The second part of the mini-series on occupational therapy in geriatrics introduces two basic areas of occupational therapy in seniors—the support of self-sufficiency and activation. It presents everyday-day activities and outlines some possibilities of individual activation very briefly.

Although the following article focuses on possibilities of occupational therapy for seniors in a residential facility, much of what follows can also be applied in the home environment. By way of completeness, I list here activities that are more specific to occupational therapy in a senior’s home environment, but are not the subject of this article: counseling and suggestions regarding apartment equipment, environmental modification, fall prevention, collaboration with family members, practicing self-sufficiency in one’s own environment, and striving to keep the senior at home as long as possible.

Individual occupational therapy for seniors is based on two main pillars: support for self-sufficiency and activation. As you may have read in the previous article, the field of occupational therapy aims for clients and patients to achieve the highest possible level of self-sufficiency and participation in society. In the area of self-sufficiency, occupational therapy focuses on practicing and supporting everyday activities referred to as ADL (Activities of Daily Living). ADL can be further divided into two groups, where the first, called pADL (personal, basic activities), includes the following activities: - eating and drinking, - bathing/showering, - personal hygiene and care of appearance, - dressing, including putting on shoes, - using the toilet and post-toilet hygiene, - bladder control and bowel evacuation, - care of personal aids or supplies.

Building on personal ADL, there are then instrumental activities, i.e., iADL, including: - managing and maintaining a household (e.g., cleaning, cooking, shopping), - household budgeting and handling money, - mobility in the community (e.g., traveling by public transport), - caring for others and household pets, - caring for one’s own health (nutrition, exercise).

The goal of occupational therapy is then the practice of these skills, searching for possible alternatives, and recommending compensatory aids including possible environmental modifications. In a residential facility for seniors, we most often suggest and recommend the following aids: item carriers, lightweight containers for liquids, extended tool holders for writing supplies, a raised rim on a plate, cutlery with moldable ergonomic handles, magnifying glasses, etc. The selection of mobility aids (such as walkers, wheelchairs, and canes) is consulted with physiotherapists and rehabilitation workers.

In relation to self-sufficiency, occupational therapy also focuses on possible functional disorders of the upper limb, where the goal is to train function to the maximum possible level and to involve the limb in all daily activities. Here, the occupational therapist may practice with the senior hand grips, provide sensory stimulation to the upper limb, train fine motor skills, address possible spasticity, and address other obstacles to full use of that upper limb.

Individual activation
In addition to support for self-sufficiency, the second and often larger pillar of occupational therapy in seniors is individual activation. Activation is naturally an inseparable part of healthy aging, and no one now doubts its positive impact on a person. In the following section, only some examples of individual activation in seniors are presented very briefly. The number of options is much greater, and the task of occupational therapy is to identify or create additional activities so they are most suitable for each client. An important means of occupational therapy are the possibilities of grading and adapting activities. By grading we mean increasing or decreasing the difficulty of an activity so that it is neither too easy nor too difficult for a given senior. By adaptation we mean modifying the environment or using aids without which the activity would often not be feasible for that senior (e.g., enlarging task text, using a magnifier, etc.).

1) Training of cognitive functions (especially memory)
Under this very broad category lies the practice of a person’s cognitive and cognitive-emotional abilities. Occupational therapy focuses especially on short-term and long-term memory, orientation by time, place, person, decision-making, logical thinking, counting, word retrieval, etc. For training, one can use for example: exercise clocks, tabletop and large wall calendars, publications with memory exercises, number and letter flashcards, puzzles, brainteasers, a “Cognitive Training Set” made by the Czech Alzheimer Society, therapist-prepared materials or tasks, and much more—it depends on the therapist’s creativity and imagination. Speech and communication training is closely linked with supporting cognitive functions. In addition to regular conversation on current topics, speech maintenance is also well supported by training proverbs, rhymes, poems, sayings, or singing. In the case of less common language-production disorders, closer collaboration with a speech therapist is appropriate.

2) Reminiscence therapy
Reminiscence therapy, that is, the therapeutic use of memories, has a positive effect on seniors’ cognitive functions and psychological well-being. In addition to training long-term memory, it supports the individual’s own identity, enables better orientation in the situation, and allows one to experience feelings of safety and security. For individual reminiscence, reminiscence stimuli are useful, which can be divided into two groups: a) General stimuli to which the individual has no personal connection but are familiar. Such stimuli can include, for example, period items of everyday use, leisure items, photographs, advertising or film posters, etc. They should evoke the senior’s youth or childhood and invite reminiscence of general or specific events and experiences. For recollection purposes, so-called reminiscence corners, still lifes, or notice boards are often created in homes for seniors. b) Individual stimuli, that is, personal period items to which the individual has a close relationship. These stimuli often provoke a much stronger response due to deeper emotional involvement. In a residential facility for seniors, cooperation with the family is very important for obtaining these stimuli, as family members can provide personal items for that senior. Personal photographs are the easiest to obtain (e.g., from childhood, family, studies, residence, wedding, etc.). Personal items recalling specific events (diplomas, medals, souvenirs, jewelry, etc.) are also useful.

3) Sensory stimulation
As demonstrated by the concept of basic sensory stimulation and the importance of cognitive training, sensory stimulation is important in seniors (especially in those with more advanced dementia, when it is often one of the few means to which these individuals respond). In individual activation, it is possible to focus on all basic senses (vision, smell, taste, hearing, touch), but also on the less known ones (vibration, thermal sense, position sense, movement sense, etc.). As tools, sets of various spices and perfumes, taste strips or swabs, musical instruments, everyday objects, colored and shaped images, fabrics and materials with different surface textures, vibrating toys, tuning forks, and many others can be used. Seniors may engage with stimuli, for example, by simply registering them, recognizing them, comparing intensity, determining quality, etc.

4) Training of fine and gross motor skills
As noted above, training of fine and gross motor skills is closely related to ADL practice and self-sufficiency. Individual therapies can include: simple upper-limb exercises focusing on hands and fingers, manipulation of small objects, grip training, graphomotor training, etc. For these purposes one can use, for example, wooden and other tools/brainteasers, templates for signing, tracing, or filling in, or so-called ADL pillows with various types of fastenings sewn in. The greatest results come from combining motor training with meaningful activity, such as, for example, sewing on a button, folding napkins, folding laundry, wiping dishes, etc.

5) Zootherapy and contact with animals
A useful tool for activating seniors can also be zootheraphy, i.e., the therapeutic influence of an animal on a person’s health. Most commonly, dog handlers with canisterapeutic dogs visit homes for seniors and visit clients individually or in groups. Some homes allow seniors contact with small rodents, parrots, fish, turtles, cats, etc. Through an animal, one can target problematic areas for seniors, for example, communication, hand motor skills, memory, care for another or one’s own body, and many others.

6) Reborn doll
A reborn therapeutic doll is so far not a widely used activation method, which is especially significant for women seniors. It is an almost perfect replica of a living newborn, intended by its appearance to evoke pleasant feelings, reminding women of motherhood and a sense of usefulness. It is mainly used with women with moderately advanced dementia, where it can reduce feelings of anxiety and loneliness, support memory and communication, and arouse interest in surrounding events. The doll and its clothing can also be a good reminiscence stimulus or an aid for training memory and fine motor skills.

In all the approaches described above, the occupational therapist applies the principles of adaptation and grading and thus specifically trains concrete problem areas of seniors. It is nevertheless very important to realize that these approaches have advantages, but also risks, and are definitely not applicable to all seniors. Risks in reminiscence can include a negative life event that is not suitable to recall, in zootherapy fear or allergies to animals, in a reborn doll a traumatic experience of motherhood, and so on. A good therapist takes all these circumstances into account, works with each client individually, and gathers as much information as possible about each of them (whether from colleagues on the multidisciplinary team or family members).

Occupational therapy has a very broad scope of action for seniors, with many opportunities for supporting self-sufficiency and individual activation. The key to success is appropriate activity selection and correctly applied approach.

Mgr. Natálie Lupienská www.sue-ryder.cz

Used sources: Krivošíková, M.: Introduction to occupational therapy, Grada, 2011, 364 s. Janečková, H. – Vacková, M.: Reminiscence, Portál, 2010, 152 s. Jelínková, J. – Krivošíková, M. – Šajtarová, L.: Occupational therapy, Portál, 2009, 272 s. Velemínský, M.: Zootherapy in the light of objective findings, DONA, 2008, 335 s.

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