Dementia diseases, such as Alzheimer’s disease (AD), have a large impact on the everyday life of persons affected, their spouses, and the staff involved in their daily living (Borell, 1992). For example, the cognitive dysfunctions resulting from dementia diseases interfere largely with the performance of most activities of daily living (ADL) (Bäckman, 1992). Consequently, an urgent need exists to develop programs supporting everyday occupation for persons with dementia. Occupational therapy can help persons with a dementia disease to regain and retain meaningful life skills (Rogers, 1986). Yet few such programs are documented; and few attempts have been made to evaluate the effects of such programs on the performance of ADL among individuals exhibiting dementia. Furthermore, it is unclear what the focus of such programs should be. Should the intervention seek to improve the cognitive constituents underlying performance of ADL (e.g., memory), or should it focus on environmental and social conditions supporting task performance (Fisher, 1992)?
Several attempts have been made to enhance cognitive functions, like memory, in persons with dementia diseases (Bäckman, 1990). However, training-related gains have been small or nonexistent following these interventions (e.g., Bäckman, Josephsson, Herlitz, Stigsdotter, & Viitanen, 1991; Beck et al, 1985; Zarit, Zarit, & Reever, 1982). It is conceivable that the lack of effects of these techniques in training persons with dementia diseases is due to the reliance on effortful strategies and associative skills (e.g., imagery, organization) that are severely impaired in dementia (Bäckman et al., 1991; Josephsson et al., 1993).
Thus, persons with dementia may lack the requisite cognitive skills for making effective use of this type of training. Other functions relevant to ADL performance, like motor functioning and procedural memory, are less affected in dementia diseases (Dick, Kean, & Sands, 1988). Procedural memory has been defined as the presence of previous experience that alters or facilitates an individual’s performance in a task (Dick, 1992). In contrast to the retrieval of temporally- and spatially-bound information, procedural memory does not seem to require conscious recollection of information. An alternative to training functions that are severely affected by the dementia disease may be to arrange the task conditions so that the use of these relatively well preserved functions is facilitated.
Furthermore, in performance of ADL, factors other than functional abilities are likely to influence the outcome. The Model of Human Occupation (MOHO), introduced by Kielhofner (1985), identifies three subsystems critical to occupation on the individual level. First, the volition system is responsible for decisions to engage or not engage in occupation. Second, the habituation system maintains patterns of behavior through roles and habits. Third, the performance system is responsible for the production of behavior. To be sure, multiple interactions occur among these systems together with the environment (e.g., culture, social system, tasks, objects) in which occupations take place. Given the multifaceted nature of occupation, it is perhaps not surprising that it has been difficult to establish an overall relationship between individual level of cognitive skill and ADL performance (Fisher, 1992).
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