989; Ed- tal barriers (Pynoos, Cohen, & Lucas, 1988), caregivers
wards & Baum, 1990; Kaye & Applegate, 1990; Miller, have nor traditionally received hands-on training in using
1987; Wilson, 1990), the environment to control secondary symptoms of
This literature suggests that health services for care- dementia,
givers must be flexible to address each caregiver's specific Therapeutic strategies derived from a competence-
needs, style of care, and values, Services that are client environmental press framework are designed to alter
driven and derived through working with a health care press and thus realign the competence of the care recipi-
provider may effectively support caregivers (Gitlin & Cor- ent with environmental expectations, As in Barris et al. 's
coran, 1991b; Hasselkus, 1988; Perlman, 1973), Home- model (1985), the environment is defined as four hierar-
based services, in particular, must reflect the caregiver's chically arranged, interacting layers: (a) objects (physical

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 tools or objects in the home), (b) tasks (activities that each caregiver and his or her level of knowledge as it
compose daily routines such as meal preparation and emerges during therapeutic exchange. As the interven-
eating), (c) social groups and organizations (family, tion progresses, the therapist redirects the caregiver's
friends, and neighbors), and (d) culture (values and be- attention and problem-solving approaches to the ele-
liefs that shape care provision in the home). Therapeutic ments in the environment that may be exacerbating the
strategies involve manipulating the properties of these behavioral symptoms of dementia. The focus of each visit
layers to achieve a balance between the competence of and the basic activities that occur are described below.
the person with Alzheimer disease and the pressing envi- Visit 1. The focus of this visit is to build rappon and
ronmental forces (Corcoran & Gitlin, 1991). establish goals. First, the therapist begins to build a col-
Within this theoretical framework, the intervention laborative relationship by facilitating the caregiver's at-
uses a collaborative therapeutic structure in which the tempts to (a) share his or her perspectives about proVid-
occupational therapist and caregiver develop and imple- ing care, (b) identify problems to be addressed, and (c)
ment environmental strategies that address the secon- set goals for the subsequent visits. Second, the therapist
dary symptoms of dementia. Collaboration requires that reviews current care strategies by observing the interac-
the health professional listen actively and involve tions between caregiver and care recipient and begins to
the caregiver in identifying problems, planning treat- identify environmental influences on problem behaViors.
ment, and implementing treatment. Within a collabora- Although the problem behaviors identified by the care-
tive framework, treatment becomes contextualized and is giver as particularly difficult are the target of Visit 1, the
shaped by the caregiver's unique needs, goals, prefer- therapist also attempts to observe other care strategies to
ences, and resources. This approach to treatment enables assess the caregiver's general problem-solVing approach
families to function proactively to manage the influence and use of the environment.
that chronic illness exerts on their life-style (Corbin & Visit 2. This visit has three objectives, in addition to
Strauss, 1988; Hanft, 1989). Occupational therapy efforts the continuation of observations and dialogue to build a
respond to, and are shaped by, each caregiver's needs, collaborative relationship. First, the therapist indicates
management style, and environmental resources. This specific environmental influences on the problem beha-
approach to intervention has been identified as a critical viors identified in Visit 1. Second, the therapist introduces
step in the development and testing of meaningful ser- information regarding dementia, role modeling of specif-
vices for this population (Haley, 1991; Smith et al., 1991). ic care actiVities, and use of the environment as a treat-
ment modality. Third. the caregiver and therapist develop
a plan to address specific problem behaviors and identify
Description of Intervention
the initial steps to be implemented by the caregiver. An
The intervention, which involves five home visits in 3 example of such behavior would be a care recipient's
months by a registered occupational therapist, is targeted inability to choose appropriate articles of clothing and
for caregivers who assist with self-care activities for a don them in the correct sequence. The plan may involve
spouse with moderate to severe dementia from Alz- working with the caregiver to eliminate extraneous arti-
heimer disease. It was designed to meet caregivers' dem- cles of clothing from Sight (objects layer), match the phys-
onstrated need for instruction in care techniques (Hassel- ical assistance provided in dressing with the care reCipi-
kus, 1988; Smith et aI., 1991), major risk of physical and ent's fluctuating needs (task layer), and provide verbal
psychological decline (American Association of Retired cues regarding socially appropriate clothing for the
Persons, 1988), and high probability of institutionalizing events of the day (social and cultural layers).
their spouses (Pruchno et al., 1990; Stone, Cafferata, & Visit 3. During this visit, the therapist and caregiver
Sangl, 1987). review their plan and the initial steps implemented by the
During each visit, the occupational therapiSt and caregiver between Visits 2 and 3. They examine the care-
caregiver work together, first to identify behaviors that giver's perceptions and recollections of the plan's effect
present difficult management issues for the caregiver, on the frequency and severity of problem behaviors and
then to determine appropriate environmental solutions. explore how the caregiver felt about the modifications.
This problem-solving activity gives caregivers new strate- On the basis of this review, the caregiver and therapist
gies to change and control behavior of the person with further refine the plan, use it to develop detailed environ-
dementia by manipulating the objects, tasks, or sociocul- mental strategies for managing other problem behaViors,
tural components of the environment (Barris et al., 1985; and agree on a time frame for implementation.
Kiernat, 1982). Visit 4. During this visit, the therapist assists the
In each session, the occupational therapist prOVides caregiver in further refining specific care strategies. The
ongoing support and education about dementia anel its therapist continues to engage in role modeling and edu-
secondary behavioral symptoms and the availability of cation but begins to release ownership of management
support groups and community resources. This ongoing decisions to the caregiver. To facilitate the caregiver's
education is contextual in that it responds to the needs of skills and sense of efficacy, the therapist encourages the

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 caregiver to make more independent, informed manage- time each day (task layer). She also agreed to try to an-
ment decisions. Finally, the problem-solving process swer his repetitive questions promrtly, but just once and
used to develop the plan is identified and generalized to in a calm voice (task layer). Instead of responding to a
other problems. repeated question, Mrs, C. decided to redirect her hus-
Visit 5 An important task of the final intervention band (task layer) and to leave the room when she felt
visit is the review of the problem-solving process that the aggravated. The therapist role-played these techniques
caregiver has used to approach specific problem beha- with Mrs. C. to clarify them and gave her a copy of The 36-
viors. Other tasks may include final modifications of spe- Hour Day (Mace & Rabins, 1981).
cific strategies and refinement of caregiver's techniques. During Visit 3, Mrs. C. and the therapist reviewed
Closure includes confirmation of the caregiver's skills and their plan and the initial steps that Mrs. C. had imple-
a discussion of the application of environmental strate- mented. Mrs, C. reported that she had shouted at her
gies to future problems. The following case illustration husband much less during the interim between visits. She
shows the progression of the intervention from building had decided to direct her husband to the sink for bathing
rapport, collaboratively identifying problem areas, and only on Sundays, after he shaved, because this had been
developing and implementing environmental strategies his normal routine for years (task layer). The daily sched-
to reevaluating, modifying, and supporting management ule was not only in place, but Mrs, C. had taken the
approaches. initiative to write it in large print on a bright piece of
paper (objects layer) In this way, Mrs. C. modified the
therapist's suggestions to reduce the possibility that Mr.
Case Illustration
C. would misinterpret her verbal instructions. A final ob-
For several years, Mrs. C. has been caring for her hus- jective of this visit was to refine and expand Mrs, c.'s
band, who is moderately impaired because of Alzheimer management techniques, so the therapist began to help
disease. Mrs. C. is an anxious person who has frequent Mrs, C. explore how the environment around the sink
asthma attacks as a result of stress. She expresses fear of could be adapted to encourage her husband's inde-
her husband because he has a tendency to become para- pendent bathing,
noid and suspicious. For this reason, Mrs. C. scheduled all By Visit 4, Mrs. C. had independently set up the sink
the initial intervention appointments for times when her with a towel hanging nearby and had placed the soap in a
husband would be away from home. bright container to increase visibility (objects layer), She
Mrs. C. and the therapist spent most of Visit 1 explor- happily reponed that she had not needed to give her
ing Mrs. c.'s perspectives on the demands of her caregiv- husband instructions after she calmly reminded him to
ing role, her response to those demands, and the goals of remove his shirt for bathing (task layer). By this time, Mrs.
the intervention. Mrs. C. reported that three major issues C. had eliminated her ineffective solutions of yelling at
troubled her: her husband's tendency to repeat ques- her husband or ignoring him. Her ability to remain calm
tions, his resistance to bathing, and her own uncertainty had improved and she had established the habit of leav-
about Alzheimer disease and its management. The thera- ing the room when upset. During this visit, the therapist
pist explored with Mrs. C. how she managed each prob- and Mrs. C. discussed the success of a regular routine and
lem area. Mrs. C. explained that her solutions to the first calm atmosphere, refined her environmental modifica-
twO problems involved either yelling at her husband or tions, and began to generalize these techniques to emerg-
ignoring him to avoid a fight. Either way, she was ineffec- ing problems such as incontinence. Mrs. C. had pur-
tive in managing his problem behaviors, as evidenced by chased her own copy of The 36-Hour Day (Mace &
her high stress levels and his lack of personal hygiene. Rabins, 1981) and had called her physician for a referral to
The therapist suggested several possible environmental a dementia specialist (social groups layer), Because the
influences on Mr. c.'s behavior, such as lack of an estab- physician had refused to make a referral, Mrs. C. request-
lished bathing routine (task layer) and absence of visual ed more information about community resources from
cues in objects needed for bathing (objects layer). These the therapist.
were confirmed or refuted by Mrs. C. The two agreed to During Visit 5, Mrs. C. reported that she had contact-
establish a regular routine, identify sources of informa- ed a local hospital about caregiver education classes and
tion about Alzheimer disease and its management (social listed four other community resources of which she was
groups layer), and develop an atmosphere of calm in the aware (social groups layer), Her husband's emerging in-
home (task layer). Mrs. C. instructed the therapist to continence had not been a problem during the past week,
meet with her in her husband's absence for the next visit. but Mrs. C. was uncertain about why it had abated. The
During Visit 2, Mrs. C. and the therapist developed a therapist reviewed Mrs. c.'s problem-solving approach
plan based on the discussion from Visit 1. With the thera- and explored how Mr. c.'s incontinence might have been
pist's guidance, Mrs. C. decided to place a written sched- positively influenced as a result of the regular routine and
ule on the dining room table each morning and to direct approving attitude. By Visit 5, Mrs. C. and the therapist
her husband to the kitchen sink for bathing at the same had addressed the three identified problem areas, accom-

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 plished the goals established in Visit 1, and developed a necessitate additional effort or alteration in the thera-
problem-solving approach that Mrs. C. could generalize pist's strategy.
to other emerging issues such as incontinence. The research study in which this document was used
evaluated intervention strategies developed during treat-
ment and the extent to which these strategies were ac-
Intervention Documentation
cepted by caregivers and continued over the five interven-
Documentation of therapeutic practice and client benefit tion visits. Table 1 lists 17 distinct solutions, arranged in
becomes increasingly critical as occupational therapists descending order of frequency of use, that were imple-
must account for their activities and service effectiveness. mented by 17 caregivers in the study. These solutions
Figure 1 shows a form that documents intervention for involved modification or manipulation of one or more
Mrs. C. in one problem area, that of Mr. c.'s repetition of environmental layers and were identified as effective by
questions. In a research study, we developed and tested the therapist because a desired change in the care recipi-
this form for documenting the planning and implementa- ent's behavior was achieved. Effectiveness was deter-
tion process within each intervention visit. The form pro- mined on the basis of the caregiver's self-report and the
vides the therapist with a graphic delineation of five as- therapist's observation in each visit. Development and
pects of treatment: (a) each problem behavior addressed implementation of these effective solutions occurred
during the intervention, (b) the number and range of through independent problem solVing by the caregiver, a
management approaches used by the caregiver and an direct suggestion by the therapist, or collaboration by the
indication of effectiveness, (c) the range of environmental caregiver and therapist. As shown in Table 1, such solu-
strategies introduced by the caregiver and therapist, (d) tions as graded assistance (12%), encouragement ofsim-
the time frame in which strategies are accepted by the pIe work and leisure tasks (10%), use of formal supports
caregiver, and (e) the time frame in which ineffective (10%), and preparation of the area with needed objects
strategies are eliminated. The form also provides an on- (10%) were the most frequently used solutions; solutions
going treatment record to discern those problem areas such as eliminating clutter (3%) and identifying objects
that are effectively addressed across cases and those that with visual cues (3%) were used less frequently. These

Caregiver Number 21031

(90 min.) (100 min.) (90 min.) (75 min.) (105 min.)
Problem
.21.1.5... .2L2.l 3L.1.. 3LlL Jill...
Behavior Date Date Date Date Date

G) Husband asks the

same question over
Mrs. C. tends to yell,
"Don'r you remember.. ,"
--. [1;1~~lt;~::;'l • [1~~~;i~~:'l • Eliminated I • [ Eliminated I
and over again.

Mrs, C. will answer

question calmly and
oller reassu rance, if
husband seems upset
--.1 Continued
1 ·1 Continued
1 ·1 Continued
1 • I
Continued
I
or confused.

Mrs. C. will answer

question calmly and try
to redirect husband's
--.1 Continued
1
·1~~ntinUed I • I~~~li~~ed 1 • I~~~li~~edl
attention to something
else.
Mrs. C. will put out written
daily schedule for Sunday
and Monday (the routine of
these 2 days dillers from • I~~~li~~edl • I~onti~~edl
the rest of the week) on the
dining room table in A.M.

~o~ti~~edl
Schedule written in large
pZOZZlZZnniti

!
Ineffective Caregiver Solutions
Effective Solutions Initiated/Implemented by Caregiver
print on bright paper to
increase visibilrty
• [.

Effective Solutions Suggested by OT

Figure 1. The treatment documentation sheet. Patterned boxes differentiate between effective and ineffective care strategies
and their continuation or elimination over the intervention period. Note. OT = occupational therapist.

The American Journal of Occupational Therapy 805

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 Table 1 petitive marketing campaign to capture the geriatric con-
Effective Caregiver Solutions and Frequency of Use sumer (Capitman et aI., 1988). Although current congres-
(N = 17) sional discussions and legislative hearings may expand
Number of % of Total reimbursable services to this population, there is current-
Times Solutions
Solution a ly no mechanism in place to do so, Home care therapi5t5
Used Implemented
are perhaps in the best position to adopt these interven-
Use graded assistance 33 12.0
Identify/encourage simple work and tion principles and may receive Medicare reimbursement
leisure tasks 27 10.0 for documenting improved functioning of the care reCipi-
Use formal supports 27 10.0 ent. In addition, therapists in private practice can market
Prepare area with needed objects 27 10.0
Use safety precautions (e.g., locked doors, thiS service model to clients who pay their own expenses
nightlight, 10 bracelet) 18 7.0 and can maintain treatment documentation that supports
Use tactile guidance/demonstration 18 70 expanding reimbursement at the state and federal levels.
Use clear verbal instructions 18 7.0
Convey calm and approving allitude 17 65 The second challenge to the profession is to develop
Establish and communicate a regular innovative educational models to train therapists to use
routine 15 60 this framework. Intervention effectiveness depends on
Use commode/adaptive equipment 12 40
Use energy conservation and pacing the therapist's ability to assume and understand the care-
(caregiver and care recipient) 12 40 giver's perspective, creatively adapt the principles of
Use informal suPPOrtS 11 4.0 competence-environmental press to specific household
Use caregiver education opportunities 9 3.0
Identify objects and their use through arrangements, and suspend a medical model framework
visual cues 9 - 30 while collaborating with persons from diverse socioeco-
Eliminate clutter 9 3.0 nomic and cultural backgrounds. Such treatment assump-
Use mattress pads/absorbent pads 5 2.5
Control nuid intake 3 1.0 tions necessitate the development of educational models
Total 270 100.0 that emphasize team assessment and treatment ap-
"As reported by therapist during Visits 1 through 5. proaches, expose therapists to treatment in the home,
and orient therapists on assuming a caregiver or insider
perspective to jointly derive meaningful and relevant care
approaches to behavioral problems may be more diffi- management strategies.
cult for caregivers to incorporate into their routine or may The third challenge to the profession is to further
not be viewed by caregivers as effective. Future clinical develop and refine therapeutic strategies that address the
studies are needed to fully describe how caregivers se- multiple needs of caregivers as identified by caregivers.
lect problem-solving approaches and to develop and test The intervention methods described here may work for
occupational therapy strategies for assisting caregivers one group of caregivers but not for all. These methods
in using a greater range of effective solutions. Fur- may have to be extended, modified, and adjusted to en-
thermore, determining the comparative effectiveness of hance the well-being of other caregiver groups. An evalu-
each management approach and examining the relative ation of the relative effectiveness of specific environmen-
effect of the therapist's suggestions, caregiver-initiated tal solutions for particular caregiver groups warrants
approaches, and joint solutions would provide important further research. Future studies must also examine the
insights from which to guide occupational therapy interactive effects of time, experience, and caregiver
practice. stress on the ability of a specific caregiver to benefit from
this or any other type of intervention.
Practice Considerations
Conclusion
Occupational therapists offer a unique and critical contri-
bution to helping caregivers maintain elderly persons This paper presented an intervention approach designed
with dementia in the home. Working with caregivers in to enhance caregiver use of the environment to solve
their home offers a new consultative model of practice behavioral problems associated with a person with de-
and presents three challenges to the profession. The first mentia. The intervention is grounded in a competence-
challenge is to establish a mechanism for payment for environmental press framework and the principle of col-
such services. A critical limitation to this intervention ap- laboration. The documentation form developed for the
proach is that to date, occupational therapists cannot be intervention provides an ongoing evaluative tool to deter-
reimbursed by third-party payers for these services; mine therapeutic effectiveness, rate of caregiver change,
therefore, such services must be developed in tandem and those problem areas that pose a particular challenge
with other types of hospital or community-based pro- to the therapist and caregiver.
grams that can absorb the costs. Hospitals experimenting This intervention approach offers three potential
with diversification of services in geriatric long-term care benefits. First, the effective application of principles of
may endorse such an approach as part of a broader com- the competence-environmental press model may lead to

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 decreased caregiver stress and an improved sense of effi- Bandura, A. (1977). Self-efficacy: Toward a unifying theory
cacy in the caregiver's ability to manage daily behavioral of behavioral change. Psychological Review, 84(2), 191-215
Bandura, A. (1982). Self-efficacy mechanism in human
problems Bandura's (1977, 1982) study of association
agency American Psychologist, 37(2), 122-147.
between efficacy and competence demonstrates a strong Barris, R, Kielhofner, G., Levine, R. E., & Neville, A. (1985).
positive relationship between sense of efficacy and one's Occupation as interaction with the environment. In G. Kiel-
actual performance or ability to accomplish tasks. Con- hofner (Ed.), A Model of Human Occupation. Theory and
versely, experiences of mastery or achievement reinforce application (pp. 42-62). Baltimore: Williams & Wilkins.
Barusch, A. S., & Spaid, W. M. (1989). Gender differences in
expectations of efficacy (Bandura, 1977).
caregiving: Why do wives report greater burden' Gerontologist,
Second, the intervention may have long-term bene- 29, 667-676.
fits. The expansion of a caregiver's ability to solve prob- Brody, E. M. (1981). Women in the middle and family help
lems may enable him or her to generalize environmental w older people. Gerontologist, 21, 471-480.
strategies introduced during the intervention phase to Burdz, M. P. (1988). Effects of respite care on dementia and
nondementia patients and their caregivers. Psychology and Ag-
new problem behaviors that emerge over time. Thus, one
ing, 3(1), 38-42
carryover effect of the intervention may be to prolong Capitman, ]., Prottas, ]., MacAdam, M., Leutz, W.,
caregivers' ability to manage progressive behaviors of the Westwater, D., & Yee, D. (1988). A descriptive framework for
person with dementia. Telephone interviews with select- new hospital roles in geriatric care. Health Care Financing
ed caregivers after 3 months of participation in this serv- Review, 10, 17-25.
ChiOU, I. L., & Burnett, C N. (1985). Values of activities of
ice model indicated that their understanding of environ-
daily liVing: A survey of stroke patients and their home thera-
mental influences was enhanced and that they were able pists. Physical Therapy, 65, 901-906.
to apply the skills developed during the intervention to Clark, N. M.. & Rakowski, W. (1983). Family caregivers of
other problem situations several months after the inter- older adults: Improving helping skills. Gerontologist, 23,
vention had ended (Gitlin & Corcoran, 1991b). The long- 637-642
Corbin,]. M., & Strauss, A. (1988). Unending work and
term benefits of the service for both the caregiver and
care. San Francisco: Jossey-Bass.
care recipient need to be systematically tested. Corcoran, M. A., & Barrett, D. (1987). Using sensory inte-
Third, the concept of collaboration is especially com- Wation principles with regressed elderly patients. Occupation-
pelling in a community-based service model that reqUires al Therapl' in Health Care, 4(2), 119-128.
caregivers to develop skills to adapt their physical and Corcoran, M. A., & Gitlin, I.. (1991). Environmental influ-
ences on behavior of the elderly with dementia: Principles for
social environments. The concept of a client-centered
intervention in the home. Physical and Occupational Therapy
and collaborative approach to care has emerged in the in Geriatrics, 4(34), 5-22.
occupational therapy and health care literature as a pivot- Crossman, L., London, C, & Barry. C (1981). Older women
al factor to assure treatment efficacy (Peloquin, 1990; caring for disabled spouses: A model for supportive services.
Shelton et aI., 1989). However, these relationships and Gerontologist, 21, 464-470.
Dura,]. R, & Kiecolt-Glaser, ]. K (1990). Sample bias in
the effectiveness of collaboration need continued testing.
car-egiving research. Journal a/Gerontology: Psychological Sci-
Such research will also proVide the necessary evidence to ence~ 45. 200-204.
suPPOrt development of a payment structure and health Edwards, D. F, & Saum, C M. (1990). Caregiver burden
service provision system that includes the critical per- across stages of dementia. Occupational Therapy Practice,
spective and skills of occupational therapists . • 2(1), 17-31
Gallagher, D. E. (1985). Intervention strategies w assist
caregivers of frail elders: Current research status and future
Acknowledgments research directions. Annual Review ofGerontology and Geriat-
rics, 5, 249-282
We thank Desiree Burgh, Susan Leinmiller OTR/I.. and Karen
Gallagher, D, Rappaport, M., & Benedict, A. (1985, Novem-
Schaumann, 0"1"1</1., for their valuable work on this projeCt.
ber). Reliabilitv a/selected interview and selFreport measures
The intervention was developed and tested through a 1-
withfamil)1 caregivers. Paper presented at the annual meeting
year training grant funded by TirI.awyn Consortium and a 2-year
of the Gerontological Society of America, New Orleans, LA.
research study supported by the American Occupational Ther-
Gendron, C E., Poitras, I.. R., Engels, M. L., Daswor, D. P.,
apy Foundation
Sirota, S. E, Barza. S. 1.., Davis,]. C, & Levine, N. B. (1986) Skills
u'aining with supporters of the demented.journal a/the Ameri-
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