Occupational therapy for older adults: investments for progress.
Article Type: Report
Subject: Self-help devices for the disabled (Usage)
Aged patients (Care and treatment)
Occupational therapy (Management)
Author: Borell, Lena
Pub Date: 11/01/2008
Publication: Name: British Journal of Occupational Therapy Publisher: College of Occupational Therapists Ltd. Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2008 College of Occupational Therapists Ltd. ISSN: 0308-0226
Issue: Date: Nov, 2008 Source Volume: 71 Source Issue: 11
Topic: Event Code: 200 Management dynamics Computer Subject: Handicapped access device; Company business management
Geographic: Geographic Code: 4E Europe
Accession Number: 189653986
Full Text: A keynote address given at the Council of Occupational Therapists for the European Countries' (COTEC's) 8th European Congress of Occupational Therapy, Hamburg, 22-25 May 2008, hosted by the Deutscher Verband der Ergotherapeuten e.V. (German Association of Occupational Therapists).

Key words: Ageing in place, assistive technology, older people.

Introduction

The number of people aged 65 years and over in Europe will be around 25% in 2030 (AGE--European Older People's Platform 2007). There are several reasons behind this increase in numbers of older adults. One reason is that people live longer because they live healthier lives; another reason is that it is now possible to treat previously incurable medical conditions. Perhaps as a result of this increase in numbers, we will see many more older adults participating in society; for example, working until a very old age or travelling the globe as grey backpackers. The question of this keynote address is: what can occupational therapy contribute to a society with a large population of older people?

We know that this increase in numbers of older adults in Europe will mean that it will be more common to have people with impaired hearing, with low vision and with less muscle strength, as well as people with cognitive problems, since these are problems that increase with old age. A population of people who live longer and longer also means more people with participation restrictions.

An implication of the increase in numbers of older people is that Europe will have to make society more accessible (Iwarsson and Stahl 2003). Making daily living for older adults easier will need to be high on the European agenda. This also suggests that new services will need to be developed in local communities. Overall, Europe will be required to become more inclusive to all people when the population includes more older adults. This could mean that ideas about 'design for all' and inclusive design (Clarkson et al 2003) will become more accepted and lead the way for new developments in Europe.

It is a huge challenge for European countries to handle the increase in numbers of older people and the most urgent need for our societies is to identify good ideas to make them stay healthy for as long as possible. Governments, the European market, health care providers and agencies and local communities want to learn how to enable older people to continue to engage in and participate in society. In response to this, occupational therapy can argue that we have ideas for new programmes and new evidence-based services to do this.

Our proposal to Europe is to learn from occupational therapy. Occupational therapy offers some useful concepts and good ideas, which can serve as driving forces to make Europe more inclusive and enhance the participation of older adults. In fact, occupational therapy could have a key role in future developments for older people, since we have the ideas, the visions and the knowledge that the European countries are now requesting.

The good ideas

One of the good ideas, which is also a cornerstone of occupational therapy, is: occupations can contribute to people's health and wellbeing (Kielhofner 2004, Wilcock 2006, Christiansen and Townsend 2009). This is a fundamental idea of our profession and a reason why occupational therapy is being recognised as having an essential role in health care provision.

The question that we need to ask ourselves is: what does this idea mean today for older people in Europe? It means that we believe that if we support and enable older adults to engage in occupations, especially people with activity limitations and participation restrictions, they will also stay healthy for a longer time. Wilcock and Townsend (2009) note that older adults should not be deprived of doing the everyday tasks that they have always been doing just because they are old. Older people should not be left:

What I believe that we can offer from occupational therapy is ideas about:

* New occupationally based services in the community to support older adults

* New approaches and new programmes in occupational therapy.

Perhaps occupational therapy also needs to initiate preventive self-help programmes, organised by older people themselves.

I would like to share some examples of what occupational therapy can contribute. The first example is a community intervention of a project related to the prevention of falls. This demonstrates how occupational therapy can contribute to society to develop services.

Falls prevention: a community intervention

For white Caucasian women over 80 years of age, almost 50% face the risk of falling and a fracture (Gillespie et al 2003). In some parts of the world, a hip fracture means death, while in other places it means restrictions in daily living. From an occupational therapy perspective, it is not only a bone that is fractured but also life itself, because it is difficult to manage everyday occupations after a hip fracture (Peterson and Clemson 2008). The good news is that occupational therapists know that people themselves can do much to prevent falls, as long as they have access to the knowledge on how to do this.

The project fallfritt (www.fallfritt.se), which emerged from the Karolinska Institutet, is best described as a 'community intervention'. The project started with a campaign to recruit people outside the health care system to become 'falls prevention activists'. We recruited, for example, opticians, pharmacists, podiatrists, caretakers of buildings, and assistants in shoe shops. These people all provided services to older adults at risk of falling before they fell, in contrast to health care personnel who meet older people after they have fallen.

The activists who were recruited were then educated by occupational therapists about how to prevent falls. The underlying idea was that the activists, through their normal jobs, would be able to make suggestions for prevention for people at risk; for example, older people with impaired vision or poor balance or just people with poor shoes. In addition, the activists would also become more knowledgeable about what occupational therapists can do for people at risk of falling and suggest that they contact an occupational therapist.

Apart from initiating the campaign, the contribution of occupational therapy was to provide research-based knowledge and information about what can be done and what people can do themselves to reduce the risk of falling. This was achieved through lectures, workshops and club meetings. This project, which is now being evaluated, is an example of how occupational therapy can be a part of, and create, new services to the local community by contributing research-based knowledge.

The key to the development of new programmes in occupational therapy and new services in the local community is research. More research is an urgent investment for occupational therapy in Europe. Doing research or not doing research could be the difference between the profession having an impact or not. In order to initiate the right kind of research projects that will support older people, we should ask older people about their expectations and needs. In research, we need to ask the same questions as we do in our practice: what do you want to do and what do you need to do? What do you dream about for the future?

Doing-with assistants

From an interview study with older women, we learnt that one wish for the future from women living in an urban Swedish environment was for them to receive assistance from people that came to their home to accompany them in different activities. This was not as traditional home helps do, but in a new and different way. So these assistants would not be doing things for them, but doing things with them: a kind of 'doing-with assistant', compared with the more traditional home help.

It was not very sophisticated things that these women mentioned in the interviews; it was just ordinary daily activities. For example, the assistants should help with shopping for food or doing the laundry. The assistant should make activities easier to perform and the older person would still make all the important decisions.

Doing-with assistants should be educated and trained to be supportive to older adults in daily living, without taking over the activities and without depriving older people from engaging in occupations. The idea about doing-with assistants is strongly related to the principles of occupational therapy. By making it easy for people to be engaged in occupations as long as possible, they will stay healthier for a longer time. Coaching doing-with assistants could also be a part of an occupational therapy programme to be developed in the future. This relates to the importance of being client-centred and including the family in our interventions. We will probably soon develop educational programmes or groups where relatives, families, spouses and perhaps groups of volunteers will come to be trained and educated to become the new doing-with assistants. However, there are also other options: what if this doing-with assistant could be a robot?

Robots

A robot is not a very expensive assistant and could serve as a doing-with assistant to carry home the shopping, to reach objects, to carry the laundry or to do the vacuum cleaning. Perhaps a robot could be shared, for example with neighbours. It could become a reason to meet and talk to other people for those without a family or friends nearby.

Most older adults in the west would say: 'No, I do not want a robot in my house.' This may be because what we fear most is that our parents, ourselves and the people that we love and care about will end up lonely, without anyone caring for them but a soulless robot. Nobody looks forward to that kind of future.

It is interesting, nevertheless, to learn how technology can evoke many types of feelings. Robots in the west may be seen as a threat, something that is almost evil. However, robots, or any kind of technology, are not evil or good in themselves. Robots are more accepted in parts of Asia than they are in Europe and they are especially popular in Japan. Technology is in itself neutral. It is the use that human beings make of it that provides it with meaning. That meaning is also influenced by culture (Asaba et al 2009) and becomes evident when we compare cultures. If we take a deeper look at the issue, we would find that this also has to do with cultural beliefs, values and ideas. Japanese companies are developing robots designed for care and housekeeping, and my guess is that it is also going to be possible to get caring robots in Europe soon.

One reason for discussing robots is that I think that occupational therapists should participate much more in the design and development of new technology. The great advantage that we have as occupational therapists is that we can observe and evaluate technology in occupations, in daily living and in real life. We should do more critical reviews of new technology based on our practice, since technology will be extremely important in the care of the older adults in the future. Studies by European occupational therapists have also shown how the importance of technology increases with age, so the older you get the more likely it becomes that you will need technology to assist you (Lofqvist et al 2005).

In the future, I think occupational therapists should become experts on the use of technology for older people. In addition, we should do more: not just to evaluate the use of technology but also to invest in new inclusive designs and assistive technology, together with experts from other disciplines. A great example of an investment for the future based on research is the development of new assessments and different types of measure for occupational therapy. So, next I will outline some research on a new assessment in progress.

Everyday Technology Use Questionnaire

The Everyday Technology Use Questionnaire is being developed by my colleague and PhD student, Louise Nygard (Rosenberg et al, in press). In developing this assessment, the team asked older people with and without cognitive problems what kind of technology they used in daily living. Based on this inquiry, it was possible to say something about their competence to use ordinary everyday technology.

The increase in numbers of older people in Europe also means an increase in numbers of people with Alzheimer's disease and other kinds of dementia, because the incidence of dementia increases with age. Enabling people with dementia to stay at home and live independently will be a very difficult challenge for families and communities and for the welfare systems in Europe.

Occupational therapy in Europe needs to suggest how to provide better support for older adults with dementia. Some of these ideas might relate to the information technology behind 'Smart Homes' and supportive home environments, which has the potential to provide support to people with dementia. This technology can, for example, remind people with dementia when it is time to eat, take medication or watch their favourite television programme.

The implications are that people who make use of this type of technology might feel more safe and secure and might also be more included and part of the community. Even if there is potential in technology, we also need to see beyond that and think about what occupational therapy can do in terms of empowering older people to engage in occupation. One example of research that has the potential to do that is Occupational GAPS.

Occupational GAPS

My colleagues at the Karolinska Institutet, Gunilla Eriksson and Kerstin Tham, have, through some interesting studies, identified what they named Occupational GAPS (Eriksson et al 2006). An occupational gap is defined as the gap that occurs between what a person wants and needs to do and what he or she actually does in domestic activities, leisure and social life, as well as in work. This is also close to what Clark and her team identified in the Well Elderly Study (Hay et al 2002).

In a recently published study, the researchers from the Karolinska Institutet were able to identify a strong association between the extent of occupational gaps and life satisfaction among people who had acquired a brain injury 1-4 years earlier (Eriksson et al 2006).

First, this indicates that our ideas and beliefs are accurate: occupations can influence health and wellbeing. Secondly, it tells us to base practice on research like this: if occupational therapy can fill the gaps, occupations can change people's lives. Then occupational therapists need to include the ideas about occupations in therapy. Both in practice and in research, we ask questions that do not have a simple answer. The questions occupational therapists ask and the aspects that we want to learn more about are different from those that physicians, doctors, nurses, physiotherapists or social workers ask. Occupational therapists want to know how occupations influence people's health and wellbeing. The occupational perspective makes us ask people: what do you enjoy doing? How do you spend your time every day? What is important for you to do? What activities are most rewarding and valuable for you? We ask questions that the other health professions do not ask!

Through our unique perspective, we see the world differently from other disciplines and we add something new to the full picture. When we apply an occupational perspective (Kielhofner 2004, Wilcock 2006, Christiansen and Townsend 2009) and implement the ideas about how occupation can influence health and wellbeing in our research, we suggest new, interesting and innovative results. We can open new avenues to people's lives when we ask these questions. Here is a preliminary definition of what an occupational perspective can be in research:

Why do I speak about this? I want to stress that the research we do in occupational therapy has the same focus as the profession has and that the ideas, values and beliefs that underpin the profession and make the profession's contribution to the society unique are the same ideas, beliefs and values that also make occupational therapy research unique.

I will provide more examples of research that applies the occupational perspective in research. One of our PhD students at the Karolinska Institutet, Lisa Ekstam, was able to show, through an occupational perspective in research, how the spouses of people who have had a stroke experience the same kind of loss of occupations as the person with the stroke. It became clear that the relationship between the couple was filled with dilemmas related to occupations. This study informs practice about the need to include spouses in occupational therapy, to pay attention to patterns of occupation in both partners and to tailor the occupational therapy programme based on this.

In another study, La Cour et al (2005) suggested that occupations in terms of doing a creative activity can enable the creation of connections to daily life and enlarge the experience of self as an active person, even in the face of an uncertain life-threatening illness. It was possible to identify this knowledge through an occupational perspective. Andersson-Sviden et al (in press) identified the meaning of occupations to older persons who visited a social day-care facility. The older adults enjoyed various occupations to the extent that it did not matter if they became tired or even experienced pain after engaging in occupations at the centre. The participants valued the doing so much that they could choose to manage with pain after engaging in occupations.

All these examples are qualitative studies with an occupational perspective. The benefits of doing qualitative studies are that they deepen our understanding of the context for daily living for our clients (Borell et al 2006), which also helps us to identify, as occupational therapists, what older people need. This is also why we need studies that can inform us about people's experiences, since there are always situations that we need to understand beyond the obvious. These studies also include a grounded view in philosophy on, for example, understanding or meaning (Ricoeur 1984, 1985, 1988), and they often build on interpretations. I think that it is time for us to take the philosophers out of the closet and make them speak to us and support our ambition to be rigorous and to be grounded in philosophy.

Why are occupational therapists in Europe so interested in conducting qualitative studies?

One immediate answer would be that it is because occupational therapists ask clients the kinds of question that require information of a qualitative nature as opposed to studies that only apply statistics as a method. Qualitative studies are interested in how older people experience technology, daily life or living with a disability. We give voice to the clients in studies where they are treated like participants instead of anonymous objects. This relates to the humanistic beliefs of our profession.

Occupational therapists want to understand the things that we do not understand and to find answers to the questions that we have in order to develop the best possible support to clients. We are good at finding ways to understand better and ask the right questions in practice. We need to do the same in research. We need to raise our expectations and be more critical in how we design and do the research. Descriptive studies are not enough; we need to progress, become more sophisticated, and conduct qualitative studies that can inform theory building and speak to a wider audience.

There is a need, however, for studies that inform us through numbers and statistics. For the future, we need to walk on two legs. For example, we need to conduct quantitative research that provides evidence in numbers of, for example, the effects and outcomes of occupational therapy programmes for older people. Numbers are powerful tools that we should use. We also need valid and reliable measures, based on an occupational perspective, that will tell us how occupations can contribute to people's health and sense of wellbeing. Future studies, including those with older people, need to be intervention studies where occupational therapy practitioners and researchers create and evaluate occupational therapy programmes and new technology for older adults.

Of special importance will be large-scale studies, conducted on a European level, instead of just in the local community or national studies. There are still few examples of larger studies in occupational therapy. However, Iwarsson and her colleagues from Lund University have initiated studies of this type, the ENABLE-AGE Project (Iwarsson et al 2004). We should all learn from that project.

The shared master's programme in occupational therapy and occupational science is also a promising place for collaborating in research at a European level. Overall, we need to create more collaborative efforts in the future. We need to work to make groups of creative practitioners and researchers come together to share ideas and develop our research in occupational therapy.

Conclusion

Occupational therapists can work together to meet the challenges that Europe is now facing in terms of the huge increase in numbers of older adults. To achieve this, occupational therapists need to develop innovative and effective programmes and initiate new services in the community. Occupational therapists are well suited to contribute knowledge, since the values, beliefs and ideas that we share, related to how occupations contribute to people's health and wellbeing, could be the ideas that Europe applies to meet the needs of the older adults.

Occupational therapists can be experts on design and usability issues. In relation to technology, occupational therapists should move from being consumers and prescribers to become designers and developers, participating in the design and development of new technology and services.

Research will be a key factor for occupational therapy in Europe in the future. Occupational therapy will become acknowledged as an important part of the European welfare system, especially in the provision of support for older people.

In order to develop new and much needed theory and programmes for the ageing society, occupational therapists need to do much more research. This research should emerge from our unique occupational perspective, in contrast to a medical or social perspective that limits our vision and constrains our thoughts. This occupational perspective focuses on the development of knowledge about how occupations relate to health and wellbeing.

Research in occupational therapy and research in occupational science will both have different methodological approaches, which will need to be refined and developed further. For this reason, we will need to build creative groups of occupational therapy practitioners and researchers, who will work for the shared goals of change and development in Europe and in the rest of the world.

Acknowledgement

Thanks to Christine Craik of the Editorial Board of BJOT for her assistance in preparing the manuscript for publication.

Submitted: 6 July 2008. Accepted: 22 October 2008.

References

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Correspondence to: Professor Lena Borell, Karolinska Institutet, Division of Occupational Therapy, Department of NVS, Alfred Nobels alle 23, s-14183 Huddinge, Sweden. Email: Lena.Borell@ki.se
Sitting alone in nursing homes or other confined settings
   with nothing to do ... (p196).


An occupational perspective in research refers to the study
   of human engagement in occupations in time and place.
   In this way, an occupational perspective seeks to discover
   and describe how participation as well as the experience of
   doing relates to health and wellbeing.
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