2009/6/28 1 Walks with Dementia - the clinical perspective of physiotherapist Ms Fiona Tang Physiotherapist I Kowloon 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 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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2009/6/28
1
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
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.
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
References• Chung JCC, Chan TYP, Lee IWS, 2007. “Sensory-based intervention for management of maladaptive behaviors
in people with dementia”. Asian J Gerontol Geriatri 2007, 2, p.207-210 • Craig D, Mirakhur A, Hart DJ, Mcllroy SP, Passmore AP, 2005. “ A cross-sectional study of neuropsychiatric
symptoms in 435 patients with Alzheimer’s disease”. American Journal of Geriatric Psychiatry, 13(6), p.460-468• Davidson S, “Dementia: A systemic approach to understanding behavior”, Geriatrics & Aging, 10(3), p.182-191• Forstl H, Kurz A, 1999. “Clinical features of Alzheimer's disease”. European Archives of Psychiatry & Clinical
Neuroscience, 249 (6), p.288-290• Gold CA, Budson AE, 2008. “Memory Loss in Alzheimer’s disease: implications for development of therapeutics”.
Expert Review of Neurotherapeutics, 8(12), p.1879-1891• Pomeroy VM, warren CM, Honeycombe C, et al. 1999, “Mobility and dementia: is physiotherapy treatment during
respite care effective ?” Int J Geriatr Psychiatry, May 1999, 14(5), p.389-397• “Practical Guideline for the treatment of patients with Alzheimer's disease and other dementias”, American
Psychiatric Association. October 2007.• “Recovery mind and body; a framework for the role of physiotherapy in mental health and wellbeing”. The
Chartered Society of Physiotherapy. 2007• Rolland Y, Pillard F, Klapouszczak A, et al, 2007, “Exercise program for nursing home residents with Alzheimer’s
disease: a 1-year Randomized, controlled trial.” Journal of the American Geriatrics Society, 55(2), p.158-165• Scarmeas N, Brandt J Blacker D, et al.., 2007.”Disruptive behavior as a predictor in Alzheimer’s disease”. Arch
98(6), p.636-645 • Tatsch MF, Bottino CM, Azevedo D, et al, 2006. “Neuropsychiatric symptoms in Alzheimer's disease & cognitively
impaired, nondementied elderly from a community-based sample in Brazil: prevalence and relationship with dementia severity”. Am J Geriatr Psychiatry, 14(5), p.438-445.
• Tiraboshi P, Hansen LA, Thal Lj, Corey-Bloom J, 2004. “ The importance of neuritic plaques and tangles to the development & evolution of Ad’. Neurology 62 (11), p.1984-1989
• Tuet RWK, Lam LCW, 2006. “A preliminary study of the effects of music therapy on Agitation in Chinese patients with dementia”. HK J Psychiatry , 16, p.87-91