■ORIGINAL ARTICLE
Functional Significance of Sit-to-stand by Hip
Abduction with External Rotation Angle
Takaki Kafuku1, 3, Hiromi Fujii2, 3, Yoko Kimura1, 3, Miyuki Fujikura1, 3,
Emiko Fukuda2, 3
1 Department of Occupational Therapy, Tohoku Medical College

2 Department of Occupational Therapy, Yamagata Prefectural University of Health Sciences

3 Area of Occupational Therapy, Graduate School of Health Sciences, Yamagata Prefectural University of Health Sciences

Abstract: The principal aim of this study was to analyze the effects of differences in hip abduction and external rotation
angles on sit-to-stand (STS) movements. Hip abduction and external rotation angles of 0 deg (closed legs parallel to eachother) and 45 deg (open legs) of 27 healthy participants were compared. Analysis parameters were the center of pressure,the ground reaction force, and the activities of fourteen muscles using surface electromyography. The center of pressure
parameter revealed that standing with open legs requires less anterior-posterior displacement during STS movement. The
open leg movement showed that ground reaction force differed slightly for right and left sides. Muscle activity of the erector
spinae and tibialis anterior decreased with the STS movement with open legs. In contrast, muscle activity of the adductor
longus and the biceps femoris increased.
Key words: sit-to-stand movement, center of pressure, the ground reaction forces, electromyogram, hip angle(Asian J Occup Ther 10: 1–8, 2014)

Introduction
Japanese homes typically have a 20 cm step in theentrance hall (Research Institute of Human Engineeringfor Quality Life, 2002, Chapter 7), where people almost
always put on and take off shoes. Most adults can put on
and take off shoes in a standing position, but it is necessary for functionally limited elderly to sit down on the
20 cm step. Few elderly people can rise from a 20 cm
high step without a footstool and handrails. Therefore, thedaily life of such elderly is limited without access to afootstool and handrails. Clinically, the authors fixed thehips of the elderly at an angle of bilateral symmetry. Thenthe sit-to-stand (STS) movement was attempted from thisposition. Results show that, for hip abduction and externalrotation angles of 0 deg (closed legs parallel to each other;closed legs) the elderly were unable to stand up, but they
were able to do so with hip abduction and external rotaReceived: 6 August 2012, Accepted: 26 February 2013
Corresponding to: Hiromi Fujii, Department of Occupational Therapy,
Yamagata Prefectural University of Health Sciences, 260 Kamiyanagi,
Yamagata 990-2212, Japane-mail: hfujii@yachts. ac.jp©2014 Japanese Association of Occupational Therapists

tion angles of 45 deg (open legs). We concluded, therefore, that abduction and external rotation angles of the hip
had positive effects on STS movement from a low step.
Factors affecting STS movement include chair seatheight (Arborelius, Wretenberg & Lindberg, 1992; Janssen, Bussmann & Stam, 2002; Kuo, Tully & Galea, 2010;
Schenkman, Hughes, Samsa & Studenski, 1996; Yamada& Demura, 2004), use of armrests or arms (Alexander,
Schultz & Warwick, 1991; Arborelius et al., 1992; Eriksrud & Bohannon, 2003; Etnyre & Thomas, 2007; Janssen
et al., 2002; Leung & Chang, 2009; Schultz, Alexander &Ashton-Miller, 1992), use of handrails (O’Meara & Smith,
2005; O’Meara & Smith, 2006), foot positioning (Janssen
et al., 2002; Khemlani, Carr & Crosbie, 1999; Lecours,
Nadeau, Gravel & Teixera-Salmela, 2008; Vander Linden, Brunt & McCulloch, 1994), trunk positioning(Schenkman, Berger, Riley, Mann & Hodge, 1990), STS
movement speed (Bieryla, Anderson & Madigan, 2009;
Hanke, Pai & Rogers, 1995; Pai & Rogers, 1990; Vander
Linden et al., 1994), age (Alexander et al., 1991; Lundin,
Grabiner & Jahnigen, 1995; Schultz et al., 1992; Zijlstra,
Bisseling, Schlumbohm & Baldus, 2010), and hip angles(Gotoh, Takada & Suehiro, 2002). Nevertheless, no report
describes kinematic differences in hip abduction and ex-

2Functional Significance of STS by Hip Angle

ternal rotation angles on the STS movement. This study
was intended define basic kinematic differences between
open and closed legs in the STS movement.

Methods
ParticipantsParticipants were 27 healthy volunteers (20 males
and 7 females) ranging in age from 20–41 years (mean22.3; standard deviations: SD 4.5), in weight from 39–100
kg (mean 62.6; SD 2.8), and in height from 152–183 cm(mean 167.3; SD 1.5). All participants indicated that the
open legs position was easier for standing up than that ofclosed legs. No participants had diseases or injuries which
could impair STS movement.
All participants gave their informed consent to theexperimental procedure, which was approved by the Ethics Committee of Yamagata Prefectural University of
Health Sciences, Yamagata, Japan.
Instrumentation and data acquisition
Fig. 1a (1), b (1) shows the start position of the experiment. The stool height was 50% of the length fromthe floor to the caput fibulae for closed legs (17–25 cm).
The distance between the right and left heels was thesame as the distance between the two acromia. Each participant comfortably positioned the neck and trunk. The
STS movement speed was self-selected. Participants were
instructed to fold their arms across their chest to remove
any upper limb influence. The end point of the experiment
was a standing position with complete extension of knee
and hip joints.
The analysis parameters were the center of pressure(COP), the ground reaction forces (GRF), and electromyograms (EMG) of fourteen muscles.
COP and the magnitude of the right and left GRF
were recorded using a sampling frequency of 50 Hz with
two force plates (Kineto Gravicorder G-7100; Anima
Corp, Tokyo). Low pass was filtered with a cutoff frequency of 50 Hz. COP was calibrated after setting the twoforce plates. Participants were positioned with both legs
and the buttocks on each force plate.
STS movement images were recorded from the front
and lateral sides at 30 frames per second using two digital
video cameras (NV-GS300; Panasonic Inc, Osaka).
EMGs of the erector spinae (ES), gluteus maximus(GMA), vastus lateralis (VL), adductor longus (AL), biceps femoris (BF), tibialis anterior (TA), and gastrocnemius (GC) were recorded with one pair of disposablesurface electrodes (L-600C; Nihon Kohden Corp, Tokyo), attached longitudinally 2 cm apart on the central
part of the contracted muscle belly. EMGs were amplified, band pass filtered (10–500 Hz), sampled at 1,000

Hz, and fed into the computer (Teraview; Gigatex Ltd,
Osaki). Then they were integrated (rectified and averaged) using a raw EMG (EMG integration program, Gigatex, Ltd., Osaki).
The movement pictures, the COP, GRF, and EMG
data were recorded using Teraview.

Procedure
Participants performed sufficient practice trials inclosed and open leg positions before the data collection.
Data were collected from three trials under each condition. Participants were given adequate rest between trials
to avoid fatigue.
Finally, according to methods of muscle testing (Hislop & Montgomery, 2002, Chapter 3, 5), we recorded
EMGs of maximum voluntary contraction of the measured muscles.
Data analysis
1. Movement Phases
Using video data STS movements were divided into
three phases according to previous studies (Millington,
Myklebust & Shambes, 1992; Riley, Schenkman, Mann
& Hodge, 1991; Schenkman et al., 1990). During phase1 (flexion-momentum phase), the buttocks left the chairseat (Fig. 1, (2)) as the head began to move horizontally.
Phase 2 began after the buttocks separated from the chairseat and continued until ankle maximum dorsiflexion of
the ankle. Phase 3 was from the ankle maximum dorsiflexion position to the complete standing position.
2. Analysis of COP
Analysis of COP consisted of two points. First, westudied COP at the initiation of movement in the anterior-posterior COP (COP-Y) and the medial-lateral COP(COP-X) direction. Second, we measured the maximum
movement displacement of COP-Y and COP-X in eachphase.
3. Analysis of GRF
The analysis of GRF examined the differences between the absolute values of the right and left load at identical points every 20 ms. Furthermore, we calculated themean difference in each phase.
4. Analysis of EMG
To facilitate intra-individual and inter-individualcomparisons of EMG, a standardization procedure was
performed. For standardization, the contraction level ofthe muscle was indicated by expressing the amplitude of
the integrated EMG as a percentage of that produced by
the maximum contraction (%max). The %max data wereused as reference values in each phase. The analyzed data
were the data in which EMG indicated no artifacts.
The analyzed COP, GRF, and EMG data compared
the open legs with closed legs. Statistical processing used

Asian J Occup Ther 10: 1–8, 2014

Kafuku T et al.

Fig. 1. Results of photographic playback, electromyogram (EMG), and integrated EMG (i-EMG). Vertical dotted lines indicate
start (1), hip lift-off (2), maximal dosiflexion of the ankle joint (3), complete standing position (4). Calibration bar for
EMGs and percentage of the amplitude produced by the maximum voluntary contraction (%max). EMG activities oferector spinae (ES), gluteus maximus (GMA), vastus lateralis (VL), adductor longus (AL), biceps femoris (BF), tibialis
anterior (TA), gastrocnemius (GC) during the STS movement with closed legs (a) and open legs (b). Phase 1 (P1), Phase
2 (P2), Phase 3 (P3). Abbreviations in this as well as Figs. 2–4, and Table 1.

3

4

Functional Significance of STS by Hip Angle

Fig. 2. The comparison of the maximum movement displacement during STS movement with anterior-posterior (a) and medial-lateral (b).

Fig. 3. The comparison of ground reaction forces.

student’s t tests, and a significance level of 0.05 was selected.

Results
COP study
The means and SD of COP-Y position at the startof movement with closed and open legs were –14.48 ±5.80 cm and –11.24 ± 5.64 cm, respectively. The COP-Y
point at the start of movement with open legs was located significantly forward of the starting position (p<.01).
COP-X position at the start of movement showed no statistically significant differences between closed and open
legs.
The comparison of the maximum movement displacement of COP-Y in each phase is shown in Fig. 2a.
In open legs, the maximum movement displacement of
COP-Y was significantly less smaller than that of closed
legs in phase 3 (p<.01). For comparison, the maximum

movement displacement of COP-X in each phase isshown in Fig. 2b. The maximum movement displacementof COP-X showed no statistically significant differences
between closed and open legs in each phase.

GRF study
The comparison of GRF in each phase is shown in
Fig. 3. In all phases, the average differences in right andleft GRF were significantly smaller for open legs thanclosed legs (p<.01).
EMG study
Comparisons of the right and left %max of eachphase are shown in Table 1. Measurement of muscles
found no significant difference between the right and left
side. Comparison of right side %max of the STS movement in closed and open legs is shown in Fig. 1 and Fig.
4. TA showed significantly decreased muscle activity inphase 2, although AL activity increased significantly inKafuku T et al.

Asian J Occup Ther 10: 1–8, 2014

5

Table 1. The comparison of muscle activities in the left and right side limbs

Percentage of the amplitude produced by the maximum contraction; %max. ES; GMA; VL; AL; BF; TA; GC.

Fig. 4. The comparison of %max in each muscle.

open legs (p<.01). In phase 3, ES showed significantly
decreased muscle activity, and BF significantly increased
for open legs (p<.01).

Discussion
Kinematic analysis of variable hip joint angles inhealthy people has documented that the STS movementsfrom hip external rotation positions increased to partial
lumbar extension and pelvis anteversion (Gotoh et al.,6Functional Significance of STS by Hip Angle

2002). In comparing sitting postures in Fig. 1 (right side,(1), a, b), open legs seemed to show greater increaseof partial lumbar extension and pelvis anteversion thanclosed legs sitting in phase 1. This suggests that the results of open legs resembled the above report. In this way,
we speculate that COP-Y at the starting position with
open legs was located significantly forward by pelvis anteversion. Moreover, another report stated that there wasa center of force under the heels during the buttocks liftfrom the seat (Riley et al., 1991). In other words, COP ofphase 1 is under the heels. This research shows that open
legs with COP-Y at the time of initiation of STS movement were located in a forward position due to a short
COP-Y displacement. It is speculated that this is one factor in making the STS movement easier.
Phase 2 was defined to be from after the buttocks lift
off the chair seat to maximum dorsiflexion of the ankle(Schenkman et al., 1990). The center of mass is locatedin a maximum forward position at the time of ankle maximum dorsiflexion (Schenkman et al., 1990), and TA acted
mainly in this ankle dorsiflexion (Gotoh et al., 2002). In
addition, it was reported that STS movement from the hipexternal rotation angle decreased the anterior shift of the
COP (Gotoh et al., 2002). Our results showed no significant differences in COP-Y between open and closed legs,
but open legs decreased the anterior shift of the COP-Y inphase 2 (Fig. 2a, P2). Thus, our results indicate that there
was slightly more ankle dorsiflexion with open legs thanclosed legs. Therefore, we suggest that TA showed significantly decreased muscle activity in open legs (Fig. 4). On
the other hand, %max of AL was significantly different
between open legs and closed legs in this phase (Fig. 4).
It isn’t clear if activities of AL increased with open legs inphase 2. The analysis of video data did not show hip joint
adduction from the start (Fig. 1b (2)) to the end (Fig. 1b(3)) in phase 2. It seems that an increase of AL activities
does not affect hip joint adduction. AL arises mainly fromthe medial border of the pectineus muscle and from under
the pubic tubercle, spreading outside from underneath, andpartly attaches about halfway along the femur medial lip(Fagerson, 1998, p. 18; Jenkins, 2002, p. 288). Thus, AL
influences adduction and flexion of the hip joint (Fagerson,
1998, p. 18; Jenkins, 2002, p. 288). Furthermore, AL acts
as the hip external rotator (Moore, 1997, p. 103; Pansky,
1996, p. 255). In the present study, AL seems to maintainthe hip joint external rotation position. It is suggested thatAL acts as an external hip rotator at the hip joint abduction and external rotation position. Furthermore, AL underopen legs position should be effective for approximately
20 cm heights in phase 2 of the STS movement.
In the present study, during phase 3 from the maximum ankle dorsiflexion position to the complete standing
position, open legs had less displacement of COP-Y thanclosed legs, because open legs has less anterior-posterior
displacement in phase 3. It has been reported that ES acts
to suppress body bending in STS movement (Millington
et al., 1992). In other words, muscle activity of ES decreases at the time of slight bending of the body. In comparing postures at the start of phase 3, open legs seemed toshow less body bending than closed legs (see Fig.1, rightside, (3), a, b). Therefore, in open legs with slight bendingof the body, ES decreased muscle activities in comparison
with phase 3 of closed legs. BF and VL showed increments of synchronous activities at phase 3 from the latter
half of phase 1 (Fig. 1). In addition, BF of open legs increased %max more than closed legs in phase 3. Anatomy
textbooks describe BF as arising mainly from the ischial
tuberosity of ischium (long head) and the lateral lip offemur (short head) and attaches to the head of the fibula.
The long head of BF acts as an extensor, abductor andexternal rotator of hip joint, and a flexor of the knee joint.
The short head of the BF acts as flexor of the knee joint. It
was described that the knee joint is nearly fully extended,
the long head of BF acts as an extensor of the hip joint(Kapandji, 2011, p. 44). In this study, the knee joint has toextend so that the BF acts as a hip extensor. The open legs
knee extension angle was larger than closed legs at theend of phase 2 (see Fig. 1a(3), b(3)). It is suggested that
activities of BF promote hip extension, and help antigravity movement of the body.
In kinematic studies, it has been reported that GRF
of STS movement was asymmetric for both right and left
limbs, and STS movements of healthy subjects could becompleted with different distributions of the body weight
on both feet, because healthy people have strong muscle
power (Lundin et al., 1995). Our closed legs results weresimilar to the above report. However, GRF of open legs
had right and left symmetry in all phases. It is speculated
that the STS movement of open legs is effective for the
standing up of the elderly who have decreased muscle
power.
As mentioned above, the STS movement from theopen legs position has anterior position of COP, shortdisplacement distance of COP, and symmetrical GRF.
Therefore there is less muscle activity of ES and TA with
open legs in comparison with closed legs. Furthermore,
AL must be active during phase 2, which must be very
beneficial to fix the hip joint during the STS movementfrom open legs. The functional significance of the STS
movement with open legs promotes hip and knee extension, and helps antigravity movement of the body.

Study limitations
This study analyzed the effects of differences in hip
abduction and external rotation angles on the STS movements of young people. However, the relation of STS

Asian J Occup Ther 10: 1–8, 2014

movements between young people and the functionallylimited elderly is unclear. In the future, we would like toinvestigate the STS movement by hip abduction and external rotation angles in the elderly.

Conclusion
This study analyzed the influence of differences in
hip abduction and external rotation angles on STS movement. The STS movement from open legs showed lesstrunk flexion, and it indicated that GRF differed slightly
for right and left. In addition, muscle activity of ES andTA decreased with open legs. In contrast, muscle activityof AL and BF increased.

References
Alexander, NB., Schultz, AB., & Warwick, DN. (1991). Rising from a chair: effects of age and functional ability on
performance biomechanics. J Gerontol. 46, M91–M98.
[Medline] [CrossRef]
Arborelius, UP., Wretenberg, P., & Lindberg, F. (1992). The
effects of armrests and high seat heights on lower-limb
joint load and muscular activity during sitting and rising.
Ergonomics. 35, 1377–1391. [Medline] [CrossRef]
Bieryla, KA., Anderson, DE., & Madigan, ML. (2009). Estimations of relative effort during sit-to-stand increase when
accounting for variations in maximum voluntary torquewith joint angle and angular velocity. J Electromyogr Kinesiol. 19, 139–144. [Medline] [CrossRef]
Eriksrud, O., & Bohannon, RW. (2003). Relationship of knee
extension force to independence in sit-to-stand performance in patients receiving acute rehabilitation. Phys
Ther. 83, 544–551. [Medline]
Etnyre, B., & Thomas, DQ. (2007). Event standardization of
sit-to-stand movements. Phys Ther. 87, 1651–1666. [Medline] [CrossRef]
Fagerson, TL. (1998). Anatomy and biomechanics. Fagerson T.L, The hip handbook (p. 16). Boston: Butterworth
Heinemann.
Gotoh, A., Takada, T., & Suehiro, K. (2002). Standing up. J
Kansai Phys Ther. 2, 25–40. (in Japanese).
Hanke, TA., Pai, YC., & Rogers, MW. (1995). Reliability ofmeasurements of body center-of-mass momentum during
sit-to-stand in healthy adults. Phys Ther. 75, 105–113, discussion 113–118. [Medline]
Hislop, HJ., & Montgomery, J. (2002). Chapter 3, 5. Daniels
and Worthingham’s muscle testing, techniques of manual
examination. 7th ed (pp. 33–40, pp. 181–241). Philadelphia: W.B. Saunders Company.
Janssen, WG., Bussmann, HB., & Stam, HJ. (2002). Determinants of the sit-to-stand movement: a review. Phys Ther.
82, 866–879. [Medline]
Jenkins, DB. (2002). Chapter 16. Waltner, P, Hollinshead’sfunctional anatomy of the limbs and back. 8th ed (p. 288).

Kafuku T et al.

7

Philadelphia: W.B. Saunders Company.
Kapandji, AI. (2011). Chapter 1. Lally, N, The Physiology of
the Joints, Volume two: Lower Limb, 6nd ed (p. 44). London: Churchill Livingstone.
Khemlani, MM., Carr, JH., & Crosbie, WJ. (1999). Muscle
synergies and joint linkages in sit-to-stand under two initial foot positions. Clin Biomech (Bristol, Avon). 14, 236–
246. [Medline] [CrossRef]
Kuo, YL., Tully, EA., & Galea, MP. (2010). Kinematics ofsagittal spine and lower limb movement in healthy older
adults during sit-to-stand from two seat heights. Spine. 35,
E1–E7. [Medline] [CrossRef]
Lecours, J., Nadeau, S., Gravel, D., & Teixera-Salmela, L.
(2008). Interactions between foot placement, trunk frontal
position, weight-bearing and knee moment asymmetry atseat-off during rising from a chair in healthy controls andpersons with hemiparesis. J Rehabil Med. 40, 200–207.
[Medline] [CrossRef]
Leung, CY., & Chang, CS. (2009). Strategies for posture transfer adopted by elders during sit-to-stand and stand-to-sit.
Percept Mot Skills. 109, 695–706. [Medline] [CrossRef]
Lundin, TM., Grabiner, MD., & Jahnigen, DW. (1995). On
the assumption of bilateral lower extremity joint moment
symmetry during the sit-to-stand task. J Biomech. 28, 109–112. [Medline] [CrossRef]
Millington, PJ., Myklebust, BM., & Shambes, GM. (1992).
Biomechanical analysis of the sit-to-stand motion in elderly
persons. Arch Phys Med Rehabil. 73, 609–617. [Medline]
Moore, NA. (1997). Chapter 3. Underdown, E.D, Mosby’s
USMLE step 1 reviews – anatomy (p. 103). St. Louis:
Mosby.
O’Meara, DM., & Smith, RM. (2005). Differences between
grab rail position and orientation during the assisted sitto-stand for able-bodied older adults. J Appl Biomech. 21,
57–71. [Medline]
O’Meara, DM., & Smith, RM. (2006). The effects of unilateral grab rail assistance on the sit-to-stand performance ofolder aged adults. Hum Mov Sci. 25, 257–274. [Medline][CrossRef]
Pai, YC., & Rogers, MW. (1990). Control of body mass transfer as a function of speed of ascent in sit-to-stand. Med Sci
Sports Exerc. 22, 378–384. [Medline] [CrossRef]
Pansky, B. (1996). Unit Six. Review of gross anatomy. 6th ed(p. 225). Gavert, G, New York: McGraw Hill.
Research Institute of Human Engineering for Quality Life.
(2002). Guidelines on daily living related apparatus andequipment design for elderly people. Retrieved fromhttp://www.hql.jp/project/funcdb2000/guideline.ver.2/
nitijo-tekiyourei27.pdf (in Japanese).
Riley, PO., Schenkman, ML., Mann, RW., & Hodge, WA.
(1991). Mechanics of a constrained chair-rise. J Biomech.
24, 77–85. [Medline] [CrossRef]
Schenkman, M., Berger, RA., Riley, PO., Mann, RW., &Hodge, WA. (1990). Whole-body movements during rising to standing from sitting. Phys Ther. 70, 638–648, discussion 648–651. [Medline]
Schenkman, M., Hughes, MA., Samsa, G., & Studenski, S.

8Functional Significance of STS by Hip Angle(1996). The relative importance of strength and balance inchair rise by functionally impaired older individuals. J Am
Geriatr Soc. 44, 1441–1446. [Medline]
Schultz, AB., Alexander, NB., & Ashton-Miller, JA. (1992).
Biomechanical analyses of rising from a chair. J Biomech.
25, 1383–1391. [Medline] [CrossRef]
Vander Linden, DW., Brunt, D., & McCulloch, MU. (1994).
Variant and invariant characteristics of the sit-to-standtask in healthy elderly adults. Arch Phys Med Rehabil. 75,
653–660. [Medline] [CrossRef]

Yamada, T., & Demura, S. (2004). Influence of the relative
difference in chair seat height according to different lower
thigh length on floor reaction force and lower-limb strength
during sit-to-stand movement. J Physiol Anthropol Appl
Human Sci. 23, 197–203. [Medline] [CrossRef]
Zijlstra, W., Bisseling, RW., Schlumbohm, S., & Baldus, H.
(2010). A body-fixed-sensor-based analysis of power during sit-to-stand movements. Gait Posture. 31, 272–278.
[Medline] [CrossRef]

■ORIGINAL ARTICLE
The Present State of Fieldwork Education and the
Problems of Psychiatric Occupational Therapy inSouth Korea
Eom Yoon-jeong1, Yamane Hiroshi, PhD2
1 Doctor course, Graduate School of Medicine, Kyoto University
2 Graduate School of Medicine, Kyoto University

Abstract: Occupational therapy (OT) provided by psychiatric institutions across South Korea is typically conducted bymental health professionals rather than occupational therapists (OTR). There are few psychiatric OTRs in Korea, and none
have studied OT through an official program. To identify possible remedies for this situation, we analyzed questionnaire surveys and interviews from 14 OTRs and compared our data to the current literature. We found that OT in Korean psychiatry
departments was fraught with legal, educational, and clinical problems. There were no established minimum standards for
OT education, OT was typically conducted by other mental health professionals, OTRs found it difficult to gain confidence,and students had not been given the necessary psychiatric fieldwork experience. Examining these results, we found a needfor the revision of existing laws and enactment of better laws regarding OT, rationalization of treatment costs, verificationof clinical effects, and reform of psychiatric OT training programs.
Key words: Occupational therapy, Fieldwork education, Psychiatric rehabilitation in South Korea(Asian J Occup Ther 10: 9–16, 2014)

Introduction
The Mental Health Act of South Korea was amended
in 2008 and executed from March 2009 onward. This act
was the first law to define occupational therapy (OT) for
hospitalized patients (Ministry of Health and Welfare,2008) and the occupational therapist (OTR) as an agentof rehabilitation activities (Ministry of Health and Welfare, 2009). However, the therapy currently provided in
psychiatry departments throughout Korea is implemented
by social welfare workers, nurses, or other clinical psychologists; these are referred to as mental health agents,of which OTRs are not considered to be a part (Ministry of Health and Welfare, 2008; Ministry of Health andWelfare, 2010). The duties of mental health agents are, in
general, focused on hospital cleaning, outdoor work, andoccupational training for the rehabilitation of patients;
this phenomenon has been noted to be problematic, such
Received: 2 July 2012, Accepted: 1 March 2013
Corresponding to: Eom Yoon-jeong, Graduate School of Medicine,
Kyoto University, 53 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto, Japane-mail: oolleda@gmail.com©2014 Japanese Association of Occupational Therapists

as group administration and exploitation of incomes in
Seikatu-ryoho (Japanese) domains in Japan (Ministry of
Health and Welfare, 2012a; Yoon-Jeong, E., & Hiroshi,Y., 2011; Hiroshi, Y., 2010). No formal system for OT
for the mentally ill has been established in Korea, unlike
in Japan and throughout the West. While the number of
OTRs in Japan reached 57,196 (association members:
44,942) in March 2012 (The Secretariat of the Japanese
Association of Occupational Therapists, 2012), and thecountry had 7,637 psychiatric OTRs according to 2010
statistics (The Secretariat of the Japanese Association of
Occupational Therapists, 2011), the number of OTRs in
Korea reached only 6,446 in 2011 (The Secretariat of the
Korean Association of Occupational Therapists, 2013),
with only 20 psychiatric OTRs (Joo-Eon, L., 2011). Korea has few psychiatric OTRs, and they have not beenformally trained in OT or psychiatric OT in an official
program. Thus, psychiatric OTRs end up performing activities similar to those performed by mental health agentsand the professionalism of psychiatric OT remains underdeveloped (Table 1).
In this study, we analyzed the problems related tothe current conditions of psychiatric clinical education inSouth Korea and existing laws and training regulations

10

Fieldwork Education of Psychiatric OT in Korea

Table 1. Comparison of mental health agent and agent of rehabilitation activities
Qualifications or requirements

DutiesMental health agent

Social welfare workers, nurses, clinicalpsychologists

In general, focused on hospital cleaning, outdoor work,and occupational training for the rehabilitation of patients

Agent of rehabilitation activities

OTRs, social welfare workers, nurses,
and so on

Psychiatric OTRs end up performing activities similar to
those performed by mental health agents

Table 2. Details of the questionnaire
1. How many students do you receive a year?
2. Please explain what aspects of training you place emphasis on when supervising and educating your students.
3. Please give your opinion of the current situation of psychiatric clinical training in Korea and any problems you
encountered during your time as a supervisor of fieldwork education.
4. Do you currently lecture at a college or university? If yes, please write the name(s) of places where you lecture,and briefly explain how you feel about giving lectures on psychiatry.

in order to fully understand the task of developing andexpanding psychiatric OT.

Research Methods
To analyze the current state of the clinical educationof psychiatric OT in Korea, questionnaires were sent via
e-mail to 14 OTRs working in psychiatry departments
throughout Korea. We collected additional data by conducting personal interviews with the six OTRs that consented to participate. Table 2 presents the details of theself-administered questionnaire.
Furthermore, after comparing and analyzing the current literature and data regarding clinical training rules,laws, and institutions, we were able to review the problems that hinder OT in Korea on the basis of the interviews held with psychiatric OTRs.

Results
Clinical training of psychiatric OT in Korea
The questionnaire was sent to 14 OTRs working in
the psychiatric departments of 12 institutions in Korea in2010. Results are based on data from 10 respondents from
10 institutions; the collection rate was 71% (83% per institution).
1) Questionnaire results(1) Number of trainees per year
Results showed that five institutions (50%) had received trainees in the past year. The number of students
annually received in each institution ranged from 6 to 40,
with 89 students receiving training in psychiatry departments nationally. The remaining 50% of institutions did
not administer OT training to their students.
(2) Emphasis on training guidance
Many subjects reported that they tended to placeemphasis on teaching the most basic concepts to theirtrainees. Three subjects selected the following items: “explain the basic concepts of OT and the current status of
the psychiatry department,” “teach the necessity and roleof OT in the psychiatry department,” “pay attention to
privacy and confidentiality issues,” and “teach the basic
terms, symptoms, and drugs related to various mental disorders.” In contrast, two subjects selected the following
items: “make sure trainees gain diverse experiences in thepsychiatry department” and “pay attention to communication skills used with patients.” In addition, two subjects
mentioned students’ lack of knowledge of the main concepts of psychiatry.
(3) Problems and opinions associated with psychiatricclinical training“Students’ lack of knowledge regarding psychiatric
OT,” “difficulty of carrying out clinical training with students who have not received a basic theoretical education,” and “students’ lack of understanding of psychiatric principles, as students are taught by faculty with little
clinical experience” were selected by three subjects. Thisfinding confirms that many OTRs were discontented withthe low quality of the available training programs. Furthermore, subjects also mentioned problems related to human resources; three subjects selected “less time to teachstudents due to a busy clinical schedule,” and two subjects
selected, “lack of clinical training facilities” and “difficulties related to lack of adequate psychiatric OTRs.”
In addition, “outdated development of psychiatric OT,”
“absence of psychiatric OT supervisor,” “communication
problems,” and “lack of places required for training, providing support, and exchanging information in relation topsychiatric OT” were each selected by two subjects.
(4) University lectures
Only one of the OTRs surveyed gave university lectures, having worked at two four-year colleges. This indicates that among the 25 four-year colleges nationwide,
only two (8%) provided a psychiatric OT curriculum inAsian J Occup Ther 10: 9–16, 2014

which students could learn from a psychiatric OTR withclinical experience. In addition, two of the surveyed OTRs
had given lectures in the past, and one OTR occasionallygave special lectures.
(5) Views on the lectures
In their lectures, subjects generally acknowledged
the lack of psychiatric OTRs in South Korea and the few
employment opportunities available in psychiatric health.
Other views included “the need to attract national attention to students’ preferences for larger hospitals,” “thetendency for students to show a greater interest in fields
other than psychiatry,” “the need for lectures provided by
specialists with clinical experience,” “the need for support from a professional association,” “the need to establish formal OT concepts,” and “the need for support, assistance, and interest in OT.”
2) Interview results
In general, subjects were apprehensive about the future of psychiatric OT in Korea and requested the active
support of the Korean Association of Occupational Therapists (KAOT) with regard to the legal and institutional
problems that psychiatric OT must solve.
Subjects were largely dissatisfied with the fact thatstudents without basic knowledge in clinical training had
been sent to the psychiatry department, and they noted astrong need to recruit teachers with clinical experience.
Because many students who attended psychiatric training
sessions did not know even the most basic concepts related to mental disorders and general psychiatry, the firstfew weeks were generally spent on teaching basic theory.
Furthermore, many subjects indicated that the absence of
psychiatric OT supervisors led to hospitals presenting different OT content, making it difficult to have confidencein currently implemented therapy throughout the country.

Comparison with clinical training laws in various
countries
Clinical training of more than 1,000 hours is expected to meet the minimum educational standards for
OTRs according to the World Federation of Occupational
Therapists (WFOT) (World Federation of Occupational
Therapists, 2002), which have become the standards for
OT training. Furthermore, students must have two monthsof a clinical training, and supervisors, at least one yearof experience. Although the standards do not state thetime or specifics of the arrangement for clinical training
in psychiatry, they do mention the following: “Students
experience a range of different fieldwork placements that
require them to integrate knowledge, skills, and attitudes
to practice with a range of people with different needs
and in different circumstances” (World Federation of Occupational Therapists, 2002). The reason for avoiding any
detailed requirements is that the standards in the 2002 re-Eom Y et al.

11

vised version (World Federation of Occupational Therapists, 2002) were created to allow flexibility in curriculum
content and to relax clinical training requirements. As thestandards were written in consideration of national characteristics, rules differ according to country (Table 2).
The U.S. clinical training rules present precise regulations, qualifications, purposes, and roles for all of thefollowing: Level I/Level fieldwork, OTR/Occupational
Therapy Assistant (OTA), doctoral/master’s degree levels, and student/fieldwork educators (FWE)/academic
fieldwork coordinators (AFWC)/program faculty. Whilethey do not present specific rules for clinical training in
psychiatry, their specifications for Level II fieldwork state
the following: “It is recommended that the student be exposed to a variety of clients across the life span and to avariety of settings.” Furthermore, they also specify that
Level II fieldwork must last at least 24 weeks, must be
implemented in 1–4 institutions, and supervision must
be provided by an OTR or OT with at least one year ofexperience (American Occupational Therapy Association, 2010; American Occupational Therapy Association,2009).
Like the U.S., Canada does not present specificrules regarding psychiatric clinical training. However,it requires university fieldwork coordinators/professors
to “coordinate offers and requests for placements andwhenever possible match students and sites according tostudents’ academic and fieldwork profiles and interests”(Committee on University Fieldwork Education, 2011).
In addition, detailed regulations are stated in their academic accreditation indicators (Canadian Association of
Occupational Therapists, 2010) (Table 3).
In contrast, Ireland presents the following detailed
regulations in addition to the WFOT standards: a minimum of 250 hours of training in psychiatry and a minimum of 250 hours of training in body and sensory disorders (Association of Occupational Therapists of Ireland,2013).
Japan adopted the rules of the Japanese Associationof Occupational Therapists (JAOT) and the Ordinance ofthe Ministry of Health, Labour and Welfare. Although thedesignated rules of the Ministry recommend 810 hours ofclinical training (two-thirds of which must be conductedin hospitals and medical centers), the JAOT designates
the minimum as 1,000 hours in accordance with the minimum standards of the WFOT. Furthermore, both the Ordinance of the Ministry of Health, Labour and Welfare
and the JAOT designate a clinical educator as a person
who has accumulated at least three years of clinical experience after acquiring a license, and they indicate the needto carry out training regardless of disorder, stage, or age(Japanese Association of Occupational Therapists Education Division, 2003; Ministry of Education, Culture,

12

Fieldwork Education of Psychiatric OT in Korea

Table 3. Minimum standards for psychiatric OT fieldwork education in several countries
WFOT

USA*

CanadaIreland

Japan

Korea

JAOT: about 1,000
hours Government:
810 hours

None

No particular amountNone

All fieldwork occurs
in approved sites

Same as WFOT More than two-thirds
is at hospitals or
clinicsNone

OTR (1 year)

Same as WFOT OTR (3 years)

None

Minimum fieldwork
hours and duration

1,000 hours

24 weeks

1,000 hours

1,000 hours

Minimum fieldwork
hours in psychiatriccare

No particular amount(a range of different
fieldwork placements)

No particular amount(students should be
exposed to a variety
of settings)

No particular amount 250 hours(match students andsites according tostudents’ interests)

Fieldwork placements

A range of different 1–4 institutions
fieldwork placements

Supervisor (minimum
fieldwork experience)

OTR or OT educator OTR (none)(1 year)
OTA (1 year)

Table 4. Occupational qualifications including OTRs
Occupations and qualifications
Rehabilitation activity
personnel

1) Social welfare workers, nurses, and OTRs.
2) Any person who has graduated from the Department of Psychology in a university which conforms to
Article Two of the Higher Education Act.
3) Any person who has taken courses related to psychiatric rehabilitation activities at a college for three ormore years and has graduated.

Job coaches

OTRs, social welfare workers, nurses, nurse assistants

Sports, Science and Technology of Japan, 2010; Ministryof Health, Labour and Welfare of Japan, 1999; Ministryof Education, Culture, Sports, Science and Technology ofJapan, 1976). In Korea, OTR training standards have notbeen designated by either the KAOT or the government.
Furthermore, while Japanese WFOT standards haveapproved 132 out of 183 schools (72%) (The Secretariatof the Japanese Association of Occupational Therapists,2013) as suitable for training, Korea has only approved
8 out of 55 schools (15%) (The Secretariat of the Korean
Association of Occupational Therapists, 2013; The Secretariat of the World Federation of Occupational Therapy,2013), including universities and junior colleges in 2013.
Maximum number of incoming students accepted is 1,985
in 2013 (The Secretarit of the Korean Association of Occupational Therapists, 2013).

Rehabilitation in the field of psychiatry in Korea
Unlike other countries, Korea provides psychiatricrehabilitation under the “mental health agent system.”This system was first introduced when the need for the rehabilitation and social integration of the mentally ill was
raised by the enactment of the Mental Health Act in 1995.
This converted the law from a policy focused on hospitalization and isolation to a policy focused on rehabilitationand social return.
As the development of specialists in various fields
was required by this process, Korea introduced the mental
health agent system in March 1997. Under this system,

training institutions designated by the Ministry of Healthand Welfare recruit trainees once a year to begin training programs during March and September. Programs areclassified into Level 1 and Level 2 programs. The Level
2 program requires at least one year of training, whereas
the Level 1 program requires at least three years. However, qualifications vary, as in some cases students are
permitted to apply for the Level 1 program after gaining five years of clinical experience since acquiring theLevel 2 certificate. After completing the training program,subjects can apply for a certificate from the Ministry of
Health and Welfare and thereby become an official mental
health agent.
The number of mental health agents reached 9,947
in December 2009, and nearly 1,000 students acquire thecertificate every year (Ministry of Health and Welfare,2010). However, this system is restricted to nurses, social welfare workers, and clinical psychologists; OTRs
are affiliated with rehabilitation activity personnel andjob coaches, as shown in Table 4 (Ministry of Health andWelfare, 2009; Ministry of Health and Welfare, 2010;
Ministry of Health and Welfare, 2012b).
Thus, OT was first implemented in Korea by individuals in other occupations rather than by OTRs. Although
OT can be implemented by either mental health agentsor OTRs according to a psychiatrist’s direction, in cases
where the patient has legally requested and consented totreatment, OT is generally implemented by job coaches(OTRs, social welfare workers, nurses, and nurse assis-

Eom Y et al.

Asian J Occup Ther 10: 9–16, 201413

Table 5. Sections of the Korean Mental Health Act relevant to OT
Article 46-2 (Occupational therapy in mental hospitals)
1. If it is judged that simple work such as making crafts may be helpful for the treatment of a hospitalized patient or the social reinstatement of a
hospitalized patient, the chief of the psychiatric institution may instruct them to do such work when it presents no risk to their health.
2. The occupation in Section 1 will be enforced only with application or consent of the person and in accordance with the psychiatrist’s instructions. In the case of mental recreation facilities, however, mental health professionals may direct the specific method of the occupation under
the guidance of a psychiatrist.
3.	If the occupation is instructed as per Sections 1 or 2, the chief of the psychiatric institution must record the details in the medical chart or occupational therapy record of the patient or inmate.
4. Specific matters of Section 1 such as occupation time, risk, and place will be decided by the Ministry of Health, Welfare and Family.
[Enactment of this article 2008.3.21] [Date of enforcement 2009.3.22]

Table 6. Sections of the Enforcement Regulations of the Mental Health Act relevant to OT
Article 23-2 (Occupational therapy for hospitalized patients)
1. If the occupation is conducted at a psychiatric institution as per Section 1 of Article 46-2, the total hours must not exceed 6 hours a day or 30
hours a week. If the occupation is conducted outside, instead of at the psychiatric institution, the total hours must not exceed 8 hours a day or
40 hours a week. Moreover, the occupation must be conducted in a place with facilities equipped appropriately for the occupation, for example,
an occupational rehabilitation training room.
2. The occupation in Section 1 will be conducted with the consent or application of the patient and carried out under the instruction of a psychiatrist. However, the occupation must be conducted in a safe environment by hiring a mental health professional or occupational therapist, andtools that may harm mental patients or others, such as scissors or cutters, must be monitored and used safely.
3. If the occupation brings in money, as per Section 1, the amount will be calculated by subtracting the charges of the occupation, for example, thepurchase of raw materials, and it must be paid directly to the bank account of the hospitalized patient.
[Enactment of this article 2009.3.20]

Table 7. Related matters of occupational therapy and social rehabilitation training in nursing facilities
1. The chief of the psychiatric institution may instruct hospitalized patients to do simple occupations, such as making envelops, cleaning, cooking,and washing of the hospital where patients can be admitted, in consideration of their health and the types/hours/dangers/places of that occupation,
for the purpose of rehabilitation training.
2. The occupation in Section 1 must not exceed 6 hours a day or 30 hours a week. (If the occupation is conducted outside the nursing facilities,
the total hours must not exceed 8 hours a day or 40 hours a week, and the occupation must be conducted in a place with facilities equipped appropriately for the occupation, e.g., an occupational rehabilitation training room.)
3. The occupation in Section 1 will be enforced with the consent or application of the patient and carried out under the instruction of a psychiatrist
or mental health professionals under the guidance of a psychiatrist. However, occupation therapists, social workers, nurses, and assistant nurses
will be used as vocational training instructors, and hospitalized patients must be protected by providing the occupation in a safe environment.
Vocational training instructors must make a record of the occupational therapy specified in appended form 15, and must receive further confirmation from a psychiatrist.

Table 8. Medical expenses of health insurance relating to OTClass No.

Code

-4

NN040

Classification
Occupational or recreation therapy [music, painting, calligraphy, sculpture, sports, etc.]

Points54.15

Notes:
1. Stated points will be calculated regardless of the number of treatments carried out.
2. For outpatients, points will be calculated once a week, and for hospitalized patients,
points will be calculated five times a week.
3. The price for raw material will not be calculated separately.

tants) under the guidance of mental health agents who are
directly supervised by a psychiatrist (Ministry of Healthand Welfare, 2008; Ministry of Health and Welfare, 2009;
Ministry of Health and Welfare, 2012a). Tables 5–7 present these details.

As OTRs are not currently affiliated with mental
health agents, “Occupational or Recreation Therapy” isthe only health insurance item that can be requested (Ministry of Health and Welfare, 2012b), and as 66 KRW is
paid per point (unit cost of hospitals, nursing hospitals,

14

Fieldwork Education of Psychiatric OT in Korea

Table 9. Comparison of medical treatment fees related to psychiatric OT between Japan and Korea
Country Class

Points

₩/¥

US$

Korea

54.15

3,574

3.13

220
100
75
275
330
590
700
540
1040
320
575

2,200
1,000
750
2,750
3,300
5,900
7,000
5,400
10,400
3,200
5,700

27.57
12.53
9.40
34.46
41.35
73.93
87.72
67.67
130.33
40.10
71.43

380
1040
40

3,800
10,400400

47.62
130.33
5.01

Japan

Occupational or recreation therapy[music, painting, calligraphy, sculpture, sports, etc.] 6 hours a day, 30 hours a week
Psychiatric occupational therapy, 2 hours once a day
Social skills training therapy at the hospital (within 6 months after admission), once a week
Social skills training therapy at the hospital (over 6 months after admission), once a week
Short-stay psychiatric care (small scale), 3 hours a day
Short-stay psychiatric care (large scale), 3 hours a day
Psychiatric day care (small scale), 6 hours a day
Psychiatric day care (large scale), 6 hours a day
Psychiatric night care, 4 hours a day, after 16:00
Psychiatric day/night care, 10 hours a day
Psychiatric discharge guidance fee, once during hospitalization
Psychiatric home visit nursing guidance fee (I), 3 times a week(within 3 months after discharge is 5 times a week)
Psychiatric home visit guidance (before discharge) fee, 3 times during hospitalization
Severe dementia day care fee, once per day
Addition of environmental improvement for life with medical treatment* Exchange rate: reference date is 2012.03.09 (\/US$: 1,140, ￥/US$: 79.77).

and general hospitals) (Ministry of Health and Welfare,2012b), the cost amounts to about 3,574 KRW (Table 8).
This is extremely low when compared with the numberof health insurance items related to OT and their cost inJapan (Japanese Association of Occupational Therapists,2010). Table 9 compares the status of OT in Korea withthat of Japan.

Review
As the survey and interviews were conducted with
only psychiatric OTRs, this study is limited in that the
problems indicated in the research are based on the perspectives of OTRs only. However, the results indicate thatthe current state of clinical training for psychiatric OTs
in Korea is complicated and problematic. The causes ofthese problems were observed to be related to the lackof clinical training institutions and training programs andlegal, institutional, and regulations-related problems.
1) Clinical training institutions
Although the questionnaire was carried out in 2010,
there have been no significant changes in the psychiatric
OT training situation since that time. The number of psychiatric OTRs remains currently at about 20 (2012). Thus,
when considering that the number of freshmen enrolled inuniversities and junior colleges was 1,870 in 2011, students who graduated with psychiatric clinical experienceaccount for only 5% of the total number of students. The
remaining 95% graduated without receiving any sort ofexperience or training in psychiatric practice. The reason
for the scarcity of clinical training institutions in Korea isconsidered related to the low position relegated to OTRs
in psychiatry and their overall lack of confidence. Consequently, OTRs do not want to accept students or reveal
their skills and position to trainees.

This study first examined the position of OT and
OTRs in psychiatry departments across Korea. As OTRs
are affiliated with rehabilitation activity personnel or job
coaches rather than mental health agents, they do nottake a leading role in treating patients. Instead, they focus more on assisting with therapy or reporting on theoverall safety of patients. Furthermore, the fact that it
is more cost-effective to hire mental health agents also
serves as an obstacle to increasing the number of clinicaltraining institutions. In addition, 50% of the institutions
surveyed did not receive trainees at all, even though they
had employed OTRs in their psychiatry departments. Thisis probably because although there are many OTRs working, they might be anxious and doubtful about the therapy
itself, as they themselves have never received in-depth
training in psychiatric OT. In addition, many institutions
do not receive trainees because they have begun operating
only recently and thus cannot afford it.
2) Training programs
With regard to psychiatric OT training in universities, many subjects expressed strong discontentment withthe fact that students must learn the basics during theirtraining program due to a lack of knowledge in psychiatric OT caused by inadequate training, theory-based curriculums, and a lack of professors with sufficient clinicalexperience in psychiatric care. Thus, it is important forSouth Korea to increase the number of college professors teaching psychiatric OT and to improve the qualityof their teaching. To do this, the KAOT must establish
minimum training standards and take the time to foster
teachers who can properly teach students the basics ofpsychiatric OT before graduation. Furthermore, the demand for OTRs is low, and it is difficult for OTRs to gain
confidence in practice. They tend to have trouble obtaining appropriate medical fees in clinical situations, as they

Eom Y et al.

Asian J Occup Ther 10: 9–16, 201415

Fig. 1. Major problems in psychiatric OT in Korea

have a somewhat ambiguous position within the hospital. In order to improve this situation, it is important tohelp OTRs gain confidence in their abilities and the carethey provide, enhance the overall quality of OT offered in
hospitals, and emphasize the advantages of OTRs above
other medical staff in administering OT. Furthermore, it isessential to recruit supervisors responsible for mentoring
future psychiatric OTRs. The KAOT must plan and eventually implement a more appropriate training program for
OTRs who specialize in psychiatry.
3) Legal/institutional/designated regulations
Both the health insurance system and the Mental
Health Act of Korea have allowed non-OTRs to conduct
OT, thus giving it a low treatment cost and an insignificant position in care facilities. Although there is a fundamental problem in the development and dissemination of
psychiatric OT in Korea, the quality of psychiatric OTRs
has also been viewed as a significant problem from a legal
perspective. The therapy currently administered in psychiatry departments throughout Korea is conducted primarily by mental health agents. To acknowledge the merits of using OTRs to conduct psychiatric OT, researchers
must emphasize how the characteristics and advantages
differ from the conventional methods with regard to thetherapy’s structure, content, and effects.
Furthermore, another significant problem is the absence of formal standards for OT training in Korea. As
different standards have been designated for different
OT training programs in other countries, including differences in teaching qualifications, curriculum, and clinical training time, the quality of such programs varies significantly throughout Korea. Furthermore, because of thesmall number of hospitals that have implemented clinicaltraining in their psychiatry departments, it is impossible

for all students to receive practical psychiatric experience.
It remains necessary to increase the overall quality ofgraduate students and OTRs by providing better psychiatric OT training, enacting official OT training standards
by law, establishing minimum training requirements forthe association, maintaining a consistent level of training
across schools, and making it mandatory for all schools toprovide basic psychiatric OT education.

Conclusion
As psychiatric OT in Korea is fraught with legal, educational, and clinical problems (Figure 1), it is difficult
to present clear solutions. Although many areas must be
improved, such as revising and enacting laws related to
OT, rationalizing treatment costs, and verifying the clinical effects of OT, it is essential to reform psychiatric OTR
training programs on a national level. Before the legal defects, problems of treatment costs, and inadequate clinicalenvironments can be discussed, it is important to publicize the necessity for psychiatric OTRs through the practice of quality psychiatric OT; this would help establish
OTR as an essential occupation in the field of psychiatryin the near future.

References
American Occupational Therapy Association (2010). Accreditation Council for Occupational Therapy Education(ACOTE®) standards and interpretive guidelines. American Occupational Therapy Association.
American Occupational Therapy Association (2009). Recommendations for occupational therapy fieldwork experiences. American Occupational Therapy Association.
Association of Occupational Therapists of Ireland (2013, Feb

16

Fieldwork Education of Psychiatric OT in Korea25), available from http://www.medicine.tcd.ie/occupational-therapy/practice-education/docs/Minimum-Standards-for-Practice-Education-in-Ireland.pdf.
Canadian Association of Occupational Therapists (2010).
CAOT academic accreditation standards and self-study
guide. Canadian Association of Occupational Therapists.
Committee on University Fieldwork Education (2011). Canadian guidelines for fieldwork education in occupational
therapy. Association of Canadian Occupational Therapy
University Program.
Hiroshi, Y. (2010). The mental disorders and occupational
therapy. (3rd ed.). Tokyo (in Japanese).
Japanese Association of Occupational Therapists (2010).
Guidance of medical insurance, care insurance, supports
for persons with disabilities system of occupational therapy. Japanese Association of Occupational Therapists (inJapanese).
Japanese Association of Occupational Therapists Education
Division (2003). Minimum standards for the education ofoccupational therapists. Japanese Association of Occupational Therapists (in Japanese).
Joo-Eon, L. (2011). The present state of the occupational therapists is somewhat changed. Korean Institution of Mental
Health Occupational Therapy. http://cafe.naver.com/otmentalhealth/(accessed 2012-02-18).
Ministry of Education, Culture, Sports, Science and Technology of Japan (1976). Standards for establishment of special
training colleges. Ministry of Education, Culture, Sports,
Science and Technology (in Japanese).
Ministry of Education, Culture, Sports, Science and Technology of Japan (2010). Ministry of Health, Labour and Welfare: Designated provisions of training facility of physicaltherapists and occupational therapists school. Ministry of
Education, Culture, Sports, Science and Technology (inJapanese).
Ministry of Health, Labour and Welfare of Japan (1999). Regarding training facility guidelines of physical therapists
and occupational therapists. Ministry of Health, Labourand Welfare (in Japanese).
Ministry of Health and Welfare (2008). Mental health law.
Ministry of Health and Welfare, Seoul (in Korean).
Ministry of Health and Welfare (2009). Enforcement regulations of mental health law. Ministry of Health and Welfare,

Seoul (in Korean).
Ministry of Health and Welfare (2010). The managerial guidance of mental health professionals system. Ministry of
Health and Welfare, Seoul (in Korean).
Ministry of Health and Welfare (2012a). The guidance ofmental health operations. Ministry of Health and Welfare,
Seoul (in Korean).
Ministry of Health and Welfare (2012b). The medical expenses to be paid among employees’ (monthly) salaries for therecovery of their diseases in health insurance. Ministry of
Health and Welfare (in Korean).
The Secretariat of the Japanese Association of Occupational
Therapists (2011). Statistics materials of Japanese Association of Occupational Therapists members in 2010. Occupational Therapy 30, 496-516 (in Japanese).
The Secretariat of the Japanese Association of Occupational
Therapists (2012). Occupational therapists as of March 1,
2012. Japanese Association of Occupational Therapists
News 362, 24 (in Japanese).
The Secretariat of the Japanese Association of Occupational
Therapists (2013). A List of the national occupational
therapists schools. Japanese Association of Occupational Therapists. http://www.jaot.or.jp/wp/members/
members2/2013school/(accessed 2013-02-25).
The Secretariat of the World Federation of Occupational Therapists (2013). Entry level Educational Programmes WFOT
Approved. World Federation of Occupational Therapists.
http://www.wfot.org/Education/Entrylevel Educational
Programmes WFOT Approved. aspx (accessed 2013-0225).
The Secretariat of the Korean Association of Occupational
Therapists (2013). The present state of the establishedschools. Korean Association of Occupational Therapists.
http://www.kaot.org/(accessed 2013-02-25).
World Federation of Occupational Therapists (2002). Revised
minimum standards for the education of occupational therapists. The Council of the World Federation of Occupational Therapists.
Yoon-Jeong, E., & Hiroshi, Y. (2011). The current state of
Korean psychiatric occupational therapy. The Journal of
the Japanese Association of Occupational Therapists. 30,
137–146. (in Japanese).

■ORIGINAL ARTICLE
Behavioral and Physiological Observations During theDay: How Patients with Advanced Dementia Spend
Time in a Care Facility
Kaori Yamaguchi1,2, Minoru Hoshiyama, PhD2
1 Department of Rehabilitation for Brain Functions, Research Institute of National Rehabilitation Center for Persons with

Disabilities

2 Department of Rehabilitation Sciences, School of Health Sciences, Nagoya University

Abstract: Objective: To clarify how patients with advanced dementia in a care facility spend time during the day throughsequential observation of activities. Methods: Activities of 12 patients with dementia were observed using an originalform for monitoring their behavior and applying electroencephalograms (EEGs) with electrooculograms (EOGs) to identify
awake and sleep states. Results: The amount of time in an awake state was significantly longer than in the other states, although the awake/sleep rhythm fluctuated in all participants. The subjects were mainly occupied with “unpurposed period”,
in which they were inactive, although fully awake. Conclusion: Through reporting daily activities and awake/sleep states
during the daytime in patients with dementia in a care facility, serial monitoring of behavior and the recording of biologicalactivity revealed precise knowledge of the actual daily situation of patients with advanced dementia.
Key words: occupational balance, dementia, activity, lifestyle(Asian J Occup Ther 10: 17–24, 2014)

Introduction
A considerable number of people who suffer fromdementia are living in care facilities in Japan, where 23.3
and 11.6% of residents were over 65 and 75 years old, respectively, in 2011 (Japanese Ministry of Health, Labourand Welfare, 2011a). Occupational therapy is important insuch a situation, and occupational therapists are required
to have sufficient knowledge of the elderly with dementia(Padilla, 2011).
Again, in Japan, the number of patients living in carefacilities has markedly increased in recent years. Whilethe number of registered elderly care facilities and patients in such facilities in 2000 was 10,992 and 648,559,
respectively, they were 11,319 and 805,889 in 2009 (Japanese Ministry of Health, Labour and Welfare, 2011b).
Therefore, how occupational therapists provide intervenReceived: 6 February 2012, Accepted: 10 September 2013
Corresponding to: Minoru Hoshiyama, Division of Occupational
Therapy, Department of Rehabilitation Sciences, School of Health
Sciences, Nagoya University, 1-1-20 Daiko-minami, Higashi-ku,
Nagoya 461-8673, Japane-mail: hosiyama@met.nagoya-u.ac.jp©2014 Japanese Association of Occupational Therapists

tions for patients with dementia in care facilities as wellas those in the community is an important issue. Although
there are many problems to be solved in care facilities, interventions for so-called bed-ridden elderly patients havebeen the most closely considered over the last decade. The
development of percutaneous endoscopic gastrostomy(PEG), instead of intravenous hyperalimentation in the
1990s (Shintani, Fumimura, Shiigai, Nakamura, Kataoka,
Yokoi, & Ariyasu, 2001), has certainly changed the situation for these patients (Higaki, Yokota, & Ohishi, 2008;
Yamaguchi, Hoshiyama, & Takano, 2011). Although thepotential benefit of PEG to improve a patient’s nutritional
condition has been emphasized, the role of treatment inpatients with advanced dementia has recently been debated (Garrow, Pride, Moran, Zapka, Amella, & Delegge,
2007; Gillick & Volandes, 2008; Sanders, Leeds, & Drew,
2008; Freeman, Ricevuto, & DeLegge, 2010; Yamaguchi
et al., 2011). Occupational therapists in Japan have been
struggling to find a better intervention for bed-ridden patients, and the number of such patients is still increasing(Suzuki et al., 2010). Therapists may easily imagine thatpatients with advanced dementia and poor oral intake exhibit little activity. However, there is a dearth of information regarding their actual activity in care facilities during

18

OBSERVATION OF PATIENTS WITH ADVANCED DEMENTIA DURING THE DAY

Table 1. Profile of the participantsParticipant

Sex

Age (years)

BI*(/100)

MMSE**(/30)

P-01
P-02
P-03
P-04
P-05
P-06
P-07
P-08
P-09
P-10
P-11
P-12

F
F
F
M
F
F
F
F
F
F
F
F

89
78
76
78
82
77
88
82
85
75
80
75

5
5
55
30
40
10
0
0
5
5
5
10

0
0
14
12
13
10
0
7
11
7
0
16

Mean (± SD)

M:F = 11:1

80.4 ± 4.9

14.2 ± 17.7

7.5 ± 6.1

* BI: Barthel Index. ** MMSE: Mini-Mental State Examination.

daily life.
The objectives of the present study were to investigate how the elderly with advanced dementia spend theirtime in a care facility, and to provide basic information
for therapists in care facilities on activities during the
day of patients with advanced dementia. Jacobs, AncoliIsrael, Parker, & Kripke, (1989) previously investigated
24 hour sleep-awake patterns of the elderly in a nursing
home by observing their wrist movement with an approximate evaluation (one value per hour). However, determining awake/sleep states in elderly patients with dementia
through open observation is not practical, since those patients often make only a few movements even in awake
states. For this purpose, continuous behavioral and biological observations of patients were conducted. We continuously recorded and quantified their activities and biological signals using electroencephalography (EEG) andelectroculography (EOG), as well as behavioral observation during the day. The EEG signals with EOG recording
have been one of the most reliable methods to document
the awake/sleep status (Martin, Johnson, Viglione, Naitoh, Joseph, & Moses, 1972). We considered that precise
knowledge of patients’ biological activities would enable
us to identify efficient interventions for them from cognitive functional aspects. This pilot study aims to clarify theactivity of patients with advanced dementia to help themlead a more balanced life.

Materials and Methods
We collected personal profiles, and observed andrecorded the behaviors of the participants every 2.5 minstarting before breakfast (7:40) to before supper (18:00)
on a single day (Wednesday). We also continuously recorded EEG and EOG during the observation period.

Participants
Twelve patients with dementia in a care facility participated in the present study. They were comprised of one
male and eleven females, ranging in age from 75–89 years(mean 80.4; SD ± 4.9). The mean admission period of thepatient ranged from 11.8 months to 73.4 months (mean54.1; SD ± 21.0). All subjects suffered from advanced dementia, and were wheelchair bound. The average score of
the 100-point Barthel Index (BI) (Shah, Vanclay, & Cooper, 1989) for all patients was 14.2 ± 17.7 (± SD). A summary of the participants is shown in Table 1.
No participants had a history of focal cortical symptoms, but evaluating precise higher brain functions suchas agnosia and apraxia proved difficult due to their poor
response at the onset of the study. Participants with specific causes of dementia, i.e., massive cerebral infarction/
hemorrhage, encephalitis, toxic and metabolic encephalopathy, brain tumors, and other focal intracranial lesions,were excluded. Therefore, the participants suffered fromslowly progressive dementia, including senile dementia
of the Alzheimer type (SDAT) and dementia with Lewy
bodies (DLB), although further diagnostic examination
was not applied. None of the participants showed involuntary movements of the head, neck, or extremities, andocular movement was not disturbed by physical examination at the bedside. They did not show major problems
related to behavioral and psychological symptoms of dementia (BPSD) at the time of the study, which often cause
difficulty in care, and hence increase the caregiver burden(Finkel, 2000).
The mean Mini-Mental State Examination (MMSE)(Folstein, Folstein, & McHugh, 1975) score of the participants was 7.8 ± 5.9. Written informed consent to participate in the study was obtained from the families, and,if possible, from all participants prior to commencing thestudy. The study was approved by the Ethical Committeeof Nagoya University, School of Health Sciences, basedon the Helsinki declaration (World Medical Association,

Yamaguchi K et al.

Asian J Occup Ther 10: 17–24, 201419

Table 2. Scoring criteria for awake and sleep states
Awake/Sleep state

EEG findings

Full-awake (FA)Rest-awake (RA)
Drowsy (S1)

Beta or alpha activity
Alpha activity
Suppression of alpha activity,
sporadic vertex potentials
SpindlesLight sleep (S2)

EOG

EMG

Blinking or saccadic eye movement
Bursts of EMG
Loss of blinking or saccadic eye movement Spontaneous bursts of EMG
Loss of blinking or saccadic eye movement Silent EMG
Loss of blinking or saccadic eye movement Silent EMG

Table 3. Monitoring sheet for behavioral observation
R

Place
H

OthersPostureL

S

OthersTime

Activity

Notableobservation

7:10
7:20
7:30
7:40
7:50
8:00
:
:
10:40
10:50
11:00
11:10
:
:
R: room, H: hall, L: lying, S: sitting.

Table 4. All activities shown during observation for every participant
Category

Activities

ADL
Purposeful
Un-purposed
Rest

Dressing (1)*, Eating (12), Medical treatment (6), Oral hygiene (11), Personal device care (1), Toilet hygiene (12), Transfer (12)Conversation (7), Watching television (2), Afternoon tea (2), Walking around inside (1)(12)
Sleep (11)( )* the number of patients who participated in the activity.

2008).
Participants were all inpatients in a mid-sized carefacility, where approximately 100 elderly patients withand without dementia were provided with medical careand underwent rehabilitation with occupational and physical therapists.

Experiment design
1. Continuous recording of behavioral activities
We selected Wednesday as the day of the observation,
since bathing and outside activities were not scheduled onthat day. From 8 a.m. to 5 p.m., we carefully observed anddescribed each participant’s behavior every 2.5 min using
an original monitoring sheet (Table 3) because some activities were completed in less than a few minutes. We recorded the location of the patients, the patients’ postures,
their activities, and anything worthy of note; e.g., talking

with a caregiver, watching television, eating, and dressing(Table 4).
2. Continuous recording of biological activities
A wireless amplifier was employed so as not to disturb each participant’s movements during the recording
period. EEG signals were recorded from two scalp areas,Oz and C3, with referential electrodes of the linked mastoid process, using surface electrodes which were 7-mm
silver-silver chloride disc electrodes. Those recording
areas were selected to observe basic alpha activity andsleep-specific responses, the vertex potential, and sleep
spindle. EOGs were recorded from the right eye by placing electrodes 2 cm below the infra-orbicular edge and 2
cm lateral to the lateral canthus of the right eye. Impedance between electrodes was kept at less than 10 kOhm.
The EEG and EOG signals were recoded with an initialband-pass filter from 1.6 to 60 Hz and transferred through20

OBSERVATION OF PATIENTS WITH ADVANCED DEMENTIA DURING THE DAY

a wireless amplifier (WEB-5000, NIHON-KOHDEN,
Japan) with an analog to digital converter (ADC) (CSI320312, Interface Co., Japan). The data were digitized at
1.0 KHz to store on a personal computer.
3. Data analysis
All observed activities were recorded and divided
into four categories: activities of daily living (ADL),
purposeful activities (work, productive activities, andleisure), un-purposed activities and sleep. We referred tothe uniform terminology defined by the American Occupational Therapy Association for categorization (Rockville, 1979; American Occupational Therapy Association,
1994, 2004). The category of ADL included grooming,
oral hygiene, bathing/showering, toilet hygiene, personal
device care, dressing, feeding and eating, medication routine, and health maintenance. The category of purposefulactivities included both “work and productive activities”
and “play and leisure activities”. The other period when
patients did nothing was categorized as an unpurposed
period. The period of time in each activity category was
expressed as a percentage of the recording period, since
the total recording period varied in each participant, as
described in Results.
Biological signals were also evaluated every 2.5 min.
Awake and sleep states were investigated based on EEG
signals and were evaluated based on the scoring system
of Rechtschaffen & Kales (1968), although the score waspartially modified using the EOG data. Full-awake (FA),rest-awake (RA), drowsy (S1), and light sleep (S2) states
were defined as shown in Table 2.
From EOG signals, the period of time spent blinking or showing step-wise rapid (saccadic) eye movement,
corresponding with the full-awake state, was measured.
Since blinking and saccadic eye movements could not be
separated on EOGs, we measured the time period showing both eye movements.
We compared BI or MMSE and the amount of timein an awake state using Peason’s correlation coefficienttest. We also compared the time period of FA, RA, andsleep with Student’s t-test. P-values less than 0.05 wereconsidered significant.
The awake/sleep score was determined every 5 min:i.e., FA = 5; RA = 3; sleep (S1 or S2) = 1. The mean awake/
sleep score every 20 min from 07.40–17.00 hours wascalculated and described as a chart for each participant.

Results
All activities and biological signals were successfully obtained from all patients. The total recording period was 523 (8 hours and 43 min) ± 56 min (SD). Since
the light-sleep state (S2) was determined by spontaneous
sleep spindles, it was difficult to identify the exact onset

Fig. 1. Relative amount of awake/sleep states of patientsduring the daytime. Percentage of amount of timefor full-awake (FA), rest-awake (RA), and sleep.
The FA state was significantly longer than the otherstates (p<0.05).

and end of S2 during the recording period. Thus, S1 andS2 were put together and determined as a sleep state.
We also calculated the amount of time for FA, RA,
and sleep during the entire recording period (Fig. 1).
The average percentage of the FA and sleep states wasapproximately 80% and 20%, respectively. The RA status period was minimal. The patients were fully awake
for significantly longer than for sleeping or resting while
awake during the day. There was no significant difference
between the resting while awake and sleep states. The
correlation between BI or MMSE and the time period of
FA was not significant. Sequential changes in the awake/
sleep score during the day for all participants are shownin Fig. 2. The awake/sleep rhythm fluctuated in all participants, and the awake state was mostly maintained aroundmeal times.
All activities performed by every patient were dressing, eating, medical treatment, oral hygiene, personal device care, toilet hygiene, and transferring (ADL), afternoon tea, conversation, walking around the facility, andwatching television (purposeful activities), and sleeping.
The period in which patients spent their time inactively
was divided into an unpurposed category (Table 4).
The percentage of the four categories performed byeach patient is shown in Fig. 3. The percentage for the
category of ADL was around 30% in the twelve patients.
Purposeful activities were shown in 8 patients, and theYamaguchi K et al.

Asian J Occup Ther 10: 17–24, 2014

21

Fig. 2. Sequential changes of awake and sleep states for each participant. Each connected line indicates a participant. Awake and sleep
states fluctuated during the daytime. The awaking state was maintained around meal times, and patients were not always insleep states but awake during the day.

Fig. 3. Relative amount, expressed as a percentage, of activities during a day. The majority of time was observed as unpurposed. Participants’ numbers corresponds to those in Table 1. Activities in each category were described in the text
(2. 2. 3. Data analysis).

percentage was less than 12%. The percentage of timein the unpurposed period was the highest in 11 patients,
ranging from approximately 40 to 70%. Sleep was noted
in 11 patients. The percentage of unpurposed and sleep
categories totaled more than 70% in all patients.
According to the results of EEG and EOG, the unpurposed periods consisted of 2 kinds of awake/sleep states:
FA and RA. Four patients were fully awake during theunpurposed period, and the others were fully awake during more than 90% of the unpurposed period. Thus, all patients spent their time inactively during the un-purposed
period, even though they were completely awake.

Discussion
In the present study, we investigated the daily performance and awake/sleep states of patients with dementia
in a care facility during a single day. To our knowledge,
such detailed observations have not been reported. The
results are 1) a fully awake state remained, but the awake/
sleep rhythm fluctuated except for meal times; 2) the patients were occupied by just a few activities except for
ADL; and 3) the un-purposed period was the longest inalmost all patients. All patients were fully awake duringthat period.

22

OBSERVATION OF PATIENTS WITH ADVANCED DEMENTIA DURING THE DAY

Clinicians may assume that elderly patients with advanced dementia lack activity and tend to sleep during
the day. However, there is no data regarding how longand how often such patients sleep during the day. In fact,patients often stay awake during the day, although theirawake/sleep states fluctuate. Jacobs et al. (1989) measured awake-sleep patterns in 19 elderly patients withand without dementia in a care facility, but they did notseparately record the patterns for patients with advanced
dementia. This is the first report, as far as we know, whichinvestigated the awake/sleep states in elderly patientswith advanced dementia by continuous recording of biological signals.
The relationship between activity and cognitive
function in the elderly has been reported (van Gelder, Tijhuis, Kalmijn, Giampaoli, Nissinen, & Kromhout, 2004;
Weuve, Kang, Manson, Breteler, Ware, & Grodstein,
2004; Klusmann, Evers, Schwarzer, Schlattmann, Reischies, Heuser, & Dimeo, 2010; Leung, Fung, Tam, Lui,
Chiu, Chan, & Lam, 2011). Decreasing activity leads toa decline in cognitive function, and leisure or cognitive
activities could reduce the risk of dementia (Verghese etal., 2003; Helzner, Scarmeas, Cosentino, Portet, & Stern,
2007; Hall, Lipton, Sliwinski, Katz, Derby, & Verghese,2009). Although physical activities do not always show alink to cognitive impairment (Laurin, Verreault, Lindsay,
MacPherson, & Rockwood, 2001), reduced physical activity could be a risk factor for Alzheimer’s disease (Larson, 2008; Lautenschlager et al., 2008). Thus, maintaining an active daily life, especially linked with a positive
emotional state, has been considered an important factor
maintaining the quality of life (QOL) of elderly patients(Skevington, Lotfy, O’Connell, & WHOQOL Group,2004), although evaluation of QOL of patients with advanced dementia is not easy (Schölzel-Dorenbos et al.,2007). Therefore, therapists must identify the most appropriate intervention for low-activity patients with advanced dementia to prevent functional decline and maintain their QOL.
The patients in the present study spent most of theirtime without purpose, although they were in a fully awake
state. This is the most significant finding of the present
study. Because they were not asleep but in an awake stateproviding them with cognitive interventions and activities, even physical environmental control could improve
the awake/sleep cycle (Sloane et al., 2007; Flick, GarmsHomolová, & Röhnsch, 2010). Thus, adequate occupational intervention may reduce awake/sleep fluctuation inthese patients. However, keeping the patients awake is not
the sole solution. Previous research pointed out a similar
issue in patients with advanced dementia, who spent thegreater part of their day unoccupied (Perrin, 1997). They
also stated that simply facilitating intervention might not

be sufficient, but improving the skills and qualities that
individual staff members bring to their interventions wasimportant (Perrin, 1997). Occupational therapy for daily
activities, such as washing, dressing sanitary services andeating improved functional scores (Baldelli et al., 2007).
Previous studies also referred to the lifestyle or life balance in the field of occupational therapy (Jackson, Carlson, Mandel, Zemke, & Clark, 1998; Pentland, & McColl,2008). However, in Japan, the number of patients withadvanced dementia has increased far more rapidly thanany other country, and the recent situation regarding carefacilities for patients with advanced dementia is rapidlychanging in terms of quantity and quality. The number oftherapists and caregivers is far from enough ( Japanese
Ministry of Health, Labour and Welfare, 2011b), and how
such patients with advanced dementia should be managedwith occupational therapy in care facilities is still being
debated. It is clear that occupational therapists experience
difficulty with elderly patients suffering from advanced
dementia who lack activity or occupation. Further research may be required to investigate the criteria for awell-balanced life for elderly patients with advanced dementia, in order to know how much intervention and rest
time should be provided.
Limitations of the present study were an inability topropose a clear solution to improve the status of the patients with dementia, as described in the previous paragraph. The present study reported only the behavioral andphysiological aspects of the patients. Effects of intervention on the states of patients, variation of the data among
facilities, psychological evaluation of the patients, andtheoretical and practical proposals to improve QOL ofthe patients and caregivers should be investigated in the
future.
The present study reported daily activities and theawake/sleep status during the daytime in patients withdementia in a care facility. Serial monitoring of behavior and recording of biological activity revealed precise
knowledge of actual daily situation in patients with advanced dementia.
Acknowledgement: This study was partially supported by
the Japan Society for the Promotion of Science (Grantin-Aid for Scientific Research C: 21591110, 24591292),
Ministry of Health, Labour and Welfare (Kenko-zoshin
23-2, 24).

References
American Occupational Therapy Association (2004). Association policy. American Journal of Occupational Therapy.
58, 693–695. [CrossRef]
American Occupational Therapy Association(1994). Uniform
terminology--third edition: application to practice. Ameri-

Asian J Occup Ther 10: 17–24, 2014

can Journal of Occupational Therapy. 48, 1055–1059.
Baldelli, MV., Boiardi, R., Ferrari, P., Bianchi, S., & Bianchi,
MH. (2007). Dementia and occupational therapy. Archivesof Gerontology and Geriatrics. 44(Suppl 1), 45–48. [Medline] [CrossRef]
Finkel, S. (2000). Introduction to behavioural and psychological symptoms of dementia (BPSD). International journalof geriatrics and psychiatry. 15(Suppl 1), S2–S4. [Medline] [CrossRef]
Flick, U., Garms-Homolová, V., & Röhnsch, G. (2010). ‘When
they sleep, they sleep’: daytime activities and sleep disorders in nursing homes. Journal of Health Psychology. 15,
755–764. [Medline] [CrossRef]
Folstein, MF., Folstein, SE., & McHugh, PR. (1975). “Minimental state”. A practical method for grading the cognitive
state of patients for the clinician. Journal of PsychiatricResearch. 12, 189–198. [Medline] [CrossRef]
Freeman, C., Ricevuto, A., & DeLegge, MH. (2010). Enteralnutrition in patients with dementia and stroke. Current
Opinion in Gastroenterology. 26, 156–159. [Medline][CrossRef]
Garrow, D., Pride, P., Moran, W., Zapka, J., Amella, E., &Delegge, M. (2007). Feeding alternatives in patients withdementia: examining the evidence. Clin Gastroenterol
Hepatol. 5, 1372–1378. [Medline] [CrossRef]
van Gelder, BM., Tijhuis, MAR., Kalmijn, S., Giampaoli, S.,
Nissinen, A., & Kromhout, D. (2004). Physical activity
in relation to cognitive decline in elderly men: the FINE
Study. Neurology. 63, 2316–2321. [Medline] [CrossRef]
Gillick, MR., & Volandes, AE. (2008). The standard of caring:
why do we still use feeding tubes in patients with advanced
dementia? Journal of the American Medical Directors Association. 9, 364–367. [Medline] [CrossRef]
Hall, CB., Lipton, RB., Sliwinski, M., Katz, MJ., Derby, CA.,& Verghese, J. (2009). Cognitive activities delay onset ofmemory decline in persons who develop dementia. Neurology. 73, 356–361. [Medline] [CrossRef]
Helzner, EP., Scarmeas, N., Cosentino, S., Portet, F., & Stern,
Y. (2007). Leisure activity and cognitive decline in incident Alzheimer disease. Archives of Neurology. 64, 1749–
1754. [Medline] [CrossRef]
Higaki, F., Yokota, O., & Ohishi, M. (2008). Factors predictiveof survival after percutaneous endoscopic gastrostomy inthe elderly: is dementia really a risk factor? The American
Journal of Gastroenterology. 103, 1011–1016, quiz 1017.
[Medline] [CrossRef]
Jackson, J., Carlson, M., Mandel, D., Zemke, R., & Clark, F.
(1998). Occupation in lifestyle redesign: the Well Elderly
Study Occupational Therapy Program. Am J Occup Ther.
52, 326–336. [Medline] [CrossRef]
Jacobs, D., Ancoli-Israel, S., Parker, L., & Kripke, DF. (1989).
Twenty-four-hour sleep-wake patterns in a nursing home
population. Psychology and Aging. 4, 352–356. [Medline][CrossRef]
Japanese Ministry of Health, Labour and Welfare (2011a).
Annual Reports. Retrieved from http://www.mhlw.go.jp/
english/index.html, http://www.mhlw.go.jp/toukei/list/24-

Yamaguchi K et al.

23

21-2.html (in Japanese), http://www.e-stat.go.jp/SG1/estat/NewList.do?tid=000001029805 (in Japanese).
Japanese Ministry of Health, Labour and Welfare (2011b).
White Papers & Reports, Annual Health, Labour and Welfare Report 2009-2010. Retrieved from http://www.mhlw.
go.jp/english/wp/wp-hw4/dl/honbun/2_2_8.pdf (in English).
Klusmann, V., Evers, A., Schwarzer, R., Schlattmann, P., Reischies, FM., Heuser, I., & Dimeo, FC. (2010). Complex
mental and physical activity in older women and cognitive performance: a 6-month randomized controlled trial.
J Gerontol A Biol Sci Med Sci. 65, 680–688. [Medline][CrossRef]
Larson, EB. (2008). Physical activity for older adults at risk
for Alzheimer disease. JAMA. 300, 1077–1079. [Medline][CrossRef]
Laurin, D., Verreault, R., Lindsay, J., MacPherson, K., &Rockwood, K. (2001). Physical activity and risk of cognitive impairment and dementia in elderly persons. Archivesof Neurology. 58, 498–504. [Medline] [CrossRef]
Lautenschlager, NT., Cox, KL., Flicker, L., Foster, JK., vanBockxmeer, FM., Xiao, J., Greenop, KR., & Almeida, OP.
(2008). Effect of physical activity on cognitive function inolder adults at risk for Alzheimer disease: a randomized
trial. JAMA. 300, 1027–1037. [Medline] [CrossRef]
Leung, GT., Fung, AW., Tam, CW., Lui, VW., Chiu, HF., Chan,
WM., & Lam, LC. (2011). Examining the association between late-life leisure activity participation and global
cognitive decline in community-dwelling elderly Chinese
in Hong Kong. International Journal of Geriatric Psychiatry. 26, 39–47. [Medline] [CrossRef]
Martin, WB., Johnson, LC., Viglione, SS., Naitoh, P., Joseph,RD., & Moses, JD. (1972). Pattern recognition of EEGEOG as a technique for all-night sleep stage scoring. Electroencephalography and Clinical Neurophysiology. 32,
417–427. [Medline] [CrossRef]
Padilla, R. (2011). Effectiveness of interventions designed tomodify the activity demands of the occupations of selfcare and leisure for people with Alzheimer’s disease andrelated dementias. Am J Occup Ther. 65, 523–531. [Medline] [CrossRef]
Pentland, W., & McColl, MA. (2008). Occupational integrity:
another perspective on “life balance”. Can J Occup Ther.
75, 135–138. [Medline] [CrossRef]
Perrin, T. (1997). Occupational need in severe dementia: adescriptive study. Journal of Advanced Nursing. 25, 934–
941. [Medline] [CrossRef]
Rechtschaffen, A., & Kales, A. (1968). A manual of standardized terminology, techniques, and scoring system for sleep
stages of human subjects. The U.S. Department of Health,
Education, and Welfare in Bethesda, Maryland.
Rockville, MD. (1979). Occupational therapy product output
reporting system and uniform terminology system for reporting occupational therapy services. American Occupational Therapy Association.
Sanders, DS., Leeds, JS., & Drew, K. (2008). The role of percutaneous endoscopic gastrostomy in patients with demen-

24

OBSERVATION OF PATIENTS WITH ADVANCED DEMENTIA DURING THE DAY

tia. British journal of nurssing. 17, 588–594.
Shah, S., Vanclay, F., & Cooper, B. (1989). Improving thesensitivity of the Barthel Index for stroke rehabilitation.
Journal of Clinical Epidemiology. 42, 703–709. [Medline][CrossRef]
Shintani, S., Fumimura, Y., Shiigai, T., Nakamura, M., Kataoka, T., Yokoi, Y., & Ariyasu, Y. (2001). [Feeding methods
for long-term bedridden patients with dysphagia underhome health care—percutaneous endoscopic gastrostomy(PEG) and intravenous hyperalimentation (IVH)]. Gan To
Kagaku Ryoho. 28(Suppl 1), 61–64. (in Japanese). [Medline]
Skevington, SM., Lotfy, M., O’Connell, KA. WHOQOLGroup (2004). The World Health Organization’s WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A reportfrom the WHOQOL group. Qual Life Res. 13, 299–310.
[Medline] [CrossRef]
Sloane, PD., Williams, CS., Mitchell, CM., Preisser, JS.,Wood, W., Barrick, AL., Hickman, SE., Gill, KS., Connell,
BR., Edinger, J., & Zimmerman, S. (2007). High-intensity
environmental light in dementia: effect on sleep and activity. Journal of the American Geriatrics Society. 55, 1524–
1533. [Medline] [CrossRef]
Schölzel-Dorenbos, CJ., Ettema, TP., Bos, J., Boelens-van
der Knoop, E., Gerritsen, DL., Hoogeveen, F., de Lange,J., Meihuizen, L., & Dröes, RM. (2007). Evaluating theoutcome of interventions on quality of life in dementia:
selection of the appropriate scale. International Journal of
Geriatric Psychiatry. 22, 511–519. [Medline] [CrossRef]
Suzuki, Y., Tamez, S., Murakami, A., Taira, A., Mizuhara, A.,

Horiuchi, A., Mihara, C., Ako, E., Muramatsu, H., Okano,
H., Suenaga, H., Jomoto, K., Kobayashi, J., Takifuji, K.,
Akiyama, K., Tahara, K., Onishi, K., Shimazaki, M.,
Matsumoto, M., Ijima, M., Murakami, M., Nakahori, M.,
Kudo, M., Maruyama, M., Takahashi, M., Washizawa, N.,
Onozawa, S., Goshi, S., Yamashita, S., Ono, S., Imazato,
S., Nishiwaki, S., Kitahara, S., Endo, T., Iiri, T., Nagahama, T., Hikichi, T., Mikami, T., Yamamoto, T., Ogawa,T., Ogawa, T., Ohta, T., Matsumoto, T., Kura, T., Kikuchi, T., Iwase, T., Tsuji, T., Nishiguchi, Y., & Urashima,
M. (2010). Survival of geriatric patients after percutaneousendoscopic gastrostomy in Japan. World J Gastroenterol.
16, 5084–5091. [Medline] [CrossRef]
Verghese, J., Lipton, RB., Katz, MJ., Hall, CB., Derby, CA.,
Kuslansky, G., Ambrose, AF., Sliwinski, M., & Buschke,H. (2003). Leisure activities and the risk of dementia inthe elderly. The New England Journal of Medicine. 348,
2508–2516. [Medline] [CrossRef]
Weuve, J., Kang, JH., Manson, JE., Breteler, MMB., Ware,
JH., & Grodstein, F. (2004). Physical activity, including
walking, and cognitive function in older women. JAMA.
292, 1454–1461. [Medline] [CrossRef]
World Medical Association (2008). Declaration of Helsinki.
Retrieved from: http://www.wma.net/e/policy/b3.htm.
Yamaguchi, K., Hoshiyama, M., & Takano, M. (2011). Biological observation during the daytime of elderly patientswith advanced dementia cared for with and without artificial nutrition by percutaneous endoscopic gastrostomy.
Geriatrics & Gerontology International. 11, 221–228.
[Medline] [CrossRef]