Definition/Introduction

Occupational therapy is a service provided in long-term care (LTC) facilities to promote quality of life through participation in meaningful occupations. Occupational therapy practitioners are skilled in physical and psychological evaluation of residents living in LTC. The psychological wellbeing of residents in LTC facilities is a primary concern; 49% of the residents have a diagnosis of depression.[1] This aspect of occupational therapy rehabilitation service in LTC is often overlooked; therefore, occupational therapy practitioners need to include psychological assessments in their overall evaluation of residents to create interventions that facilitate participation in meaningful occupations.

Issues of Concern

Participation and Psychological Well-being

Lack of participation in meaningful occupations, called occupational deprivation, leads to depression among LTC residents, which compromises overall psychological well-being.[2] The risk for occupational deprivation increases in LTC because many residents experience age- and illness-related decline in capabilities. Helping residents to compensate for age-related changes promotes occupational justice, which is a term used to describe humans' right to engage in valued occupations.[3] This engagement promotes health, well-being, and quality of life. Leisure participation, a specific occupational engagement, enhances motivation and physical and psychological abilities.[4] It is, therefore, essential to include leisure in the overall assessment of participation in meaningful activities.

Cognition Ability and Psychological Well-being

Researchers associated poor quality of life and psychological well-being with impaired cognitive abilities.[5] Other researchers found a clear association between cognitive decline and lower well-being on almost all measures (five out of six).[6] It is, therefore, essential to assess cognition as a component of psychological well-being.

Emotional Health and Psychological Well-being

With depression rates escalating after admission to LTC facilities, it becomes even more critical to assess the emotional well-being of residents.  Emotional well-being affects motivation to engage in once meaningful activities; depression may appear as a lack of interest, loneliness, and a decline in cognitive capabilities, which further compromises overall well-being.[7] 

Psychological Assessment

Psychological well-being encompasses participation in meaningful occupations, cognitive ability, and emotional health. Occupational therapy practitioners are proficient in the performance of evaluations for psychological well-being in residents living in LTC.  Comprehensive assessments for psychological well-being should target participation in meaningful activities (including leisure), cognitive abilities, and emotional well-being.  Because there are limited guides for the psychological evaluation available for occupational therapy practitioners in LTC, I list evidence-based assessment resources below.  Due to productivity demands in LTC settings, practitioners can complete most of these selected assessments within a reasonable amount of time.

Assessments of Occupational Participation

• Activity Card Sort [8]: Assessment of participation in meaningful occupations; 30-45 min
• Canadian Occupational Performance Measure (Law, Baptiste, Carswell, McColl, Polatajko, Pollock, & Opzoomer, 1990)[9]: Identify and prioritize occupations and assess occupational performance; 30 to 45 minutes
• Barthel Index[10]:  Standardized assessment of ADL performance on a numerical scale; 15 minutes
• Functional Independence Measure [11]:  Frequently used observation tool to assess the performance level of ability; 15 minutes

Assessments of Cognitive Health

• Montreal Cognitive Assessment [MoCA][12]: Screening for mild cognitive dysfunction; 10 minutes
• Short Blessed Test (Katzman, Brown, Fuld, Peck, Schechter, & Herbert Schimmel, 1983)[13]: Screening for mild cognitive dysfunction; 10-20 minutes
• Global Deterioration Scale [14]: Screening that summarizes cognitive function to caregivers; Time Varies
• Louis University Mental Status (SLUMS) exam[15]: Screening for detecting mild cognitive impairment and dementia; 15 minutes
• Mini Kingston Standardized Cognitive Assessment Revised [16]: Screening for cognitive dysfunction. The bridge between cognitive screens and evaluations; 30 minutes
• Ross Information Processing Assessment-Geriatric:2 [RIPA-G:2][17]: Assessment of memory, spatial orientation, recall of general information, temporal orientation, organization, problem-solving, and abstract reasoning; 45 to 60 minutes

Assessments of Emotional Well-being

• Geriatric Depression Scale[18][19]: Screening to rate the level of depression; 5 to 7 minutes
• Beck Depression Inventory-II [20]: Simple assessment to quantify depressive symptoms; 15 minutes
• Cornell Scale of Depression in Dementia [21]: 19-item interview; 15 minutes

Clinical Significance

Psychological assessments for residents living in LTC should examine residents’ participation in meaningful activities, cognitive abilities, and emotional well-being because of the interconnectedness between each of them as they impact health, well-being, and quality of life.  Occupational therapy practitioners should incorporate these assessments into the traditional rehabilitation evaluations they already conduct. 

Occupational therapy practitioners should use psychological assessment results further to promote participation in meaningful activities, especially leisure-type, because of the strong correlations with health, well-being, and quality of life.[4] The use of leisure participation as an intervention, or therapeutic activity, which is a Medicare current procedural terminology billing code, is invaluable to the therapy process.  Leisure-type interventions promote motivation and enjoyment in the therapeutic process. They are also highly gradable and adaptable, such as doing the activity in standing, increasing speed, raising the work surface, adding wrist weights to the resident.  Leisure-type interventions are also more therapeutic than rote exercise because they offer the ability to recruit multiple body systems and skills, such as proprioception, vestibular, vision, cognition, emotion, muscle tone, range-of-motion, endurance, motor planning, and gross and fine motor coordination.

Practitioners can also integrate leisure activities into functional maintenance programs (FMP) with restorative aide staff or activity personnel who continue helping the residents to do the leisure-type interventions/therapeutic activities after practitioners discontinue occupational therapy services. Traditionally, the FMPs have been rote exercised-based; however, leisure-based FMPs will offer superior outcomes because these types of activities are often more meaningful and engaging to the residents, which prompts residents to exert more effort in the therapeutic process.

An occupational therapy practitioner can also share psychological assessment results with the LTC team to guide care planning.  Medical doctors can then use results for the Annual Wellness Visit (a Medicare benefit under the Patient Protection and Affordable Care Act) to address medical areas of concern and make referrals to other healthcare team members further to promote health, well-being, and quality of life.

Psychological assessments should include an analysis of participation in meaningful occupations, cognitive health, and emotional well-being.  Results are useful to enhance participation, health, well-being, and quality of life among residents in LTC facilities.