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Walks with Dementia - the clinical perspective of

physiotherapist

Ms Fiona TangPhysiotherapist IKowloon Hospital

12th June 2009

Contents

• Common Presentation of Dementia • Key Principles of Physiotherapy • Identifying Needs• Management• Conclusion

Dementia

• Dementia of Alzheimer’s type, the most commonest form of dementia.

• Research indicates the disease is associated with plagues & tangles in the brain. (Tiraboschi, 2004)

• As a progressive disease, characterized by loss of neuron & synapses in the cerebral cortex & certain subcortical regions. (Wenk, 2003)

Common Presentation Common Presentation

Stage I (Early dementia)

• Memory problems. • Executive function & perception difficulty.• Language problems of shrinking vocabulary,

decrease word fluency. • Impaired execution of movement, fine motor

& coordination.• Patient may rebel & refuse to accept the

disease, become depressed / irritable or withdrawal into apathy.

Stage II (Moderate dementia) • Worsen memory problem.• Speech difficulties due to inability to recall

vocabulary, affecting reading & writing skill.• Progressive apraxia, affecting daily living

activities.• Patients tends to be restless, wandering,

sundowning, irritability, outburst of aggression, resistance to caregivers.

• Stress & strain on caregivers.

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Stage III (Severe dementia)

• Obvious intellectual impairment.• Disorientation about time, people & place. • Speech become unintelligible, eventually

complete mutism occurs.• Reduced mobility, loss of muscle mass,

developed generalized muscular rigidity, flexion gradually into fetal position & finally bedridden.

Stages of Alzheimer’s diseaseDuration Features

Stage I 1-3 years Poor memoryImpaired learning abilitiesLanguage problemsMinimal apraxiaPersonality change

Stage II 2-10 years Profound memory lossSpeech difficultiesProgressive apraxiaBehaviour problemsCarergiver stress

Stage III 8-12 years Severe impairment of cognitive functionsPhysical impairmentLoss of ability to care for oneself

The Key Principles of

Physiotherapy

The Key Principles of

Physiotherapy

The Key Principles of Physiotherapy

Identifying Patient and Caregivers’ Needs

Identifying Patient and Caregivers’ Needs

Psychosocial InterventionPsychosocial Intervention

Delivering Holistic Management

Physical InterventionPhysical Intervention

OptimizingOutcome OptimizingOutcome

Identifying NeedsIdentifying Needs

The Needs• Physical disability under aging process• Pain disorder • Mobility inhibition• Fall incident• Mood disarrangement • Behavioral problem • Caregiver burden

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Stage and Patients’ needsPresentation Needs

Stage I Memory dominant Mobility PromotionMood EnhancementCaregiver Support

Stage II Memory & cognitive dominant, physical disability progress

Pain ControlMobility PromotionFall PreventionMood EnhancementBehavior ManagementCaregiver Support

Stage III Physical dominant Physical Disability Management Caregiver Support

Holistic Approach

Physical needsPhysical needs

Psychosocial needsPsychosocial needs

ManagementManagement

Physiotherapy Management

1. Pain Control2. Mobility Promotion3. Fall Prevention4. Mood Enhancement 5. Behavior Management6. Caregiver Support

1. Pain Control

• Pain signals in dementia are under attended.• Patient has difficulty to present their pain,

distorted pain perception.• Patient might missed diagnosis as “somatic”

or attention seeking behaviour. • Pain and low mood is closely related. Patient

suffering from depressed mood often complain of physical pain.

Sharing Points:• Asking patient to draw picture of body figure or

to shade in a body chart. • Exploring the complex cause of pain, such as

neuro-tension, muscle imbalance, or prolonged unfavorable posture, which might be likely to be mistaken as “somatic”.

• Body awareness training with senses stimulation, boost the sense of body control.

• Acupuncture or Aromatic massage as adjunct.

1. Pain Control

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1. Pain Control

Benefits:• Patient gain personal satisfaction of retaining

certain amount of independence, hence delaying dependence on caregiver.

• Mobility meet the need of exercise, providing an outlet of energy; keeping elders active at day time, as to promote sleep pattern at night.

• Exercise habit development can help patient maintain mobility, muscle strength, balance, bone mass, cardio-pulmonary function & even digestion.

2. Mobility Promotion

2. Mobility Promotion

Potential causes of immobility:• Physical incapable contributes immobility.• Pain elicit on movement, inducing fear to

move.• Forget where to move.• Lack of interest about external environment• Easily fatigue or motor sluggish induced by

medication.

2. Mobility PromotionSharing Points:• Giving ‘positive’ instructions & prompting when

asking patient to move. • Avoiding distracting & noisy training environment.• Use of gestures & cues, e.g. touch cues, visual

cues, sound cues.• Ensure that elder can see the chair throughout

the sitting down sequence. • Making movement enjoyable; e.g. favorite

interests & pastimes, music, group dynamic.

2. Mobility Promotion 3. Fall prevention

Potential risk factors:• Patient forget that they cannot do a task without help. • Patient with wandering but poor sense of environment

hazard.• Misjudgment affect their safety & that of others, e.g.

frail person may attempt to help another to walk, they both fall.

• Misjudgment about the distance from the chair, results in landing on the floor.

• A strong color contrast on the floor or shinny strip may be ’seen’ as a step, patient may lose balance & fall when he takes an necessary step up.

• Medication causing postural hypotension and rigidity.

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3. Fall prevention

Sharing Points:• Recruiting visual-spatial facilitation on top of

physical training.• Ensuring sensory deficits are corrected with

eyeglasses or hearing aids.• Advice to caregiver on clearing of

environmental risks, e.g. loose furniture, poor lighting, cluttered surroundings.

• Community visit with home modification as indicated.

3. Fall prevention

3. Fall prevention 4. Mood enhancement• Patients with early-stage dementia recognize

poor prognosis & feel hopeless, tend to withdraw& become apathetic.

• If elders presented severe depressive symptoms, such as suicidal thought, close observation & therapeutic environment to be ensured.

• Exercise enhance mood by making them mindful with their body at work.

• ‘Movement with music’ program was conducted in PGDH, KH, in 2008; data reported increase in Happiness Score & decrease in Depression Scale.

4. Mood enhancement 5. Behavior Management

• Difficult behavior are usually grounded in; the tasks patient faces appear insurmountable, communication breakdown exist or environmental provoking.

• Try to approach in a calm, & explanation of treatment procedures allows elders with a sense of control over his body & personal space.

• Elders may misinterpret routine activities are being invasive & respond aggressively out of self-defense, so get patient psychological readybefore treatment.

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5. Behavior Management

• When fear & anxiety are the root cause of behavior, try to provide a sense of safety &security to patient, e.g. reducing stimulus in environment, touching, using a low, loving tone of voice.

• Local data reported that aromatic massagewith Melissa essential oils reduced the agitation level in intervention group of dementia with BPSD. (Chan K.T, 2006)

5. Behavior Management

6. Caregiver support

• Physical burden in assisting daily functioning of the dementia, especially as the disease progress with more physical dependency of the dementia.

• Problematic behaviour exhaust caregiver. • Feelings of guilt, frustration, anger,

powerlessness & hopelessness.• Caregiver leaves little time or energy for

themselves, e.g. neglect of socialization, poor sleep, etc.

• Utilizing community resource, such as HK Alzheimer's Association.

• Caregiver support groups.• Caregiver training, such as prosper manual

handling techniques, maneuver of walking aids or wheelchair, assistance in patient’s home exercise, relaxation techniques, healthylife-style establishment, etc.

6. Caregiver support

6. Caregiver support ConclusionIdentifying Patient and Caregivers’ NeedsIdentifying Patient and Caregivers’ Needs

Psychosocial InterventionPsychosocial Intervention

Delivering Holistic Management

Physical InterventionPhysical Intervention

Optimizing Outcome Optimizing Outcome

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Thank You …Thank You …

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