Benefits of Occupational Therapy in Dementia Patients: Findings from a Real-World Observational Study

Abstract

Background: There is a growing interest in developing non-pharmacological approaches in dementia. Clinical efficacy of occupational therapy (OT) under routine care conditions has not been investigated yet.

Objective: To analyze the short-term effects of OT in patients with dementia; and to identify factors related to greater benefit.

Methods: Patients referred to OT were evaluated before starting a 3-month intervention and at 3 and 6 months later. Measures included: Mini-Mental State Examination (MMSE), Disability Assessment in Dementia (DAD), Neuropsychiatric Inventory (NPI) Questionnaire, patients’ quality of life (EQ 5D-VAS), caregivers’ burden (Zarit scale), and amount of informal care. Linear mixed models were used to analyze trajectories of outcomes. Logistic regressions with stepwise descending selection were used to study factors associated with benefits.

Results: 421 dementia patients benefited from OT (mean MMSE = 17.3). Patients remained cognitively stable over time. Functional performances also remained stable at 3 months and significantly decreased at 6 months (crude reduction of 2.8 points, p < 0.01). Behavioral troubles were significantly reduced over the intervention period and remained stable after (p < 0.01). Patients’ quality of life increased over the 3-month intervention (p = 0.16) and significantly decreased thereafter. Caregivers’ burden and informal care significantly decreased over the 3-month intervention and remained stable thereafter. Patients who benefited from OT with regard to function were less educated and had higher cognitive level.

Conclusion: OT may be an effective intervention to maintain cognition and functionality and to reduce psychiatric symptoms in dementia patients. Mild stages of dementia could gain more benefits from OT with regard to functional decline.

Keywords

Behavioral troubles cognition dementia function non-pharmacological intervention observation study occupational therapy

INTRODUCTION

Dementia has received considerable interest over the last decade. At the present time, there are no curative treatments that can alter or prevent the pathophysiology of dementia, thus it is necessary to explore interventions that may delay the progressive functional decline [1]. To face the expected demographic burden of dementia and its impact on health care systems, many Western countries have implemented national strategies. In France, a global and massive effort targeted the optimization of dementia care by offering gradual personalized approaches to cover patients’ and families’ needs at home [2]. Indeed, several innovative health care services have been implemented nationwide, notably services offering occupational therapy (OT). OT permits tailored home support in terms of rehabilitation for subjects with mild-to-moderate dementia; it aims to restore or mobilize the remaining capacities of individuals and adapt their domestic environment so that they may improve and maintain social and relational life. A growing interest in OT currently exists [3 –5] and several trials are ongoing [6 –8]. In France, OT especially targets early dementia stages. A recent review has concluded that the literature provides a “proof of concept” that dementia related functional decline may be delayed via OT interventions [9]. However, even if OT has shown to be effective in some trials’ context, it does not mean that implementation in routine care brings similar benefits. Indeed, trials include convenience samples of dementia patients whereas the general dementia population is highly heterogeneous in terms of socio-demographic and clinical characteristics. Moreover, routine care practices can differ from the conceptual frame in clinical trials. The clinical efficacy of OT has been demonstrated in the Netherlands [10 –12], but the intervention’s replication in another national context failed to demonstrate any effectiveness with dementia patients [13]. Thus, there is a need to investigate OT’s effects under real-world conditions. We conducted an observational study based on routine care practice in order to systematically investigate the clinical evolution of patients benefiting from OT with pre- and post-clinical assessments. In this study, we aimed to document the benefits of OT on patients’ cognitive, functional, and behavioral aspects as well as on patient’s quality of life, caregivers’ burden, and informal care. Secondly, we aimed to identify the factors that affect the likelihood that a patient will benefit from the intervention.

METHODS

Subjects

The study took place in Aquitaine, a region in the South West of France, where 28 settings offering occupational therapy have been implemented. All were contacted in order to propose the study project and 16 accepted. All patients referred to these settings were systematically assessed over an inclusion period of 6 months from January 2014 to June 2014. No exclusion criteria were applied because we wanted to cover the whole scope of patients benefiting from OT. It means that some patients could have be included and followed even if they had no primary caregiver or only a professional caregiver. Box 1 describes the recommendations that should be followed by general practitioners or specialists to refer diagnosed dementia patients to OT.

Box 1.

Referral’s recommendations for occupational therapy

Indications:

Community dwelling

Patient with Alzheimer’s disease or other type of dementia

Early stage of the disease (ideally MMSE > 18, potentially MMSE > 15)

Restriction in daily functioning

Accept principles for occupational therapy intervention

Lack of indication:

No restriction in daily functioning

Advanced stage of the disease, no communication, no possibility to train remaining abilities

Caregiver compensate the patient daily functioning difficulties and has no demand for specific intervention

Patient refusing any home intervention

The study was approved by the research committee of the Regional Health Agency and all patients and potential caregivers were informed and gave informed consent for their data to become part of a database for future research.

Occupational therapy

Patients are referred to occupational therapy under medical prescription and followed a standardized treatment procedure consisting of 12 to 15 home sessions performed by therapist over a period of 3 months focusing on patients and potential primary caregivers. The initial assessment (1 or 2 sessions) allows the therapist to evaluate remaining abilities, and to define patients’ and caregivers’ expectations and needs. In the following sessions, patients were taught to optimize these compensatory and environmental strategies to improve their performance in daily activities. Primary caregivers were trained to use effective supervision, problem solving, and coping strategies to sustain patients’ social participation. At the end, a few sessions are devoted to initiate and prepare the home care support following the OT intervention.

Clinical outcomes

A neuropsychological screening battery was administered by the occupational therapist to all patients and caregivers at baseline, 3 months, and 6 months. This means that the 3-month assessment occurred at the end of the 12 to 15 sessions and the 6-month assessment occurred after a 3-month wash-out period without OT. The battery included the Mini-Mental State Examination (MMSE) to evaluate global cognitive function [14], the Disability Assessment in Dementia (DAD) scale to evaluate functional status [15, 16], the Neuropsychiatric Inventory (NPI) to assess neuropsychiatric symptoms [17], the Zarit scale to evaluate caregivers’ burden [18], the Visual Analogue Scale in the EQ-5D to evaluate patient’s quality of life [19], and the amount of informal care (in hours) provided by caregivers in the last month through the Resource Utilization in Dementia’s scale [20]. We considered only the care provided by caregivers in basic and instrumental activities of daily living; supervision time was not considered.

Statistical analysis

Trajectories of the outcomes were modeled according to time since initiation of OT using a linear mixed model [21]. Time was considered in three categories (baseline, 3 months, and 6 months), with the 3-month visit being considered as the reference time for comparison. Indeed, the primary purpose of the project was to investigate the potential benefits of OT over the intervention period as well as the short-term benefits after the intervention. Within-subject correlation was taken into account through correlated errors with an unstructured covariance matrix. Due to ceiling and floor effects and curvilinearity (unequal interval scaling) for MMSE, NPI scores, and amount of informal care, we used a previously published procedure that corrects the metrological properties to normalize the score distributions [22]. We adjusted all analyses for age, gender, and level of education. Sensitivity analyses were performed excluding patients who refused at least one follow-up assessment over the 6-month period.

We also studied which patients’ characteristics were associated with better improvement in two clinical outcomes: patients’ function and caregivers’ burden. Therefore, patients were classified into the following two groups: the “responders group” who experienced a decline above the median of the DAD (or Zarit score) change between baseline and 3 months and the “non-responders group”, who had a decline below the median. We adopted a pragmatic approach by studying only demographic and clinical variables that were easy to assess by therapists: all characteristics listed in Table 1, with the exception of caregivers’ characteristics, were considered (patients’ age, sex, education level, living situation, level of incomes, dementia etiology, time since diagnosis, use of drug, and MMSE). Responders and non-responders were compared with logistic regressions using a stepwise descending selection procedure. Significance level was set at p < 0.05. All analyses were carried out using SAS software, version 9.3 (SAS Institute Inc).

RESULTS

Study population

Four hundred and twenty-seven patients were referred to occupational therapists over the study period and 6 patients refused the intervention after the initial assessment sessions, leaving 421 for the current analyses. Table 1 describes the main sample characteristics. The mean age of participants was 82.2 (SD = 7.2). With regards to their educational level, 25% reported a primary level, 34.4% a secondary level, and 40.6% a high school or university level. Most patients had Alzheimer’s disease (61.9%). One hundred and fifty-two patients (38%) had a recent diagnosis of dementia (less than one year), 76 (19%) had a diagnosis made between 1 and 2 years before, and 172 (43%) reported a time since diagnosis more than 2 years. Referral recommendations concerning MMSE score that should be >15, were respected for only 65% of the sample: 25.3% had a MMSE between 10 and 15 and 7.1% had a MMSE below 10.Figure 1 describes the flowchart of included patients. Among the 421 patients, 382 (90.7%) were evaluated at the 3-month follow-up and 317 (75.3%) at the 6-month follow-up. Not surprisingly, the main reason for attrition was institutionalization (7% at 6-month follow-up). Respectively, less than 2% and 4% of the participants refused to be assessed at the 3-month and 6-month follow-ups. Other reasons for attrition comprised patients’ death, difficulties to contact caregivers, or patients’ hospitalizations.

Patients’ outcomes

Means and standard errors (SE) of the cognitive, functional, psychiatric, and patients’ quality of life measures at baseline, 3 and 6 month follow-ups, as well as p-values gained from linear mixed model analyses are reported in Table 2. With regard to cognitive performances, the mixed model analysis did not demonstrate a significant time effect. The MMSE mean score was 17.3 at baseline and remained stable over time. With regard to functional performances, the mixed model analysis showed a statistically significant time effect with a stabilization phase between baseline and the 3-month follow-up and a significant worsening between 3 and 6 months (crude worsening of 2.9 points, p < 0.0001). Concerning neuropsychiatric troubles, we found a significant reduction in NPI scores between baseline and the 3-month follow-up (crude reduction of 3.3 points, p < 0.0001), followed with a non-significant reduction (–1.3 points, p = 0.47). Lastly, quality of life was improved at the 3-month follow-up in a non-significant trend (crude improvement of 1.1 points, p = 0.16) followed with a significant worsening between the 3- and 6-month follow-ups (crude reduction of 2.6 points, p = 0.02).

Caregivers’ outcomes

Means and standard errors (SE) of caregivers’ burden and amount of informal care at baseline, 3 months, and 6 months as well as p-values gained from linear mixed model analyses are reported in Table 3. The studied sample consisted of non-professional caregivers who were interviewed both at baseline and at the 3- and 6-month follow-ups. The score on the Burden Zarit scale rated by caregivers at 3 months was significantly reduced compared to baseline (crude reduction of 1.8 points, p = 0.03), whereas the score remained stable after 3 months (p = 0.47). With regard to informal care, the linear mixed model analysis also demonstrated a significant reduction in amount of time over the 3 months of intervention (crude reduction of total hours = 9 hours, p = 0.003) whereas the amount of informal care slightly increased between the 3- and 6-month follow-ups (p = 0.65).

Sensitivity analyses

After exclusion of all participants who refused at least one follow-up assessment, all the results were similar to those from the initial analyses.

Characteristics of the responders

Three hundred and twenty-seven patients had data on DAD scores at the 3-month follow-up and 301 had data on the Zarit scale score allowing for the investigation of responders’ characteristics for each of these outcomes (Table 4). According to functional performances, the variables significantly associated with responder’s status based on DAD decline were educational level and cognitive performances: dementia patients with high school or university level were more frequently non-responders than those with lower educational levels (OR = 0.39, 95% CI 0.22–0.71) and patients with advanced stage of dementia (10≤MMSE≤15) benefited less from OT than those with mild dementia (MMSE≥21) (OR = 0.37, 95% CI 0.20–0.69). According to caregivers’ burden, the variables significantly associated with responder’s status were patient’s gender and time since diagnosis: caregivers of female patients were more frequently responders (OR = 1.94, 95% CI 1.13–3.34) as well as patients with more recent diagnosis compared with those who had a 1 to 2 years old diagnosis (OR = 0.40, 95% CI 0.20–0.79).

DISCUSSION

In this prospective observational study, our findings suggest that occupational therapy could benefit dementia patients and caregivers on several clinical outcomes including neuropsychiatric symptoms and functional performances. A significant worsening of function was found between 3 and 6 months, after the 3-month stabilization phase corresponding to the intervention period; psychiatric symptoms were reduced over the intervention period and remained steady over the 3 following months. Moreover, patients’ quality of life assessed by caregivers slightly increased over the intervention period and was significantly reduced thereafter. Additionally, these potential clinical benefits also correspond to caregivers’ well-being with reduction in subjective burden and in provision of informal care over the intervention period.

Providing community-based programs that aim to improve the quality of life for people with dementia and their carers, and training and supporting carers are key aspects of French policy. In this perspective, several evidence-based interventions have been implemented through the national Alzheimer plan 2008–2012 [2]; even if high-quality, well-controlled intervention studies are essential to test effective strategies for people with dementia, translation under routine practice and real-world conditions is particularly challenging for such vulnerable individuals [23].Although such strategies would deserve to be tested on a systematic basis, we did not find any study assessing the efficacy of OT under routine care conditions. Our study represents a first step toward closing this gap in the literature. Managing neuropsychiatric behaviors is one of the most challenging aspects of caring for individuals with dementia. Thus our findings may be of importance because families’ difficulties to cope with behavioral troubles are important risks factors for poor prognosis [24]. Consensus reports recommended nonpharmacological approaches as the initial treatment modality for neuropsychiatric symptoms [25, 26]. Nevertheless, routine management of behavioral troubles firstly involve pharmacologic treatments that have modest to no benefits [27 –29]. A multifaceted program with OT as the core of the intervention and focusing on behavioral symptoms management reported significant benefits on patient’s behavior and caregiver’s burden [30]. OT also improved communication with patients. Because OT focuses on tailored activities providing pleasure and social stimulation, the intervention may afford control over self-identity, a critical attribute of selfhood that may endure throughout the disease process [30, 31]. Moreover, occupational therapists contribute to train caregivers’ supervision skills and self-abilities to interact with patients which can in turn improve patients’ well-being and reduce their behavioral troubles. Important clinical implications can be derived from these findings. Indeed, there is a growing attention toward early stage of dementia because it could represent a relevant temporal window for therapeutic strategies and facilitate later home support acceptance. Dementia care has been described as suboptimal even at early stages [32, 33]. Indeed, recent findings have suggested that lack of specific medical follow-up after diagnosis could explain poor prognosis of dementia patients who have been early diagnosed [34, 35]. Because the process of the loss of skills in performing complex activities (e.g., the independent activities of daily living) starts much earlier than the loss of skills in performing self-care activities, opportunities to improve skills in performing daily activities remain and early home tailored support should be promoted at diagnosis [36].

Our study also demonstrated that despite established recommendations, the sample was heterogeneous in terms of type of dementia as well as cognitive performances. One third of patients referred to OT had low cognitive performances under the threshold of 15 with the MMSE; the latter could less frequently benefit from OT than those with mild dementia with regards to functional decline. Since its implementation in France, OT has appeared as highly solicited new services with up to 6 months waiting list. Thus, our findings could also contribute to foster clinicians to follow the recommendations in order to prioritize patients and optimize OT benefits in a population perspective. Mild dementia stages should be foremost concerned.

This research has some limitations, primarily because of its observational design. In order to assess the efficacy of OT under routine care conditions and after its nationwide implementation, a control group would have been advisable but for ethical reason, being in a waiting-list (without any OT over the study period) could not be proposed to dementia patients referred to occupational therapists. Others limitations are that all patients were not subjected to the same intervention duration and that initiation of specific pharmacological treatment, particularly neuroleptics (not assessed in our study) between follow-ups could have impacted on patients’ clinical course. As this study was based on an observational routine care design, some patients may not have a diagnosis based on recommended dementia criteria; however, they were considered by their physicians both as demented and as requiring home support, meaning that they have a real functional repercussion of their cognitive problems. Moreover, more than 90% of the included patients had received a diagnosis performed by a specialist, either in a memory consultation or in liberal activity, who are used to applying dementia criteria in their practice.

Furthermore, although mixed design with external assessments should be privileged for such observational studies, patients and caregivers were not assessed by blind assessors. Nevertheless, the ecological context of our study is also a strength of our findings because trusting relationships between therapists and patients/caregivers allowed a very low attrition rate due to refusal. Other strengths of our study include the important sample size and the representativeness of dementia patients referred to OT; a recent study on dementia patients at a national level reported the same distribution of demographic characteristics and cognitive performances as in our study sample [37]. Lastly, lack of exclusion criteria allowed us to include isolated individuals (those without a primary caregiver) who are classically excluded in clinical trials [6 , 38].

CONCLUSION

The short-term gains in clinically relevant outcomes obtained with OT for both patients and their caregivers underline the importance of adequate and timely diagnosis with proactive dementia management. Future studies should explore more in detail which sub-groups of patients could gain more benefits from OT as well as its long-term clinical effects, notably on global care quality and users’ satisfaction. Moreover, as OT has been designed as a short-term intervention, consequences of its disruption should be studied in more detail [39].

Footnotes

ACKNOWLEDGMENTS

The authors acknowledge all the therapists and ESA (French acronym for Equipe Spécialisée Alzheimer) staff for their collaboration in data collection and management.

The current project was conducted under a partnership agreement between the Institut National de la Santé et de la Recherche Médicale (INSERM), the University of Bordeaux, and the Regional Health Agency (ARS d’Aquitaine). The project received a financial support from France Alzheimer’sassociation.

Authors’ disclosures available online ().

References

Cermakova

, Szummer

, Johnell

, Fastbom

, Winblad

, Eriksdotter

, Religa

(2016) Management of acute myocardial infarction in patients with dementia: Data from SveDem, the Swedish Dementia Registry. J Am Med Dir Assoc, pii: S1525-8610(16)30304-8. doi: 10.1016/j.jamda.2016.07.026

Pimouguet

, Bassi

, Somme

, Lavallart

, Helmer

, Dartigues

(2013) The 2008-2012 French Alzheimer plan: A unique opportunity for improving integrated care for dementia. J Alzheimers Dis 34, 307–314.

Ciro

, Hershey

, Garrison

(2013) Enhanced task-oriented training in a person with dementia with Lewy bodies. Am J Occup Ther 67, 556–563.

Peloquin

, Ciro

(2013) Self-development groups among women in recovery: Client perceptions of satisfaction and engagement. Am J Occup Ther 67, 82–90.

Ciro

(2014) Maximizing ADL performance to facilitate aging in place for people with dementia. Nurs Clin North Am 49, 157–169.

Wenborn

, Hynes

, Moniz-Cook

, Mountain

, Poland

, King

, Omar

, Morris

, Vernooij-Dassen

, Challis

, Michie

, Russell

, Sackley

, Graff

, O’Keeffe

, Crellin

, Orrell

(2016) Community occupational therapy for people with dementia and family carers (COTiD-UK) versus treatment as usual (Valuing Active Life in Dementia [VALID] programme): Study protocol for a randomised controlled trial. Trial 17, 65.

Callahan

, Boustani

, Schmid

, Austrom

, Miller

, Gao

, Morris

, Vogel

, Hendrie

(2012) Alzheimer’s disease multiple intervention trial (ADMIT): Study protocol for a randomized controlled clinical trial. Trials 13, 92.

Gitlin

, Piersol

, Hodgson

, Marx

, Roth

, Johnston

, Samus

, Pizzi

, Jutkowitz

, Lyketsos

(2016) Reducing neuropsychiatric symptoms in persons with dementia and associated burden in family caregivers using tailored activities: Design and methods of a randomized clinical trial. Contemp Clin Trials 49, 92–102.

McLaren

, Lamantia

, Callahan

(2013) Systematic review of non-pharmacologic interventions to delay functional decline in community-dwelling patients with dementia. Aging Ment Health 17, 655–666.

10.

Graff

, Vernooij-Dassen

, Thijssen

, Dekker

, Hoefnagels

, Rikkert

(2006) Community based occupational therapy for patients with dementia and their care givers: Randomised controlled trial. BMJ 333, 1196.

11.

Graff

, Vernooij-Dassen

, Thijssen

, Dekker

, Hoefnagels

, Olderikkert

(2007) Effects of community occupational therapy on quality of life, mood, and health status in dementia patients and their caregivers: A randomized controlled trial. J Gerontol A Biol Sci Med Sci 62, 1002–1009.

12.

Graff

, Adang

, Vernooij-Dassen

, Dekker

, Jonsson

, Thijssen

, Hoefnagels

, Rikkert

(2008) Community occupational therapy for older patients with dementia and their care givers: Cost effectiveness study. BMJ 336, 134–138.

13.

Voigt-Radloff

, Graff

, Leonhart

, Schornstein

, Jessen

, Bohlken

, Metz

, Fellgiebel

, Dodel

, Eschweiler

, Vernooij-Dassen

, Olde Rikkert

, Hull

(2011) A multicentre RCT on community occupational therapy in Alzheimer’s disease: 10 sessions are not better than one consultation. BMJ Open 1, e000096.

14.

Folstein

, Folstein

, McHugh

(1975) Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 12, 189–198.

15.

Gelinas

, Gauthier

, McIntyre

, Gauthier

(1999) Development of a functional measure for persons with Alzheimer’s disease: The disability assessment for dementia. Am J Occup Ther 53, 471–481.

16.

Gauthier

, Gelinas

, Gauthier

(1997) Functional disability in Alzheimer’s disease. Int Psychogeriatr 9(Suppl 1), 163–165.

17.

Cummings

, Mega

, Gray

, Rosenberg-Thompson

, Carusi

, Gornbein

(1994) The Neuropsychiatric Inventory: Comprehensive assessment of psychopathology in dementia. Neurology 44, 2308–2314.

18.

Zarit

, Todd

, Zarit

(1986) Subjective burden of husbands and wives as caregivers: A longitudinal study. Gerontologist 26, 260–266.

19.

EuroQol

(1990) EuroQol–a new facility for the measurement of health-related quality of life. Health Policy 16, 199–208.

20.

Wimo

, Nordberg

, Jansson

, Grafstrom

(2000) Assessment of informal services to demented people with the RUD instrument. Int J Geriatr Psychiatry 15, 969–971.

21.

Laird

, Ware

(1982) Random-effects models for longitudinal data. Biometrics 38, 963–974.

22.

Proust-Lima

, Philipps

, Liquet

, Estimation of extended mixed models using latent classes and latent processes: The R package lcmm. ArXiv Prepr ArXiv150300890 [online serial]. Accessed at: http://arxiv.org/abs/1503.00890. Accessed July 2, 2016.

23.

Nehen

, Hermann

(2015) Supporting dementia patients and their caregivers in daily life challenges: Review of physical, cognitive and psychosocial intervention studies. Eur J Neurol 22, 246–252, e219-e220.

24.

Cepoiu-Martin

, Tam-Tham

, Patten

, Maxwell

, Hogan

(2016) Predictors of long-term care placement in persons with dementia: A systematic review and meta-analysis. Int J Geriatr Psychiatry 31, 1151–1171.

25.

Lyketsos

, Colenda

, Beck

, Blank

, Doraiswamy

, Kalunian

, Yaffe

, Task orce of American Association for Geriatric Psychiatry (2006) Position statement of the American Association for Geriatric Psychiatry regarding principles of care for patients with dementia resulting from Alzheimer disease. Am J Geriatr Psychiatry 14, 561–572.

26.

Salzman

, Jeste

, Meyer

, Cohen-Mansfield

, Cummings

, Grossberg

, Jarvik

, Kraemer

, Lebowitz

, Maslow

, Pollock

, Raskind

, Schultz

, Wang

, Zito

, Zubenko

(2008) Elderly patients with dementia-related symptoms of severe agitation and aggression: Consensus statement on treatment options, clinical trials methodology, and policy. J Clin Psychiatry 69, 889–898.

27.

Sink

, Holden

, Yaffe

(2005) Pharmacological treatment of neuropsychiatric symptoms of dementia: A review of the evidence. JAMA 293, 596–608.

28.

Schneider

, Tariot

, Dagerman

, Davis

, Hsiao

, Ismail

, Lebowitz

, Lyketsos

, Ryan

, Stroup

, Sultzer

, Weintraub

, Lieberman

, CATIE-AD Study Group (2006) Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med 355, 1525–1538.

29.

Ballard

, Hanney

, Theodoulou

, Douglas

, McShane

, Kossakowski

, Gill

, Juszczak

, Yu

, Jacoby

, DART-AD investigators (2009) The dementia antipsychotic withdrawal trial (DART-AD): Long-term follow-up of a randomised placebo-controlled trial. Lancet Neurol 8, 151–157.

30.

Gitlin

, Winter

, Vause Earland

, Adel Herge

, Chernett

, Piersol

, Burke

(2009) The Tailored Activity Program to reduce behavioral symptoms in individuals with dementia: Feasibility, acceptability, and replication potential. Gerontologist 49, 428–439.

31.

Cohen-Mansfield

, Parpura-Gill

, Golander

(2006) Utilization of self-identity roles for designing interventions for persons with dementia. J Gerontol B Psychol Sci Soc Sci 61, P202–P212.

32.

Pimouguet

, Rizzuto

, Fastbom

, Lagergren

, Fratiglioni

, Xu

(2016) Influence of incipient dementia on hospitalization for primary care sensitive conditions: A population-based cohort study. J Alzheimers Dis 52, 213–222.

33.

Callahan

, Boustani

, Sachs

, Hendrie

(2009) Integrating care for older adults with cognitive impairment. Curr Alzheimer Res 6, 368–374.

34.

Pimouguet

, Delva

, Le Goff

, Stern

, Pasquier

, Berr

, Tzourio

, Dartigues

, Helmer

(2015) Survival and early recourse to care for dementia: A population based study. Alzheimers Dement 11, 385–393.

35.

Pimouguet

, Le-Goff

, Rizzuto

, Berr

, Leffondre

, Peres

, Dartigues

, Helmer

(2015) Effect of early referral to specialist in dementia on institutionalization and functional decline: Findings from a population-based study. J Alzheimers Dis 49, 819–828.

36.

Delva

, Pimouguet

, Helmer

, Peres

, Brechat

, Le Goff

, Jacqmin-Gadda

, Amieva

, Orgogozo

, Auriacombe

, Berr

, Tzourio

, Barberger-Gateau

, Dartigues

(2013) A simple score to predict survival with dementia in the general population. Neuroepidemiology 41, 20–28.

37.

Caisse Nationale de Solidarité à l’Autonomie Rapport d’activité 2011: Équipes Spécialisées Alzheimer à domicile (ESA) Pôles d’Activités et de Soins Adaptés (PASA) Unités d’Hébergement Renforcées (UHR)Accessed at: http://www.plan-alzheimer.gouv.fr/IMG/pdf/Rapport_Alzheimer_activite_2011_ESA-PASA-UHRdef_18102012_2_.pdf.

38.

Gitlin

, Winter

, Burke

, Chernett

, Dennis

, Hauck

(2008) Tailored activities to manage neuropsychiatric behaviors in persons with dementia and reduce caregiver burden: A randomized pilot study. Am J Geriatr Psychiatry 16, 229–239.

39.

Hynes

, Field

, Ledgerd

, Swinson

, Wenborn

, di Bona

, Moniz-Cook

, Poland

, Orrell

(2016) Exploring the need for a new UK occupational therapy intervention for people with dementia and family carers: Community Occupational Therapy in Dementia (COTiD). A focus group study. Aging Ment Health 20, 762–769.