Dementia and Physical Therapy

1. Dementia and Physical Therapy

2. Dementia • Decline in brain function that affects memory, thinking, language, judgment, and behavior.1 • Progressive disease that develops over time1,2 • Most common forms of dementia are Alzheimer’s disease and Vascular dementia2 • Many symptoms including difficulty concentrating, memory loss, irritability, personality changes, anxiety, depression, and sleep disturbances1,2

3. 10 Warning Signs of Dementia • Memory changes that disrupt daily life • Challenges in planning or solving problems • Difficulty in completing familiar tasks • Confusion with time and place • Trouble understanding visual images and spatial relationships • New problems with words in speaking or writing • Misplacing things and losing the ability to retrace steps • Decreased or poor judgment • Withdrawal from work or social activities • Changes in mood and personality3

4. Prevalence • 13.9% of older adults 71+ in the USA4 • As high as 50% of residents in nursing homes5

5. Memory Deficits • Intact implicit memory system6 -Demonstration of the effects of prior experience without conscious recollection of that experience, also described as habit. • Impaired explicit memory system6 -Conscious and intentional recollection of specific information and previous experience

6. Evidence • Controlled and automatic memory process in Alzheimer’s disease -On the Mini Mental State Examination participants with dementia did poorly on the recollection portion(explicit memory) but showed intact automatic memory process(implicit memory)7 • Psychosocial practice essentials in neurorehabilitation: Stress, coping, and adaptation -People with dementia have difficulty forming new memories but by over-learning skills, these skills evolve into memories and are processed automatically.8 • Memory interventions for persons with dementia -Spaced retrieval strategy for learning in persons with dementia found to be effective. Spaced retrieval uses the implicit memory system and uses little cognitive effort.9

7. Increased Fall Risk • Fall incidence is as high as 60%10 • As many as 4 falls per year10 • Three times the risk of sustaining fractures3,10 • Risk factors associated with dementia include3,10: -muscular weakness -history of falls -visual deficits -gait and balance deficits -poor decision awareness -agitation -perceptual difficulties -depression -cognitive impairment -wandering -orthostatic hypotension

8. Evidence • Increased Risk of Falling in Older Community-Dwelling Women With Mild Cognitive Impairment11

9. Benefits of Exercise/PT • Decreases fall risk • Increases fitness, physical function, and promotes positive behavior • Slows decline in ADLs • Prevents/reduces risk of developing secondary conditions12,13,14

10. Evidence • A randomized controlled trial testing the impact of exercise on cognitive symptoms and disability of residents with dementia -After 12 week exercise program participants showed slower rate of progression of cognitive symptoms and reversed disability in some ADLs12 • Effect of aerobic training on the cognitive performance of elderly patients with senile dementia of Alzheimer type -Improved scores on the Test of attentional matrix, verbal span test, supraverbal span test, MMSE after 3 month period of 3 days of 20 min of aerobic exercise13 • Exercise Program for Nursing Home Residents with Alzheimer’s Disease: A 1-Year Randomized, Controlled Trial -Simple exercise program, 1 hour 2x/wk led to slower decline in ADL score in patients with AD living in a nursing home than routine medical care.14

11. Functional Outcome Measures • Functional outcome measures can be used in the dementia population to track progress and success of treatment. • Evidence -Test-Retest Reliability and Minimal Detectable Change Scores for the Timed “Up & Go” Test, the Six-Minute Walk Test, and Gait Speed in People With Alzheimer Disease15

12. Common Symptoms That Interfere with PT • -Difficulty concentrating, irritability, anxiety, depression, sleep disturbances, outbursts, paranoia, emotional distress, delusions, hallucinations, changes in ability to focus, changes in level of alertness, emotional or physical agitation changes in mood, hallucinations, delusions, suspicion of others, withdrawal from others, groaning or calling out, making faces, striking out or other signs of distress, wandering, pacing, rocking3

13. Emotional Behaviors • Behaviors and emotional state of persons with dementia are often forms of communication because person cannot make their needs known in other ways, therefore it is important to try to identify the trigger of the behavior3

14. Triggers • Triggers may include -pain, fatigue, poor sleeping patterns, fear, anxiety, sense of a loss of control, misunderstandings of the therapeutic process, underlying incipient medical conditions, clinical depression, psychotic symptoms, sensory changes, constipation, dehydration, distracting environment, presence of others during sessions may be distracting, communication patterns that are too complex and confusing3

15. Techniques • Practice task repeatedly under constant conditions--consistency • Use sensory processing • Multisensory environment • Incorporate familiar tasks • Simplify tasks • Establish structure and routine • Provide task specific training • Use “hands-on” teaching • Do not rush patient • Effective communication3,16,17,18,19

16. Effective Communication • Go with flow of conversation • Use simple hand gestures and verbal cues • Allow extra time for processing commands • Use short sentences to enhance understanding • Use positive feedback to enhance cooperation • Make and maintain eye contact at patient’s eye level to build trust • Monitor nonverbal signs • Speak slowly and calmly with simple words • Use positive instructions instead of negative instructions • Avoid interrupting patient • Repeat or reword as needed • Eliminate noise and distraction during communication • Be aware of any hearing loss • Be patient and flexible when communicating3,16,17,18,19

17. Evidence • The Effects of Salsa Dance on Balance, Gait, and Fall Risk in a Sedentary Patient With Alzheimer's Dementia, Multiple Comorbidities, and Recurrent Falls20 • Fall Management in Alzheimer-related Dementia: A Case Study16 • The effect of a multisensory exercise program on engagement, behavior, and selected physiological indexes in persons with dementia21

18. Evidence • Behavioral and endocrinological evaluation of music therapy for elderly patients with dementia22 • Music, music therapy and dementia: A review of literature and the recommendations of the Italian Psychogeriatric Association23 • Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia24

19. Sources • Dementia. Pubmed Health.2011. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001748/. Accessed February 20, 2013. • What is Dementia. Alzheimer's Association. 2013. Available at http://www.alz.org/what-is-dementia.asp. Accessed February 20, 2013. • Dementia Care Practice Recommendations for Professionals Working in a Home setting. Alzheimer;s Association Campaign for Quality Care. 2009. Available at http://www.alz.org/national/documents/phase_4_home_care_recs.pdf. Accessed February 20, 2013. • Plassman BL et al. Prevalence of Dementia in the United States: The Aging, Demographics, and Memory Study. Neuro-epidemiology. 2007; 29: 125-132. Available at http://www.karger.com/Article/FullText/109998. Accessed February 20, 2013. • Magaziner J, German P, Zimmerman SI, Hebel JR, Burton L, Gruber-Baldini AL, May C, Kittner S. The prevalence of dementia in a statewide sample of new nursing home admissions aged 65 and older: diagnosis by expert panel. Epidemiology of Dementia in Nursing Homes Research Group. 2000; 40(6): 663-72. Available at http://www.ncbi.nlm.nih.gov/pubmed/11131083. Accessed February 20, 2013. • Son GR, Therrien B, Whall A. Implicit Memory and Familiarity Among Elders with Dementia. J Nurs Scholarship. 2002; 34:3: 263-267. Available at http://deepblue.lib.umich.edu/bitstream/handle/2027.42/74185/j.1547-5069.2002.00263.x.pdf;jsessionid=C4B28EF5E318938DA12C14AA7FC6AE42?sequence=1. Accessed February 20, 2013. • Knight RG. Controlled and automatic memory process in Alzheimer’s disease. Cortex. 1998; 34: 427-435. Available at http://www.pitt.edu/~bertsch/Knight.pdf. Accessed February 20, 2013. • Levy L. 2006. Psychosocial practice essentials in neurorehabilitation: Stress, coping, and adaptation. In Giles G, editor. Core concepts in neurorehabilitation. Bethesda (MD): The American Occupational Therapy Association, Inc. 91-122. • Camp CJ, Foss JW, O'Hanlon AM, Stevens AB. Memory Interventions for Persons with Dementia. Applied Cognitive Psychology. 1999;10(3): 193-210. Available at http://deepblue.lib.umich.edu/bitstream/handle/2027.42/74185/j.1547-5069.2002.00263.x.pdf;jsessionid=C4B28EF5E318938DA12C14AA7FC6AE42?sequence=1. Accessed February 20, 2013.

20. Sources • 10. Tilly J, Reed P. Falls, wandering, and physical restraints: a review of interventions for individuals with dementia in assisted living and nursing homes. Alzheimer's Care Today. 2008; 9(1): 45-50. Available at http://ot.creighton.edu/community/EBLP/Question3/2010_Update_Falls/Tilly%202008.pdf. Accessed February 20, 2013. • 11. Liu-Ambrose TY, Ashe MC, Graf P, Beattie BL, Khan MK. Increased Risk of Falling in Older Community-Dwelling Women With Mild Cognitive Impairment. J Am Phys Ther. 2008; 88(12): 1482-1491. Available at http://ptjournal.apta.org/content/88/12/1482.long. Accessed February 20, 2012. • 12. Stevens J, Killeen M. A randomised controlled trial testing the impact of exercise on cognitive symptoms and disability of residents with dementia. Contemp Nurse. 2006; 21(1): 32-40. Available at http://www.ncbi.nlm.nih.gov/pubmed/?term=A+randomised+controlled+trial+testing+the+impact+of+exercise+on+cognitive+symptoms+and+disability+of+residents+with+dementia. Accessed February 20, 2013. • 13. Palleschi L, Vetta F, De Gennaro E, Idone G, Sottosanti G, Gianni W, Marigliano V. Effect of aerobic training on the cognitive performance of elderly patients with senile dementia of Alzheimer type. Arch GerontolGeriatr. 1996;22: 47-50. Available at http://www.ncbi.nlm.nih.gov/pubmed/18653007. Accessed February 20, 2013. • 14. Rolland Y, Pillard F, Klapouszczak A, Reynish E, Thomas D, Andrieu S, Riviere D, Vellas B. Exercise Program for Nursing Home Residents with Alzheimer's Disease: A 1-Year Randomized, Controlled Trial. J Am Geriatr Soc. 2007; 55(2): 158-65. Available at http://www.ncbi.nlm.nih.gov/pubmed/?term=Exercise+Program+for+Nursing+Home+Residents+with+Alzheimer%27s+Disease%3A+A+1-Year+Randomized%2C+Controlled+Trial. Accessed February 20, 2013. • 15. Reis JD, Echternach JL, Nof L, Blodgett MG. Test-Retest Reliability and Minimal Detectable Change Scores for the Timed “Up & Go” Test, the Six-Minute Walk Test, and Gait Speed in People With Alzheimer Disease. J Am Phys Ther. 2009; 89: 6: 569-579. Available at http://ptjournal.apta.org/content/89/6/569.long. Accessed February 20, 2013.

21. Sources • 16. Mirolsky-Scala G, Kraemer T. Fall Management in Alzheimer-related Dementia: A Case Study. J Geriatr Phys Ther. 2009; 32: 181-189. Available at http://journals.lww.com/jgpt/Fulltext/2009/32040/Fall_Management_in_Alzheimer_related_Dementia__A.7.aspx. Accessed February 20, 2013. • 17. Helbostad JL, Taraldsen K, Saltvedt I. Physical Activity in the Prevention and Treatment of Disease. 316-324. Available at http://fyss.se/wp-content/uploads/2011/06/23.-Dementia.pdf. Accessed February 20, 2013. • 18. Gitlin LN, Earland TV. Dementia(Improving Quality of Life in Individuals with Dementia: The Role of Nonpharmacologic Approaches in Rehabilitation. International Encyclopedia of Rehabilitation. Available at http://cirrie.buffalo.edu/encyclopedia/en/article/28/. Accessed February 20, 2013. • 19. Holmes T. Managing rehabilitation challenges of patients with dementia. • The University of Texas Health Sciences Center. 2008. Available at http://www.google.com/url?sa=t&rct=j&q=physical+therapy+techniques+for+dementia&source=web&cd=19&cad=rja&ved=0CHQQFjAIOAo&url=http%3A%2F%2Fwww.uthct.edu%2Ffiles%2Fppt%2Frehab_dementia.ppt&ei=_zwYUZe1FJHH0AG9n4CoAw&usg=AFQjCNFpqqwQsM52q1EZHD4FqAGDvUNf9Q. Accessed February 20, 2013. • 20. Abreu M, Hartley G. The Effects of Salsa Dance on Balance, Gait, and Fall Risk in a Sedentary Patient With Alzheimer's Dementia, Multiple Comorbidities, and Recurrent Falls. J Geriatr Phys Ther. 2012. Available at http://www.ncbi.nlm.nih.gov/pubmed/?term=The+Effects+of+Salsa+Dance+on+Balance%2C+Gait%2C+and+Fall+Risk+in+a+Sedentary+Patient+With+Alzheimer%27s+Dementia%2C+Multiple+Comorbidities%2C+and+Recurrent+Falls. Accessed February 20, 2013.

22. Sources • 21. Heyn P. The effect of a multisensory exercise program on engagement, behavior, and selected physiological indexes in persons with dementia. Am J Alxheimer's Disease and Other Dementias. 2003; 18: 247-251. Available at http://aja.sagepub.com/content/18/4/247.short. Accessed February 20, 2013. • 22.Suzuki M, Kanamori M, Watanabe M, Nagasawa S, Kojima E, Ooshiro H, Nakahara D. Behavioral and endocrinological evaluation of music therapy for elderly patients with dementia. Nurs Health Sci. Available at http://www.ncbi.nlm.nih.gov/pubmed/?term=Behavioral+and+endocrinological+evaluation+of+music+therapy+for+elderly+patients+with+dementia. Accessed February 20, 2013. • 23. Raglio A et al. Music, music therapy and dementia: A review of literature and the recommendations of the Italian Psychogeriatric Association. Maturitas. 2012; 72(4): 305-310. Available at http://www.sciencedirect.com.ezproxy.ithaca.edu:2048/science/article/pii/S0378512212002009. Accessed February 20, 2013. • 24. Huusko TM, Karppi P, Veikko A, Kautiainen H, Sulkava R. Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: Subgroup analysis of patients with dementia. BMJ. 2000; 321(7269): 1107-1111. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC27517/. Accessed February 20, 2013.