​Treating patients with Alzheimer’s and dementia

February 12th, 2019

Improving quality of life for seniors with diminishing cognitive abilities

For physical therapists, treating patients with Alzheimer's disease and dementia can seem like pushing a giant boulder up a hill. Since these patients’ are experiencing memory loss and declining cognitive abilities, becoming a little less like their old selves each day, central components of physical therapy, such as patient education, instruction and sticking to a prescribed plan of care, can be especially difficult, producing diminishing results over time.

But leading experts in elder care urge physical therapists not to assume that working with these patients will be ineffective or pointless, saying significant strides still can be made in improving patients’ mobility and quality of life.

"The No. 1 societal challenge that this population faces is discrimination based on ignorance," Lise McCarthy, who chairs the Academy of Geriatric Physical Therapy's Cognitive and Mental Health Special Interest Group, said in an interview with the American Physical Therapy Association’s PT in Motion magazine. McCarthy founded the SIG in 2014 as an educational resource and discussion forum for physical therapists and assistants working with this challenging patient group, which accounts for 5.5 million seniors in the United States, according to the Alzheimer’s Association.

McCarthy is a board-certified clinical specialist in geriatric physical therapy whose San Francisco-based home-health practice caters to seniors ages 80 and older who have Part B Medicare insurance. She said it is easy for physical therapists to give into “therapeutic nihilism,” the belief that these patients are beyond help, and many are unaware that Medicare does cover skilled therapy services for this population.

Of particular significance is the Jimmo v. Sebelius court settlement of 2013, which established that coverage for skilled therapy services does not depend on the patient’s potential for restoration but on whether skilled care is required and whether the medical reasoning and necessity of these services are clear.

“When a lot of people, even those within health-care fields, hear the word ‘dementia,’ it seems as if their mind shuts down,” McCarthy told PT in Motion. “It's because many people don’t know how to effectively communicate with this patient population. There’s a growing body of evidence about assessment and care-management strategies that PTs and PTAs can tap to help them feel more comfortable and effective serving these individuals.

“We don't have a problem thinking about how physical therapy can be successful with people with brain injury from trauma, stroke or other brain conditions such as cerebral palsy or multiple sclerosis,” McCarthy added. “The template PTs use to treat individuals with those conditions should be the same one we use for people with dementia. There’s a protocol we're trained to follow as clinicians.”

Since communicating with patients suffering from Alzheimer’s and dementia can be especially challenging, McCarthy said physical therapists will need to use different screening tools to identify their needs and establish treatment goals. Two tools she recommends are the Pain Assessment in Advanced Dementia (PAINAD) and the Functional Assessment Staging Tool (FAST), both described in detail with case studies on the Cognitive and Mental Health SIG's website.

In interviews with PT in Motion, McCarthy and other senior-care experts offered the following best practices for dealing with patients with cognitive decline:

  • Significantly slow your rate of speech, enunciate clearly and give patients extra time to process verbal cues, understanding that for many senior patients, hearing loss compounds the problem of cognitive decline.
  • Dementia patients gradually lose the ability to learn how to perform a task by thinking about it and increasingly must learn by doing it, so physical therapists should teach them how to do things the same way, in the same setting and using the same cues to prevent the encoding of mistakes.
  • Improve your writing skills so you can better advocate for coverage of skilled therapy services under Medicare.
  • Smile when appropriate because even patients with declining mental skills are able to understand this important part of nonverbal communication. Even patients with advanced Alzheimer’s who cannot remember people’s names, or even their own name, often can remember how they feel about a person, so kindness and friendliness remain important.
  • Use fitness and rehabilitation equipment that the patient is familiar with and is more likely to remember how to use, rather than introducing new equipment.
  • Identify patients’ strengths and abilities and focus on nurturing those rather than trying to help patients regain abilities that they have lost.
  • Consult with patients’ family members and caregivers to learn about their likes, dislikes, personal history, abilities, and interests. Finding ways to incorporate a patient’s hobbies and interests into physical therapy can enhance their interest in therapeutic activities and their cooperation with therapists.
  • Observe patients’ daily routine and ask caregivers how they get tasks done.
  • Screen every patient 60 or older for cognitive issues, even if no such issues are documented. It also is important to assess and treat common age-related conditions such as vision loss, hearing loss, degenerative joint disease, dehydration, and polypharmacy.

Recent studies and meta-analyses have found that even patients with severe dementia can derive some benefit from exercise and physical therapy, and physical activity can be an effective cognitive therapy for people with brain disease. Physical therapy can help these patients’ remain at home longer by improving their balance, ability to perform the tasks of daily living and ability to interact with family and caregivers.

"That's such a powerful thing for them, their caregivers and the health-care system,” Julie Ries, a professor of physical therapy at Marymount University in Arlington, Va., told PT in Motion. “And the literature is showing not just physical benefits but cognitive ones as well in slowing dementia's progression."

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