Abstract
As the population of individuals aged sixty-five and older continues to grow, the number of older individuals participating in the workforce rises alongside, with projections estimating as many as 72 million older workers by 2030. Due to this rapid increase in the number of older workers, new challenges to worker health and to health-related productivity will arise in the coming years. Occupational therapy practitioners are uniquely suited to address many of these challenges given their background in activity analysis, assessment and modification of job demands, health promotion and successful aging. However, there is need for continued research in this area to expand the role of the occupational therapy practitioner in prevention and return-to-work interventions focused on the older worker, and to advocate for the value occupational therapy practitioners can contribute to this field.
Introduction
The elderly population is increasing rapidly worldwide [1, 2], and the number of older workers will likely also increase due to labor needs and lengthened, healthy life expectancies [3]. The Bureau of Labor Statistics estimates one in four American workers will be older than fifty-five by 2024 [4]. In 2012, the CDC predicted that by 2030, the number of individuals aged 65 and older in the U.S. workforce will double to 72 million [4]. Since older workers are more susceptible to disability than their younger counterparts, the authors suggest members of all healthcare professions should increase their knowledge and understanding of the older worker and consider their unique roles in promoting the health and continued employment of an aging workforce [5].
Older workers face mixed attitudes to their presence in the workplace. Harris, Krygsman, Waschenko, and Rudman [6] surveyed diverse work forces in Europe and North America, and found more negative than positive opinions of older workers currently exist. On the other hand, studies have found the older worker is likely to offer leadership skills, attention to detail, advanced writing skills, creative problem solving, high levels of intellectual property, self-directed work habits, corporate expertise, high levels of patience, and better attendance records [1, 7–9]. Therefore, organizations and employers can benefit from retaining or rehiring older workers who demonstrate the ability to meet the competitive requirements of the workplace.
Rohwedder and Willis [10] conducted a cross-national analysis on the relationship between cognition and involvement in the labor force and found a significant association between older age of retirement and maintained cognitive skills. The authors argue this relationship may even be causal due to prior research outlining national policies as the major reason for variations in retirement age, indicating retirement may lead to decreased engagement in activities, and long-term unemployment may lead to physical and mental decline [10]. Appropriate support systems are key to facilitating older adults’ successful participation in work. Occupational therapy practitioners may contribute to these supports by facilitating continued engagement in the worker role beyond the culturally accepted retirement age [11].
Despite the physical and cognitive benefits of maintaining employment into older age, older workers frequently face physical barriers to employment including vision and hearing loss, imbalance, increased risk of disability, changes in temperature regulation, and decreased muscle strength [5, 12]. People with disabilities – age-related or otherwise – face added barriers to both hiring and inclusion throughout the employment process [13]. These combined health and social challenges, if not addressed, may lead to frequent absences and place an older worker at risk of permanently exiting the workforce due to poor health or disability. Ultimately, successful participation of the older worker requires planning, collaboration, and the involvement of a team of trained healthcare personnel.
Occupational therapy practitioners can be key members of this team, offering their therapeutic training and skills to enable older workers to achieve “health, well-being, and participation in life through engagement in occupation” [14]. The American College of Occupational and Environmental Medicine guidelines on best practices for returning an employee to work, post-injury or illness, emphasize evaluating the worker’s functional level and assessing the fit between work capacity, environment, and expected duties, all of which fall within the occupational therapy practitioner’s scope of practice [14]. In addition, occupational therapy practitioners offer distinct value in facilitating productive aging by helping older adults to remain involved in activities, roles, and communities [15].
Occupational therapy practitioners can contribute more to the health promotion of older workers, and agree on the potential for expanding current services for this population [16]. Occupational therapy practitioners offer a skilled, holistic approach to facilitate successful return-to-work in a variety of programs [17]. In 2011, the National Institute for Occupational Safety and Health (NIOSH) began promoting Total Worker Health (TWH), defined as policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness prevention efforts, to advance worker well-being [18]. This provides a unique opportunity for occupational therapy practitioners to utilize their skills in a holistic approach to health for the older worker under the umbrella of TWH programs [19].
Occupational therapy practitioners can play a role in facilitating older worker participation in the workplace through involvement in prevention, absence management, and meaningful return-to-work programs. The ultimate goal is to facilitate continuity in the process of returning the older worker to gainful employment. This article discusses specific interventions including preventive medicine in the workplace, management of health conditions, psychosocial factors, quality of work life, and the integration of OT approaches into the workplace. The objectives are to overview occupational therapy practitioners’ value in promoting older workers’ engagement in meaningful work occupations and to describe the of these interventions on health and longevity.
Preventive medicine in the workplace
Older workers are more likely to have lengthy absences from work following illness or injury. The role of the occupational therapy practitioner should initially be to emphasize prevention of workplace injury, illness, and disability by developing and implementing workplace injury and illness prevention programs [20–22].
Preventive strategies can be categorized as primary, secondary, or tertiary. For example, an occupational therapy practitioner might assess a workplace for general fall risks (primary prevention), lead stress management courses for employees juggling significant responsibilities and encourage early detection or intervention programs (secondary prevention), or educate employees with arthritis on appropriate hand care and positioning to use when typing or operating machinery (tertiary prevention) [20]. The occupational therapy practitioner’s role in preventing or adapting for disability and decline of the older worker is one facet of the role of occupational therapy in promoting successful aging [23]. According to the Well Elderly Study [24], occupational therapy interventions with healthy older adults produce significant benefits in physical function, quality of life, and mental health and decreased role limitations, when compared with social interventions or no treatment.
Although need for reimbursement can pose a barrier to implementing preventive interventions, occupational therapy practitioners can demonstrate the value of prevention and wellness in decreasing healthcare costs. For example, 82% of workers aged 65 or above have at least one chronic condition, and 65% have more than one; occupational therapy interventions may prevent long-term health expenses and increased healthcare costs for older adults by hundreds or thousands of dollars [23, 25]. Companies may consult with occupational therapy practitioners to apply preventive care to a variety of health-related issues before opting for more expensive levels of care. For example, employee exercise programs are a cost-effective secondary prevention intervention that may reduce work-related fatigue and improve physical and mental functioning in the workplace [26].
Prevention-oriented absence management (POAM)
Health-related absenteeism programs are designed to provide a systematic approach to dealing with absence resulting from illness or injury either on or off the job. They include integrated disability management, total absence management, and health and productivity management [27]. These approaches are integral to detecting health-related problems as early as possible (secondary prevention), addressing conditions as they progress from acute to chronic (early and effective intervention), and facilitating return-to- work. Employers frequently experience difficulties ensuring employees will be able to perform their essential duties and finding staff resources to manage absenteeism [28]. A skilled occupational therapy practitioner can help employers design appropriate job-site return-to-work programs to enable engagement of older workers to the maximum extent possible [29].
POAM helps to keep workers healthy and minimize the severity of illness or injury. As workers age, the risk of health-related conditions increases. In 2009, over 35% of the population aged 65 and older was overweight or obese [30]. Hypertension, diabetes, and arthritis are a few of the most common chronic conditions affecting older workers [31]. These and other comorbidities often affect older workers’ workplace participation. Primary prevention and safety regulations are among the most cost-effective approaches to address physical conditions affecting work engagement [32], because workers are more vulnerable to mismatch between physical ability and job demands [33].
POAM combines administrative and clinical models with integrated disability and absence management to maximize work participation [34]. Unfortunately, many conditions are not apparent until significant impairment occurs. Therefore, it is important that occupational therapy practitioners advise employers to emphasize primary prevention programs, in order to apply clinical evaluation skills to detect problems as early as possible, promote successful aging in the workplace, and design rehabilitation measures to prevent disability among older workers [35, 36]. POAM is also designed to enhance the older worker’s productivity, demonstrating its value to the employer [7]. A prevention-oriented approach can focus on the needs of the older worker, improve quality, and lower costs. These programs provide opportunities for employers to accumulate data to help identify optimal solutions.
The accompanying chart (Table 1) illustrates examples of preventive occupational therapy interventions that can be implemented along with absence management programs for the older worker, contrasted with disability-response interventions. Preventive interventions are discussed from a universal design perspective, which prioritizes the creation of products and environments people of all abilities can use to their full potential, without a need for person-specific adaptations [36]. Universally-designed facilities can prevent lost time from work due to aging-related disability by promoting engagement for all workers through environment and task supports. Conversely, response-oriented interventions, referred to as the “accommodation response” in Table 1, are person-specific, reasonable accommodations a company might be required to make to facilitate older workers’ return-to-work [37]. Retroactively fitting the environment to the worker’s needs is often less cost-effective than universal preventive measures [36].
Prevention-oriented occupational therapy interventions for the older worker
Prevention-oriented occupational therapy interventions for the older worker
Presenteeism is “the lost productivity that arises from continuing to work when unwell” [38]. Presenteeism may result in performance issues such as failing to meet a deadline, struggling to meet the physical demands of a job, or missing important details of an assignment due to pain [39]. For example, employees with no chronic conditions reported a mean of 3.7 unproductive days whereas employees with two or more chronic conditions that may result in pain reported a mean of 20.1 unproductive days [40]. Thus, health promotion focused on minimizing presenteeism is essential to maintaining productivity. However, it is important to note an aging workforce may exhibit chronic conditions whose effects may not be easily mitigated by health promotion programs.
Comorbidities and chronic conditions often interfere with productivity and increase absences and health care costs. Comorbidities such as obesity and high blood pressure can increase workers’ compensation claims, presenteeism rates, and indirect costs associated with lost time from work [39]. Psychosocial challenges such as mental or somatic disorders interfere with productivity without preventing an employee from coming to work [41]. Occupational therapy practitioners play a unique role in addressing mental health issues, and may collaborate with workers suffering from depression to identify wellness resources, develop coping strategies to manage negative feelings, restructure routines to allow for counseling during the workday, or collaborate with employers and job coaches to explore alternate roles and supports within the workplace [42]. For example, occupational therapy practitioners may offer interventions such as Acceptance and Commitment Therapy to facilitate skill development and self-management among individuals living with chronic physical and mental conditions to improve engagement with worker roles [41].
Presenteeism can be mitigated with flexible sick leave and POAM. Occupational therapy practitioners may facilitate mutual understanding between employers and employees by performing a job-demands analysis or by advocating for appropriate accommodations for the employee. A job-demands analysis defines the mental, physical, and cognitive skills a job requires, through formal and informal methods, to help determine a proper fit for workers, and falls within occupational therapy practitioners’ expertise given their background in task analysis [36, 43]. It is more important to allow workers with chronic conditions to return to work discretely, even if for a limited time, than to prohibit them from work engagement until remission has occurred. Eventually, however, decisions incorporating both the workers’ and company’s best interests must be made in order to decide if and when to place the worker on disability [39]. Job-demands analyses may guide employers to use reliable data and objective absence-management policies to reduce presenteeism.
Return-to-work
Return-to-work refers to a worker’s reintegration following an injury or illness. Ntsiea, Van Aswegen, Lord, & Olorunju [44] demonstrate the need for workplace intervention programs to facilitate return-to-work among older stroke survivors, reporting that 60% of included individuals returned to work within six months, compared to only 20% of the control group. Occupational therapy practitioners are uniquely trained to participate in this return process, ensuring the necessary accommodations and assistive devices are present within the individual’s workplace, and developing a treatment plan to facilitate a seamless return [5]. During the return-to-work interventions, occupational therapy practitioners with specialized knowledge can support client transitions by using actual work tasks and environments to rehabilitate worker performance [29]. Occupational therapy practitioners may work with employers and employees to alter a work method or develop workplace task modifications [42].
To illustrate the applicability of a return-to-work program, consider a 62-year-old sewing machine operator returning to work after a below-the-knee amputation in a transitional return-to-work program. The ADA [37] specifies qualified individuals who can perform a job with or without reasonable accommodations qualify for extra protections, including modified work schedules and tasks, training, and workplace aids. To facilitate ADA compliance, the employer might select to collaborate with an occupational therapy practitioner, who would work with both the employer and the client to identify appropriate accommodations. Interventions might include starting with consultations about occupational engagement in work and then proceed to worker adaptations and environmental modifications or personal and lifestyle adaptations [45].
When creating prevention-focused return-to-work programs, it is essential to focus on safety. Returning to work prematurely can be detrimental to the worker and his or her associates. For example, if a construction worker prematurely undertakes arduous activities after a heart attack, he or she might suffer an injury due to decreased cardiovascular output or improper use of energy conservation techniques, thus further interrupting work regimens.
It is, therefore, in the company’s best interests to implement work accommodation and prevention-focused programs to promote the health, well-being, and productivity of its employees. Occupational therapy practitioners could apply ergonomic principles and match an individual’s skills with task demands to improve safety [20]. Ideally, companies should identify risks and conditions in order to prevent extended absences. Direct supervisors and safety committees understand both the impact of prevention-oriented programs and the effects of the programs on disabled workers and work departments when attempting to foster a culture of safety [34, 46].
Addressing specific conditions
Pain
Chronic pain can lead to work absences and interfere with readiness to return to the workplace [47]. Pain, especially if chronic, is experienced emotionally, cognitively, and psychologically, as well as physically [48]. Culture, gender, and age may influence severity of pain symptoms experienced. Research indicates older workers may be less likely to report pain or request accommodations for pain from supervisors until the magnitude becomes great enough to impact work productivity [45]. Occupational therapy practitioners are trained to recognize the subtle signs of pain and the complexities of pain management, and to play a meaningful role in helping clients identify strategies to cope with pain and to facilitate interventions to improve function [49]. Moreover, occupational therapy practitioners may collaborate with clients to address cultural factors affecting return-to-work after hand injuries [50].
Occupational therapy practitioners offer options for preventing and managing pain. Among the chief pain management approaches in occupational therapy are functional goal setting, training, home exercise programs, and screening [49]. Other occupational therapy interventions to manage pain include proactive pain control, ergonomics training, ergonomics consultation focused on environmental modifications, proactive problem solving, and communication skills training [49]. For example, occupational therapy practitioners may emphasize intervention in a patient’s pain tolerance after hand injuries in order to optimize probability of return-to-work [50].
Musculoskeletal conditions
An estimated 54% of the U.S. adult population presents with chronic musculoskeletal conditions [51]. Muscle strength and bone density decrease with age, making musculoskeletal conditions especially prevalent among older workers [51]. Occupational therapy practitioners play an important role in preventing disability and/or lost worker productivity caused by musculoskeletal conditions. According to Welch, Haile, Boden, and Hunting [52], job-specific accommodations for roofing workers with musculoskeletal disorders, including osteoarthritis and rheumatoid arthritis, significantly improved longevity of workforce participation.
Osteoarthritis significantly impacts the ability to work and often causes lost productive workdays. Over half of individuals aged 65 and older in the U.S. suffer from osteoarthritis, and the incidence increases with age [53]. Rheumatoid arthritis, an inflammatory condition that affects the joints and causes fatigue, pain, and limitations in daily living, also affects older workers [54]. Occupational therapy practitioners can intervene by collaborating with employers and employees to promote assessment and implementation of proper workplace ergonomic interventions [29]. By intervening early, occupational therapy practitioners can preserve optimal musculoskeletal functioning for older workers. However, continued efforts to investigate occupation-based interventions and assess functional outcomes are needed [55, 56].
Psychosocial factors
In addition to physical conditions preventing older workers from returning to work following injury or illness, there are a number of psychosocial factors that must be addressed to facilitate a successful and productive return to work. These factors include altered identity following acquired disability, decreased self-efficacy, disrupted routines, lack of motivation, and unsupportive workplace environment [57]. Older workers with low self-efficacy following illness or injury may express negative attitudes toward capacity to return to work and may fear failure or re-injury upon reintegration into the workplace [58]. These fears may impact the older worker’s motivation to participate in rehabilitation and his or her level of engagement during therapy, unnecessarily-extending time away from work [58].
Occupational therapy practitioners are uniquely equipped to integrate consideration of these factors into rehabilitation interventions focused on return-to-work. Various occupational therapy assessments, such as the Worker Role Interview, can help the practitioner identify and address worker-specific psychosocial factors acting as barriers to return-to-work [57]. For some clients, occupational therapy practitioners may draw on motivational interviewing skills to facilitate a change in behavior or confidence level. Alternatively, practitioners may capitalize on a client’s volition to encourage an out-of-work worker to return to the workplace. Occupational therapy practitioners are uniquely trained to both collaborate with employers to get workers back to work and to develop interventions for improving productive work behaviors, social skills, and individual plans for productive participation [15]. Occupational therapy practitioners may also facilitate groups of older workers with experience engaging in similar work occupations in order to discuss strategies to plan for return-to-work or retirement transitions [11].
Perhaps the most influential psychosocial factor influencing return-to-work is the supervisory relationship. Surveys of workers’ attitudes toward their jobs indicate the primary reason, other than health, for not wanting to return to work is the relationship with the supervisor [39]. Older workers may feel unsupported by their supervisors, or assume supervisors will not be open to discussing accommodations following illness or injury [45]. Relationships between supervisors and workers may impact the worker’s quality of work life, leading to psychological challenges outside of the workplace and disruptions in the performance of major roles [17, 39]. Occupational therapy practitioners can help hesitant workers adjust to work as well as manage supervisor relationships by facilitating conversations on potential task modifications and educating supervisors on the importance of tailored accommodations for older workers in order to maintain job productivity and longevity [59].
Quality of work-life
Occupational therapy interventions emphasize engagement in meaningful activities to promote quality of work-life. Meaningful activity includes gainful employment, which can provide for individuals’ personal, social, and financial needs, merely by participating in worker roles, all of which contribute to overall quality of life [17]. Thus, employees, employers, and occupational therapy practitioners must collaborate effectively, quickly, and safely to reach this goal [17].
Improved quality of life results from a dynamic fit between physical, mental, and social well-being [60]. Occupational therapy practitioners evaluate a worker’s overall functioning in a worker role by performing general and specific work-related assessments. The former assesses an individual’s workplace readiness by evaluating his or her current abilities and capacities in all settings, whereas a specific vocational evaluation assesses the individual’s suitability for a specific work role [59]. The occupational therapy practitioner, in concert with doctors, employers, and employees, may aid older workers by conducting general or specific evaluations to optimize the quality of work life.
Conclusion
Occupational therapy offers distinct value in facilitating meaningful engagement and participation of the older worker in the workplace. There are a number of key areas of intervention, both inside and outside of the workplace, where occupational therapy practitioners can ease complications for older workers, promote engagement in the worker role, and preserve overall quality of life for the elderly. By expanding preventive efforts targeted at older workers before challenges lead to departure from the workplace, occupational therapy practitioners can enable older workers to maintain desired participation levels as long as possible, facilitating successful aging. Occupational therapy practitioners are well-equipped for involvement in return-to-work programs due to their consideration of workers’ health and personal characteristics including social, cognitive, and physical skills, as well as the interests and values of the worker, and the broader mission of the organization as a whole [42, 61].
However, challenges to occupational therapy practitioners’ participation in older worker health programs remain. A 2008 study of occupational therapy practitioners indicated only weak programmatic and institutional resources are available to address the needs of older workers, even though there are ample opportunities for occupational therapy practice to expand to serve the older worker [16]. Further research is needed within the profession of occupational therapy to substantiate the cost-effectiveness of workplace occupational therapy interventions, and to demonstrate the need for occupational therapy involvement in promoting engagement with meaningful work occupations to benefit the health and longevity of the older worker. Additional studies can help to determine appropriate consultative occupational therapy services to focus on preventing workplace injury. Of importance, occupational therapy practitioners should accept the challenge to advocate for their profession.
Author information
Amy Early and Ryan Walsh were graduate students in the Department of Occupational Therapy at the University of Illinois at Chicago at the time of drafting and initial submission. Bruce Douglas is Professor of Health and Aging at the UIC School of Public Health.
Conflict of interest
None to report.
Footnotes
Acknowledgments
The authors would like to acknowledge Heena Jafri, a former graduate student in the University of Illinois at Chicago’s School of Public Health for her contributions to the initial development of this article. In addition, the authors acknowledge Professor Gail S. Fisher of the University of Illinois at Chicago’s Department of Occupational Therapy for her constructive feedback throughout the development of the article.