Post on 14-Aug-2019
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 1
PT MANAGEMENT OF PATIENTS WITH DEMENTIA: USING A STRENGTH & FUNCTIONALLY
BASED APPROACH
Nicole Dawson, PT, PhD, GCSFPTA Conference – Orlando
September 26, 2015
LEARNING OBJECTIVES
• The Participant will be able to: describe the constructs affected during pathological cognitive aging
distinguish the different types of dementia and their symptomology
recognize the progression of dementia and appropriate treatment goals for each stage
contrast differences between strength‐based approach and traditional medical model
LEARNING OBJECTIVES
• The Participant will be able to: appraise remaining strengths and domains requiring compensation in patients with dementia
outline current evidenced‐based interventions and best practices in literature
utilize effective communication strategies and person‐centered care to maximize outcomes
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 2
COGNITION
• “thinking”
•Mental activity in the brain
when a person is processing
information
Introduction Communication Strategies Treatment Facilitators Research Summary
COGNITION & FUNCTION• Hierarchical relationship linking cognition and function (Marshall et al., 2011; Njegovan et al., 2001)
• More complex tasks require higher levels of cognitive ability
• Link between gait and executive function (Ijmker& Lamoth, 2012; McGough et al., 2011)
Introduction Communication Strategies Treatment Facilitators Research Summary
BASIC COGNITIVE PROCESSES
• Sensory functioning
• MemoryWorking memory
Short‐term memory
Long‐term memory
• Attention Inhibition
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 3
HIGHER‐ORDERED COGNITIVE PROCESSES
• Problem‐solving
• Decision making
• Judgment
• Reasoning & Logic
• Reading
• Language
• Orientation
• Visuospatial functioning
• Prospective memory
Introduction Communication Strategies Treatment Facilitators Research Summary
COGNITIVE PROCESSES• Implicit processing The use of unconscious and automatic processing for learning and retrieving information
• Explicit processing The use of conscious and effortful processing for learning and retrieving information
Can be considered ‘intentional’ learning/retrieval
• Meta‐cognition Higher‐level processing skills used in goal‐directed behavior
Goal selection, planning, initiation, self‐monitoring
Introduction Communication Strategies Treatment Facilitators Research Summary
Ciccarelli & White, 2009, p. 225
EXPLICIT LEARNING AND MEMORY
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 4
Ciccarelli & White, 2009, p. 235
OTHER TYPES OF MEMORY
• Prospective memory Remembering to execute an action planned for the future
Time based or event based
• Emotional memory Ability to retrieve memories that are emotionally relevant or charged
Introduction Communication Strategies Treatment Facilitators Research Summary
DEMENTIA
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 5
DEMENTIA
• Not a specific disease, classifies range of symptoms
• Symptoms must be severe enough to interfere with daily activities
• Serious mental decline is NOT a part of normal aging
Introduction Communication Strategies Treatment Facilitators Research Summary
SIGNS & SYMPTOMS OF DEMENTIA
• Memory loss
• Communication & language deficits
• Focus & attention deficits
• Difficulty with reasoning & judgment
• Visual perception deficits
• Behavioral disturbances
• Personality or affective changes
Introduction Communication Strategies Treatment Facilitators Research Summary
DEMENTIA VS. NORMAL AGING
SIGNS OF DEMENTIA** TYPICAL AGE‐RELATED CHANGES
Poor judgment & decision making Making a bad decision once in a while
Inability to manage budget Missing a monthly payment
Losing track of the date or the seasonForgetting which day it is & remembering later
Difficulty having a conversationSometimes forgetting which word to use
Misplacing things and being unable to retrace steps to find them
Losing things from time to time
Alzheimer’s Association, 2012**NOTE: compared to usual behavior
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 6
CAUSES OF DEMENTIA
• Variety of illnesses and conditions that may lead to symptoms of dementia
• Irreversible Neurodegenerative disorders
• Reversible Depression
Delirium
Introduction Communication Strategies Treatment Facilitators Research Summary
IRREVERSIBLE DEMENTIAS • Alzheimer’s disease
Introduction Communication Strategies Treatment Facilitators Research Summary
ALZHEIMER’S DISEASE• Most common type of dementia
• 5.4 millions Americans with AD, expected to triple over next 50 years
• Americans 65+, 1 in 8 has Alzheimer’s; and nearly half of people aged 85 and older have the disease
• Risk factors Age, low education, genetic (APOe4), lifestyle
• Pathobiology & Etiology
• Gradual and progressive course
Grossman, Bergmann & Parker, 2006
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 7
PROGRESSION OF ALZHEIMER’S PATHOPHYSIOLOGY (Sperling et al., 2011)
Sperling et al., 2011
IRREVERSIBLE DEMENTIAS
• Alzheimer’s disease
• Vascular dementia
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 8
VASCULAR DEMENTIA
• 2nd most common form of dementia Represents 10‐20% of cases in U.S.
• Over 4 million Americans have vascular dementia
• Prevalence is 9 times higher in patients who have had a stroke
• Risk factors Stroke, diabetes, hypertension
• PathologyGrossman, Bergmann & Parker, 2006
IRREVERSIBLE DEMENTIAS
• Alzheimer’s disease
• Vascular dementia
• Lewy body dementia
Introduction Communication Strategies Treatment Facilitators Research Summary
DEMENTIA WITH LEWY BODIES
• Primarily affects the basal ganglia
• Pathologic aggregations of alpha‐synuclein
• 0.7% prevalence rate
• No risk factors have been identified
• Progressive decline of cognitive function
Grossman, Bergmann & Parker, 2006
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 9
DEMENTIA WITH LEWY BODIES
• Core features Fluctuations
Visual hallucinations
Agitation & aggression later in disease
Spontaneous parkinsonism
• Often present in mixed dementias (with AD)
• Strong similarities with PD dementia 12‐month rule (<12 months Lewy bodies)
Grossman, Bergmann & Parker, 2006
IRREVERSIBLE DEMENTIAS
• Alzheimer’s disease
• Vascular dementia
• Lewy body dementia
• Frontotemporal lobar degeneration
Introduction Communication Strategies Treatment Facilitators Research Summary
FRONTOTEMPORAL DEMENTIA (FTD)
• Also known as Pick’s disease
• Prevalence of 3.6 – 15.0 in 100,000
• Age of onset 45‐65
• 4‐6 year duration of illness til death
• Most common presentation Profound changes in personality & social conduct
Grossman, Bergmann & Parker, 2006
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 10
FRONTOTEMPORAL DEMENTIA (FTD)
• Unaware of consequences
• Cognitive decline Attention, abstraction, planning & problem solving
Memory, language, spatial functions well preserved
• Gross atrophy in frontal and temporal lobes found on neuroimaging and autopsy
• Only moderate correlation between clinical & pathological findings
Grossman, Bergmann & Parker, 2006
IRREVERSIBLE DEMENTIAS • Alzheimer’s disease
• Vascular dementia
• Lewy body dementia
• Frontotemporal lobar degeneration
• Mixed dementia
• Parkinson’s disease
• Creutzfeldt‐Jacob disease
• Huntington’s disease
• Wernicke‐Korsakoff Syndrome
REVERSIBLE DEMENTIAS
• Depression
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 11
DEPRESSION
• Affective disorder
• Loss of ability to enjoy usual activities
• More likely to manifest somatic symptoms, hyperactive agitated behavior and delusions (Johnson, Sims & Gottlieb, 1994)
• Pseudodementia Cognitive impairment due to depression
True pseudodementia is rare, usually coexist
Consider pattern of onset and level of severity
REVERSIBLE DEMENTIAS
• Depression
• Delirium
Introduction Communication Strategies Treatment Facilitators Research Summary
DELIRIUM
• Acute disturbance of consciousness
• Decreased attention and change in cognition
• 10‐15% of all hospitalized & surgical patients (Johnson, Sims & Gottlieb, 1994)
• Disorientation to time & place
• Hallucinations may be presents leading to possible behavioral outbursts
• Hypoactive form may lead to lethargy
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 12
REVERSIBLE DEMENTIAS
• Depression
• Delirium
• Normal pressure hydrocephalus
• Brain tumor
Introduction Communication Strategies Treatment Facilitators Research Summary
DIFFERENTIAL DIAGNOSIS• Not mutually exclusive Prevalence of delirium superimposed on dementia ranged from 22‐89% (Fick et al., 2002)
44% were missed by medical professionals
• Exclude concurrent metabolic, endocrine, infection, drug effects
• Acute vs. insidious onset
• Need for interdisciplinary cooperation and assessment Physical therapist, occupational therapist, speech therapist, nursing, physician, social worker, psychologist, patient, family
Insel & Badger, 2002
PERSONHOOD
• Dementia not always just about decline & loss
• Growth can be facilitated by others in areas of coping skills, compensatory mechanisms, creativity, and emerging personality
• A “survivor” struggling to maintain personal identity
Ryan et al., 2005
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 13
PERSONHOOD
• Care provider must have skills and attitude to relate to the “person” instead of reacting to the disease
• Person‐centered care vital to successful dementia interventions
• Care provider also has weaknesses, possibly interpersonal skills or lack of patience
Ryan et al., 2005
Introduction Communication Strategies Treatment Facilitators Research Summary
FDA‐APPROVED TREATMENTS
• Cholinesterase inhibitors Donepezil (Aricept)
Galantamine (Razadyne)
Rivastigmine (Exelon)
Tacrine (Cognex: discontinued in U.S.)
• N‐methyl‐D‐aspartate (NMDA) receptor antagonistMemantime (Namenda)
Raina et al., 2008
Introduction Communication Strategies Treatment Facilitators Research Summary
DEMENTIA & REHABILITATION
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 14
CAN PATIENTS WITH DEMENTIA BENEFIT FROM REHABILITATION?
YES!Patients with dementia can participate in therapy!
Patients with dementia can improve!
Persons with dementia can learn!
Introduction Communication Strategies Treatment Facilitators Research Summary
COMMON BARRIERS
• Difficulty following directions
• Conversational barriers
• Limited follow through
• Family interference
Introduction Communication Strategies Treatment Facilitators Research Summary
DEMENTIA & REHABILITATION
• Motor function prior to a hip fracture was the most important predictor of motor gain after hip fracture, not cognitive level (Beloosesky et al., 2002)
• Participation in rehabilitation to be the mediatorbetween cognitive impairment and functional outcomes (Lenze et al., 2004)
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 15
ROLES OF THERAPY SERVICES• Early stages (GDS Stage 4) Maintain functional status Fall prevention
• Mid‐stages (GDS Stages 5‐6) Maintain ADLs Compensatory strategies Family education & training
• Later stages (GDS Stage 7) Family training Positioning Contracture management
Introduction Communication Strategies Treatment Facilitators Research Summary
STRENGTH‐BASED APPROACH
Yarry, Dawson & Judge, 2011
BENEFITS OF STRENGTH‐BASED APPROACH
• Provide challenge and meaning
• Present with tasks that can be successfully completed
• Lack of activity = distressed mood, frustration, problematic behaviors
• Activity = reduced isolation, increased self‐esteem, sense of control
Yarry, Dawson & Judge, 2011
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 16
REMAINING STRENGTHS• Focused attention remains intact (Chamberlain et al., 2011;
Perry & Hodges, 1999; Nebes & Brady, 1989)
• Procedural (implicit) memory relatively intact (Beaunieux et al., 2012; Machado et al., 2009; Mahendra et al., 2011)
• Reading remains intact until late in disease (Chamberlain
et al., 2011; McGurn et al., 2004)
• Aspects of language remains intact until late in disease (McGurn et al., 2004)
• Left/Right orientation remains intact, unless it requires mental rotation (Lezak, 2004)
• Emotional memory (Moayeri et al., 2000)
Introduction Communication Strategies Treatment Facilitators Research Summary
REQUIRES COMPENSATION
• Short‐term memory deficits occur very early
• Problem‐solving difficulty
• Orientation is compromised early
• Prospective memory deteriorates early
Introduction Communication Strategies Treatment Facilitators Research Summary
Strength‐Based Approach
For Therapists
Communication Strategies
As Treatment Facilitators
Errorless Learning
Learning by Modeling
External Memory Aids
Spaced‐Retrieval
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 17
COMMUNICATION STRATEGIES
• Patience & acceptance Understanding communication issues that affect patient
Allowing enough time for response or action
• K.I.S.S. (Keep It Short and Simple) Avoid unnecessary details or fillers during directions
Judge, Yarry & Orsulic‐Jeras, 2010
Introduction Communication Strategies Treatment Facilitators Research Summary
COMMUNICATION STRATEGIES
• Rephrasing questions Stating questions that focus on immediate rather than short‐term memory
Instead of “Did you have any pain over past few days?”, ask “Are you having pain right now?”
• Redirection with verbal and/or physical cues Repeating information or using physical cues to direct attention
Displaying a bright sign on the bathroom
Guiding hands to arms of chair during transfer
Judge, Yarry & Orsulic‐Jeras, 2010
Introduction Communication Strategies Treatment Facilitators Research Summary
COMMUNICATION STRATEGIES
• Narrowing choices Asking questions that can be answered in a few words
“Do you want to toss a ball in here or walk around outside?”
• Connecting with others Questions that encourage conversation
“What advice would you give to a young couple that wanted to get married?”
Judge, Yarry & Orsulic‐Jeras, 2010
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 18
DEMENTIA & LEARNING
• Errorless learning and learning by modeling resulted in better learning than trial & error learning in IADL (Dechamps et al., 2011)
• Motor learning is similar to healthy controls (Eslinger & Damasio, 1986)
Introduction Communication Strategies Treatment Facilitators Research Summary
EXTERNAL MEMORY AIDS
• Calendars
• Signs and labels
• Lists
• Notebooks
Yarry, Dawson & Judge, 2011; Judge et al., 2010
Introduction Communication Strategies Treatment Facilitators Research Summary
EXTERNAL MEMORY AIDS• Accessible Should be placed somewhere that will be seen
• Bright Bright and bold with adequate contrast
• Legible Large, easy to read font or handwriting
• Explicit Detailed and providing adequate explanation
• Done A way to demonstrate objective completed will be more useful
Crossing off list; check box
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 19
SIGNS & LABELS
TAKE YOUR CANE WITH YOU PLEASE
Introduction Communication Strategies Treatment Facilitators Research Summary
LISTS
Getting up out of chair
1. Scoot forward
2. Feet flat on floor
3. Hands on arm rests
4. Push up to stand
5. Hands on walker for balance
Introduction Communication Strategies Treatment Facilitators Research Summary
LISTSRemember to Check box when done
1. Take pills with breakfast
2. Take pills with dinner
3. Take pills at bedtime
4. Do exercises at bedtime
Appointments Check box when done
1. Dr. Lucas at 2:00 pm
2.
Other
1.
2
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 20
SPACED‐RETRIEVAL
• Capitalizes on maintenance of implicit or procedural memory
• Method of learning and retaining information by recalling that information over increasingly longer periods of time (Camp et al., 1996, p.196)
• Participants were able to learn to use external aids using both strategies (Bourgeois et al., 2003)
Camp et al., 1996; Cherry et al., 1999
Introduction Communication Strategies Treatment Facilitators Research Summary
APPLICATIONS OF SPACED‐RETRIEVAL
• Physical Therapy Safety issues Remembering to lock wheelchair brakes, push off from arms of wheelchair, or feel chair on back of legs before sitting
Gait training Choose most important component
Step length, stay within boundaries of
assistive device, sequence with cane
Brush & Camp, 1998b
Introduction Communication Strategies Treatment Facilitators Research Summary
APPLICATIONS OF SPACED‐RETRIEVAL
• Speech‐Language PathologyCompensatory techniques for anomia
Teaching client to describe function or attribute of object when cannot think of name
Compensatory swallow techniques
Facilitate follow‐through with alternating sips & bites
Brush & Camp, 1998b
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 21
APPLICATIONS OF SPACED‐RETRIEVAL
• Speech‐Language Pathology Dysarthria
Enable patient to recall correct tongue placement, proper rate of speech, and/or breathing techniques
Voice Training
Help remind patient to use proper placement of voice, use adequate breath support, or maintain proper pitch
Brush & Camp, 1998b
Introduction Communication Strategies Treatment Facilitators Research Summary
APPLICATIONS OF SPACED‐RETRIEVAL
•Occupational TherapyAdaptive equipment
Helps patients to remember to use new equipment
Activities of daily living Enable patient to remember one step or many steps in sequence
Brush & Camp, 1998b
Introduction Communication Strategies Treatment Facilitators Research Summary
APPLICATIONS OF SPACED‐RETRIEVAL
• Staff or family memberRepetitive questioningDetermine the answer the patient would
like to hear; teach the patient the
information
Word finding difficulty
Teach the names of important objects or people
Brush & Camp, 1998b
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 22
APPLICATIONS OF SPACED‐RETRIEVAL
• Staff or family member Times, numbers, and other important information
Enable patients to remember birthdates, a room number, anniversary
Location of a message or use of a calendar
Teach the patient where to look for information
Brush & Camp, 1998b
Introduction Communication Strategies Treatment Facilitators Research Summary
SPACED‐RETRIEVAL TECHNIQUE
• Begin with prompt question for the target behavior
• Train the client to recall the correct answer
• When retrieval is successful, the interval preceding the next recall test is increased
• If a recall failure occurs, the participant is told the correct response and asked to repeat it
• The following interval length returns to the last one at which recall was successful
Camp et al., 1996; Cherry et al., 1999
SPACED‐RETRIEVAL TECHNIQUE
• To begin next session, the participant will be asked the target question
• If correct, there is no further training that session
• If incorrect, provide immediate correct answer, ask for immediate recall then ask for recall after the amount of time for the longest successful interval from the last session
Brush & Camp, 1998b; Camp et al., 1996; Cherry et al., 1999
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 23
• If that is answered incorrectly, the correct answer will be provided immediately and a step backwards will be warranted until the correct response is given
• SUCCESS achieved when participant correctly remembers at the beginning of 3 sessions
Brush & Camp, 1998b; Camp et al., 1996; Cherry et al., 1999
Introduction Communication Strategies Treatment Facilitators Research Summary
• Identify goal
• Target question and responseMust be meaningful for patient
Choose cue that has been successful
Rely on long‐term memory
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 24
Brush & Camp, 1998b; Camp et al., 1996; Cherry et al., 1999
Introduction Communication Strategies Treatment Facilitators Research Summary
SPACED‐RETRIEVAL
• Successful integration of SR into a clinical speech therapy setting with significant results (Brush & Camp, 1998a)
• Efficacy of SR for eating difficulty and ability (Lin et al., 2010)
• Spaced Retrieval TherAppy
Camp et al., 1996; Cherry et al., 1999
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 25
“I don’t know who you are but I know your name is Jennifer. I don’t know
how I know it. Your name is Jennifer”.
Brush & Camp, 1998b
RESEARCH IN DEMENTIA
CURRENT RESEARCH ON DEMENTIA
• New Diagnostic Criteria and Guidelines for Alzheimer's Disease Dementia due to Alzheimer’s disease (McKhann et al., 2011)
Mild cognitive impairment due to Alzheimer’s disease (Albert et al., 2011)
Preclinical Alzheimer’s disease (Sperling et al., 2011)
Neuropathic assessment of Alzheimer’s during an autopsy (Hyman et al., 2012)
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 26
COGNITIVE STIMULATING TASKS & DEMENTIA
• Frequent participation in cognitively stimulating tasks reduce risk for Alzheimer’s disease (Wilson et al., 2002)
• Late life cognitive activities influence cognitive reserve independently of education (Hall et al., 2009)
• For those with lower education, engaging frequently in cognitive activities showed significant compensatory benefits for episodic memory (Lachman et al., 2010)
Introduction Communication Strategies Treatment Facilitators Research Summary
FITNESS, COGNITION & AGING
• Women with greater physical activity levels at baseline, less likely to experience cognitive decline (Yaffe et al., 2001)
• Fitness level at baseline predicted higher levels of cognitive performance six years later (Barnes et al., 2003)
Kramer, Colcombe et al., 2005
Introduction Communication Strategies Treatment Facilitators Research Summary
FITNESS, COGNITION & AGING
• Physical activity may have protective effects on cognition
• Physical activity level associated with lower risk of cognitive impairment, Alzheimer’s disease or any dementia (Laurin et al., 2001)
Kramer, Colcombe et al., 2005
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 27
DEMENTIA & EXERCISE
• Overall, evidence is mixed on efficacy of exercise for IWDs Due to heterogeneity of methodology and outcomes
Lack of clear theoretical or conceptual framework
Introduction Communication Strategies Treatment Facilitators Research Summary
DEMENTIA & EXERCISE
• Important to follow exercise science guidelines Physical Stress Theory (Mueller & Maluf, 2002)
Principle of specificity (vanBeveren & Avers, 2012)
• Adding techniques to improve implementation and adherence with IWDs Strength‐Based approach
Ensuring pleasure and enjoyment (Costello et al., 2011)
Tailoring programs to individual (Costello et al., 2011)
Introduction Communication Strategies Treatment Facilitators Research Summary
STRENGTH‐BASED APPROACH & EXERCISE
• Using familiar and functional activities Rely on procedural long‐term memory
Avoid unfamiliar exercises and equipment
• Allowing individual to choose activity
• Encouraging continuation of enjoyed activitiesMay require adaptation
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 28
Dawson, 2015
DEMENTIA & FALLS
• Risk factors for fallsMusculoskeletal & mobility deficits
Medications or medical condition
History of falls
Fear of falling
Environmental hazards
Cognitive impairment
Introduction Communication Strategies Treatment Facilitators Research Summary
DEMENTIA & FALLS
• Tinetti et al. (1988) Low prevalence but very high correlation
• Rubenstein reviews (1994, 2006) Cognitive deficits in addition to musculoskeletal, visual deficits, and hypotension
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 29
DEMENTIA & FALLS
• Current assessment tools may be difficult due to complex instructions or multi‐step directions (Nordin et al., 2006)
• Studies demonstrating reliability
• Few studies have assessed predictive validity Use of Berg Balance Scale provides mixed evidence (Kato‐Narita et al., 2011; McGough et al., 2013)
7‐item Physical Performance Test did not relate to falls (Farrell et al., 2011; Ryan et al., 2011)
Introduction Communication Strategies Treatment Facilitators Research Summary
TOP 5 TIPS TO FACILITATE SUCCESS
•Assume your patient will succeed
• Listen, stop & listen again
• Slow down
•Use multiple modes of cuing
• If you get frustrated or sense your patient is frustrated, walk away
Introduction Communication Strategies Treatment Facilitators Research Summary
TOP 5 RULES FOR PERSONHOOD
• Your patient is a person, a human‐being
• Your patient deserves to be treated with respect and dignity
• Your patient has the right to be involved in his/her care
• Your patient expects you to give your best
• Your patient needs your help
Introduction Communication Strategies Treatment Facilitators Research Summary
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 30
COMMON BARRIERS• Difficulty following directions K.I.S.S. Multiple modes of cuing Learning by modeling External memory aids
• Conversational barriers Patience & acceptance Rephrasing questions Narrowing choices
• Connecting with others Limited follow through External memory aids Family/staff training
• Family interference Educating family members on techniques Involving patient and family as active participant
CASE STUDY, age 85, Left CVA
• 85 year old male, lived with wife
• Home P.T., O.T., S.T. following CVA with 2 week hospital and rehab stay
• Residual R hemiparesis
• Hypertension, CHF, vascular dementia
• Moderate to severe anomia, mild dysarthria, short‐term memory loss, impaired judgment
• Unsteady gait, shortness of breath, impaired balance, poor endurance
STRENGTH‐BASED ASSESSMENT
• Able to follow 1‐2 step commands with familiar tasks
• His wife is healthy and ambulatory
• History of daily “mall walking” with his wife
• Hobbies included woodworking, playing checkers, and fishing
• Retired high school math teacher
FPTA Annual ConferencePT Management of Dementia
September 26, 2015
Nicole Dawson, PT, PhD, GCSUniversity of Central Florida 31
CASE STUDY, age 87, dementia
• 87 year old female, referred for recurrent falls
• Lives in secure dementia unit (7 years)
• Parkinson’s disease, COPD, chronic depression
• Wanders and furniture walks in unit
• Difficulty following 2‐step commands, poor balance, decreased functional ambulation
STRENGTH‐BASED ASSESSMENT
• Appears very social and friendly with residents and staff
• Hobbies included playing card and board games, scrapbooking
• Daughter and grandchildren visit weekly
• Owned and operated dry cleaning business for 25 years
THANK YOU!Questions?
Email: nicole.dawson@ucf.edu
References FPTA Conference
Albert, M. S., DeKosky, S. T., Dickson, D., Dubois, B., Feldman, H. H., Fox, N. C., . . . Petersen, R. C. (2011).
The diagnosis of mild cognitive impairment due to Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimer's & Dementia, 7(3), 270-279.
Alzheimer's Association. (2012). 2012 Alzheimer’s disease facts and figures. Alzheimer's & Dementia, 8(2), 131-168.
Barnes, D. E., Yaffe, K., Satariano, W. A., & Tager, I. B. (2003). A longitudinal study of cardiorespiratory fitness and cognitive function in healthy older adults. Journal of the American Geriatrics Society, 51(4), 459-465.
Beaunieux, H., Eustache, F., Busson, P., De La Sayette, V., Viader, F., & Desgranges, B. (2012). Cognitive procedural learning in early Alzheimer's disease: Impaired processes and compensatory mechanisms. Journal of neuropsychology, 6(1), 31-42.
Beloosesky, Y., Grinblat, J., Epelboym, B., Weiss, A., Grosman, B., & Hendel, D. (2002). Functional gain of hip fracture patients in different cognitive and functional groups. Clinical rehabilitation, 16(3), 321-328.
Brush, J. A., & Camp, C. J. (1998). Using spaced retrieval as an intervention during speech-language therapy. Clinical Gerontologist, 19(1), 51-64.
Camp, C. J., Foss, J. W., O'Hanlon, A. M., & Stevens, A. B. (1996). Memory interventions for persons with dementia. Applied Cognitive Psychology, 10(3), 193-210.
Chamberlain, S. R., Blackwell, A. D., Nathan, P. J., Hammond, G., Robbins, T. W., Hodges, J. R., . . . Sahakian, B. J. (2011). Differential cognitive deterioration in dementia: a two year longitudinal study. Journal of Alzheimer's Disease, 24(1), 125.
Cherry, K. E., Simmons, S. S., & Camp, C. J. (1999). Spaced retrieval enhances memory in older adults with probable Alzheimer's disease. Journal of Clinical Geropsychology, 5(3), 159-175.
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