Role of the occupational therapist on the team caring for the older person, on the ward and at discharge

Occupational therapy (OT) views humans as “occupational beings” — who we are is defined by what we do. Occupations are the ordinary and extraordinary things people do daily that occupy time, ensure survival, maintain well-being, nurture others, contribute to society and carry cultural meaning.

The core aim of OT in old age is to enable the elder to keep doing the activities that are personally meaningful to them, thereby preserving quality of life — not merely to restore muscle power.

In ICF terms, the doctor works on impairment while the OT works on the Activity and Participation boxes — OT converts a treated disease into a life that can actually be lived.

The guiding model is PEOP (Person–Environment–Occupation–Performance/ Participation), complementary to the WHO ICF: Elder quality of life = f (Personal attributes × Environmental factors × Occupational performance/participation)

Person (intrinsic): physiological, motor, cognitive, neurobehavioural, psychological and spiritual capacity; plus motivation, roles, habits and routines.

Environment (extrinsic): social support, economic systems, culture and values, technology, the built environment and the natural environment.

OT services span the whole continuum: primary (health promotion, home-safety and fall prevention, driver screening), secondary (arthritis, stroke, dementia), tertiary (rehabilitation, long-term care, palliative and hospice care). Delivered at three levels: to individuals and families, as consultation to community organisations, and as consultation to government agencies.

The process: patient identification → occupational profile → occupational performance assessment → identification of needs, problems and priorities → collaborative goal setting → occupation-based intervention → ongoing assessment and refinement → outcomes met → final/discharge assessment. The Occupational Therapy Practice Framework (OTPF) is the guiding protocol.

The occupational profile is the first and most distinctive step. It records the person’s occupational history, current patterns of daily living, interests, values and needs, then their own priorities and concerns. The approach is top-down and client-centred — the elder names the activities that matter, and the plan is built backwards from them.

Occupational performance assessment uses valid, standardised instruments, but crucially the therapist observes the actual performance of the selected activity — skilled observation covering affect, cognitive/executive function and motor function together. Assessment is ideally done in the person’s own environment, since performance in an unfamiliar setting can be quite different.

The third focus is identifying barriers — biological, psychological and social — between the older person and their desired activities.

Baseline and premorbid functional assessment. Establish competence in basic ADLs (feeding, dressing, bathing, grooming, toileting, transfers) and IADLs (cooking, cleaning, shopping, telephone, laundry, medication and money management, transport), comparing premorbid with current status.

Core ward objectives (Kane): restore, maintain and improve independent function; evaluate and improve sensory and perceptual-motor function; evaluate and improve ADL performance; fabricate and fit upper-limb splints; improve coping and problem-solving skills; improve use of leisure time.

Ward modalities: assessment of bed mobility, transfers and wheelchair propulsion; ADL practice in actual or simulated environments (a mock kitchen or bathroom on the ward); task-oriented activities such as crafts and projects; and teaching the use of assistive and safety devices.

Prescribing and training in aids is the OT’s specific expertise. Common items: long-handled reacher, sock aid, built-up cutlery and cooking utensils, dressing stick, raised toilet seat with rails, shower chair/tall stool, handheld shower, grab bars and rails. Devices are recommended only if they improve participation in an activity the elder or family has identified as important. A wrongly chosen aid fosters dependence rather than independence — yet many with real need never obtain even basic aids.

Disease-specific ward work: reinforcing hip precautions after arthroplasty; upper-limb positioning and splinting in hemiplegia to prevent contracture and subluxation; task simplification, sequencing cues and environmental orientation in dementia; energy conservation and joint protection in arthritis, COPD and heart failure; transfer devices (trapeze, transfer pole, raised quarter-length siderail) and bed/toilet height matched to lower-leg length as part of restraint reduction.

Education and secondary prevention: body mechanics, joint protection, energy conservation, activity and exercise guidance, sleep hygiene; psychosocially — role adjustment, balanced purposeful activity, time management, mastery and self-esteem, and socialisation skills.

Team role: the OT feeds directly into the interdisciplinary team conference, translating medical impairment into functional terms. The OT’s functional verdict frequently decides the discharge destination.

The pre-discharge home visit is the OT’s signature intervention. Early OT input, usually including a home visit, ensures that modifications are appropriate and timed to facilitate hospital discharge — done late, it becomes a cause of delayed discharge rather than a solution.

Home environmental assessment and modification: improved lighting in halls and stairways, grab bars in the bathroom, removal of loose rugs and clutter, ramps and railings, non-slip surfaces, covers on electrical sockets and locks on cupboards where cognition is impaired. Interventions that assess and modify home safety features reduce falls, and are more effective when carried out specifically by an occupational therapist.

Practical discharge preparation: review all ADL and IADL implications immediately before discharge; arrange equipment to be in place before the patient goes home; advise on furniture height for sitting, rising, eating and leisure (including chair-leg extensions); train the family carer; and arrange a separate community OT visit after discharge for tasks assessable only at home, such as kitchen work.

Post-discharge and community role: graded return to IADLs and valued roles, carer education and coping support, adaptation of technology (smartphone, appliances, voice-activation software), driving assessment (OT and neuropsychology form the second tier, after clinical assessment and before on-road testing), and helping the person come to terms with driving cessation by focusing on preserved areas of achievement while the social worker arranges alternative transport.

Discharge from OT itself is a defined step. Services are discontinued when targeted outcomes are met, or when the elder cannot achieve them despite refinement of the plan. A final assessment is performed, and outcome data are used to plan future therapy, discontinue services and evaluate the service programme.

The commonest cause of failed OT discharge planning is well-meaning over-help. If caregivers bathe and dress a patient who has independence goals, those goals will not be achieved — “helping” produces deconditioning, dependency, contractures and the sequelae of immobility. A restorative philosophy of care must continue at home.

Fundamental principle: OT supports the older person’s autonomy in setting priorities and making decisions, and preserves their mastery and control over their own environment and lifestyle.

Home hazard reduction — high-certainty evidence and OT’s strongest card The 2023 Cochrane review (Clemson et al., CD013258) included 22 studies from 10 countries with 8463 community-dwelling older people (mean age 78, 65% women). Home fall-hazard interventions reduce the overall rate of falls by 26% (RaR 0.74, 95% CI 0.61–0.91; 12 studies, 5293 participants; moderate-certainty evidence), and are substantially more effective in people selected for higher fall risk, with a 38% reduction (RaR 0.62, 95% CI 0.56–0.70). In contrast, assistive devices alone (eyeglasses, specialised footwear, bed alarms) and education alone do not reduce falls.

NICE NG249 (April 2025) — the OT is named in guideline text NICE recommends offering a home hazard assessment and intervention using a validated tool, and states: “consider having the home hazard assessment and intervention… carried out by an occupational therapist.” If not an OT, it may be done by an appropriately trained healthcare professional, or a trained therapy assistant or technician under supervision. The rationale is explicit: greater clinical benefit was seen when the intervention was delivered by an occupational therapist, and health economic modelling found OT delivery both less costly and more effective than delivery by an assistant or technician. Benefit was greatest in people who had fallen at least once in the previous year. NG249 also advises against standalone falls risk-prediction tools.

Real-world implementation, ED extension and early supported discharge A pilot implementation study of OT-led environmental assessment and modification in a regional Australian health service (2019–2022; 279 chart audits of people ≥65 at high fall risk) found 71% had sustained ≥1 fall and 52% ≥2 falls in the preceding year; the intervention was delivered per protocol, embedded and sustained, with OT precision in selecting recipients improving over time; a national implementation study began in 2025. A Geriatric ED Guidelines 2.0 systematic review (Academic Emergency Medicine, 2025) appraised PT/OT evaluations introduced into ED care for fall-risk evaluation and prevention — promising but not yet definitive. A 2024 BMC Geriatrics systematic review and meta-analysis examined early supported discharge after orthopaedic surgery, where OT is the pivotal discipline.

Policy and Indian context WHA76.6 (May 2023) calls for expanding and integrating rehabilitation into health systems within Universal Health Coverage, with emphasis on primary care; the World Federation of Occupational Therapists (WFOT), with ReLAB-HS, has issued guidance translating the resolution into advocacy for inclusion of occupational therapy services within UHC. In India, Rashtriya Vayoshri Yojana provides free assisted-living devices to BPL senior citizens (monthly income ≤ ₹15,000) with doorstep delivery for those aged ≥80, ALIMCO as sole implementing agency; at least 30% of beneficiaries in each district must be women. The OT must prescribe within what RVY, ALIMCO and the family can actually obtain, and must train the family attendant, since one-to-one community OT follow-up is rarely available.

OT enables occupation; physiotherapy restores movement. OT owns the Activity and Participation domains of the ICF.

PEOP model: Person–Environment–Occupation–Performance/Participation; complementary to the WHO ICF.

Occupational profile = the client-centred, top-down first step.

Assess by observation, and assess at home — performance in an unfamiliar environment differs.

OT ward objectives: independent function, sensory-perceptual motor function, ADLs, upper-limb splinting, coping/problem-solving, leisure.

Classic OT aids: long-handled reacher, sock aid, built-up cutlery, dressing stick, raised toilet seat with rails, shower chair, grab bars.

A wrongly prescribed aid fosters dependence, not independence.

The pre-discharge home visit must be early, or it becomes a cause of delayed discharge.

Home fall-hazard reduction: 26% fewer falls overall, 38% fewer in high-risk older people (Cochrane 2023).

NICE NG249 (2025): offer home hazard assessment with a validated tool; consider having an OT do it — cheaper and more effective.

Devices alone and education alone do not prevent falls.

OT is the second tier of driving assessment, between clinical evaluation and the on-road test.

Over-helping at home undoes rehabilitation — deconditioning, dependency, contractures.

OT discharge criteria: goals met, or goals unachievable despite refinement — then final assessment and discontinuation.

India: Rashtriya Vayoshri Yojana supplies free assistive devices to BPL elders through ALIMCO.