#PTonICE Daily Show – Wednesday, December 13th, 2023 – A framework for rehab for people with dementia

In today’s episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Alex Germano discusses how relationship, communication, motor learning and environment can impact your outcomes and plan of care delivery while working with people with dementia. 

Take a listen to learn how to better serve this population of patients & athletes.

If you’re looking to learn more about live courses designed to better serve older adults in physical therapy or our online physical therapy courses, check our entire list of continuing education courses for physical therapy including our physical therapy certifications by checking out our website. Don’t forget about all of our FREE eBooks, prebuilt workshops, free CEUs, and other physical therapy continuing education on our Resources tab.


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Hello everyone and welcome to the PT on Ice daily show brought to you by the Institute of Clinical Excellence. Happy Wednesday and welcome to today’s segment of Geri on Ice. My name is Alex Germano. I’m a member of the older adult division and we just finished up our last cohort of our level 2 course. this past a week or so ago and we just debuted our new week all about cognitive impairment and I found one of the articles to be very impactful and I wanted to review that here with you all today. It is called a framework for rehabilitation for older adults living with dementia by Julie Reese from Marymount University in Arlington, Virginia. We’ll dive into these four best practice domains that you can incorporate when working with this population and then how that’ll really change kind of your outlook and how you see exercising and rehabilitation in this population. So before we dive in, I just wanted to orient you to some of the new courses or the courses that we have upcoming in the new year. First, we have MMOA Level 1 and Level 2. Those are our online courses. Those begin in early January. So we would love to see you hop into those cohorts. They typically sell out or get really close to it. So we’d recommend you jump in early. We also have upcoming live courses. I’ll name some of the spots through February here. So we’ve got Santa Rosa, California, Greenville, South Carolina, Kearney, Missouri, as well as Oklahoma City, and Gales Ferry, Connecticut. So we hope to see you on the road in 2024.

Now, let’s dive in. So first, many rehab providers recognize that people with dementia would benefit from rehab services, but we run into many barriers and biases when working with a population that impact the delivery of our services. We have problems like, well, they’re non-compliant. They don’t cooperate. They won’t get better, so they don’t need our services. Or they don’t have caregivers, so our services aren’t trainable, and therefore, it’s not gonna be necessary. Or if you’re like me, you run into a lot of personal frustration. And I will speak to myself, or for myself only here, but it seems to, I’ve had some recognition from other providers that they also feel this way. I struggle bringing my fitness forward approach to this population, right? I’m, if you know me, I’m very like exercise heavy, like doing very traditional strength and conditioning movements. And sometimes those types of sessions don’t work well for subsets of patients with mild cognitive impairment or really dementia. I struggle when I have goals in mind for the session, And then we get none of them done because most of the time I’m managing behavioral outbursts or orientation problems. And when I only get three out of the 10 exercises I wanted to do get done, when I got those done, I feel like a failure, right? Three out of 10, that’s not great for me. And I feel like my immediate reaction is sometimes, oh, therapy, I’m not going to work for this person. But really it’s the type of exercise I’m providing, how I’m delivering it, that isn’t working. Okay, so it’s not them, it’s me. And my thought is that many of us are out here fighting to push our agenda on patients with dementia, when in reality, maybe our role as providers in this space is to be someone who’s providing an opportunity for movement and letting go for the concern of what type of exercise and how much exercise that we need to get done in the session.

I’ve started to reframe my vision of success during a session with somebody with dementia who may not follow those typical exercise instructions. I have started to realize that by me just being there, if we moved at all, that’s 100% more movement than they were going to do if I didn’t show up. or they didn’t have me that day. And no movement is, there’s no movements out there that are bad movements. And there’s no exercise that is bad exercise, especially in this population. So any movement or exercise should really be success for us, right? If we got them moving at all, that should be successful. And so if we change our expectation, I think the number one way, that’s the number one way we can really fight some of the burnout that we’re experiencing when working with this population. Now, how to structure these sessions. Let’s jump into this paper because I really found this super interesting. This paper explains a model with four domains that we should focus on or emphasize when working with patients with dementia. We have relationship, communication, motor learning, and environment.

First, let’s talk relationship because this is where we’re going to spend a lot of the time. A lot of the time. Nothing is going, we prioritize relationships over everything. That’s your new mindset. Relationship over everything. Nothing will get done if we don’t have a personal connection with the patient and understand with great curiosity what they enjoy in life, who they find important, and what makes them tick. So in our evaluations with patients, we’re not only trying to solve their movement problems or screen those, we need to find out about this person. Give me some details. Give me a list of names that’s important to them. Who are your loved ones? Also, what were your past hobbies? Even when we don’t have access to a ton of personal information, our approach in prioritizing a relationship will matter. We need to be consistent. We need to be empathetic. We need to always enter these interactions with the expectation of success. Our patients can feel that energy coming off of us and it’s important that we bring that to the table.

Now, a giant barrier to exercise is managing behavioral or psychological problems and symptoms of dementia. This can get in the way big time of that fitness forward approach or bringing exercise to the patient. Now, first, these symptoms, and it’s important to recognize that these symptoms are often a manifestation of something else going on. It could be an acute medical problem, could be a UTI, could be an infection. It could be unmet needs. They’re hungry. They’re tired. They need to use the bathroom. They feel unclean. It could be from a lack of a meaningful activity. It could be from stress from a caregiver or a loved one, they can feel that stress, it could be an uncomfortable environment. So before we write people off, we have to go, hey, maybe we need to problem solve some of these things and really clear and make sure none of these things are going on before we say that they’re non-compliant with therapy. And we need to lean into that problem solving during the sessions. That’s why we’re there is to solve this problem of why won’t this person move much, right? So we’re going to spend time solving the problem. Now, I’m not saying that we can spend 10 sessions with a person doing absolutely no physical interventions. I don’t think that’s terribly appropriate. And I think Medicare at some point would be wondering how they could reimburse us for all that time. But I am saying that we are going to spend time during sessions working on the behavioral problems, working through it to get to some type of skilled, meaningful movement. All of that time, all that problem solving, that behavioral management, that’s skilled time. That’s skilled and that’s billable. We just need to do a good job in our documentation of explaining what we did, how we did it, and what the result was. And then we use that information next session to kind of guide us and get the patient hopefully moving faster and getting them up and going quicker.

Now I’ll show you an example though, because I understand there are going to be subsets of this population we meet that wouldn’t be appropriate for therapy after a certain amount of time. So I’ll share this example of how behavioral management led to a discharge for me. I had a gentleman in the very end stages of dementia. I think I saw him during the last year of his life. He was very agitated and very aggressive. He wasn’t very fit. He wasn’t doing well physically, so he could not hit me, but he sure did try. And he became very agitated and very upset in my presence more often than not because he started to associate me with movement and he could not get his body to move how he wanted right he knew he there was some perception he knew what i was asking him to do was very difficult and very hard um and he associated me with that and that frustration and Stayed on for I think like 10 plus sessions like quite a bit of time Trying many different techniques trying many different behavioral management strategies giving them different equipment to use Showing really the caregiver and the wife how to do exercise with him in a meaningful way There was a lot of cursing me out. There was a lot of near hits to the face, but I Well, we started to realize that I was his trigger and that he was much happier exercising with the caregiver or the wife. So I gave them as many skills as I could. And then I bowed out. I got out, right? I was his trigger. So we parted ways, but I was able to provide some meaning and some context and at least explain how to exercise with him to his caregivers and loved ones with whom he’d exercise much better with. So I’m not saying every patient we need to fight through these issues, but we need to do a good job problem solving and giving as much meaning and value as we can. All right. Relationship number one.

Next up is communication. Highly important. We should be using communication with short, simple phrasing, yes, no options. We should consider eliminating distractions using repetition in our language, using body language, visual cues, and being comfortable with silence. So having a lot of patience. What’s more important though than slow speech, because it could be that we see people and we’re like, they have a cognitive impairment. So we’re just going to go really, really slowly. That’s not what we should do. Instead, we should speak at a normal pace, but allow more time for processing. So we’re going to consider the pacing at which we’re giving information. Now we should not see this diagnosis with dementia and automatically go to the most basic communication level. That can be, that can absolutely be wrong. People with mild to moderate, even dementia can actually understand, have meaningful conversations and execute multi-step commands. So don’t just see the diagnosis and go straight to the bottom levels of communication. Always consider eye level positioning, getting down onto their level. It kind of reduces this hierarchy effect that we can have if we’re talking above them. We’re going to use lots of positive body language and gestures. You’ve been seeing me gesture at you for the last 10 minutes. We’re going to use lots of gestures. Remember that our patients do communicate through unwanted behaviors. So if they’re getting tired, if they’re getting more confused, and that may cause disengagement and looks like they don’t want to do therapy, We need to recognize that and work to find the problem before we start saying people are uncooperative, before we start giving these super unhelpful labels. Also consider your cueing strategies in this population. I think these cueing strategies are for everyone, but especially in the context of dementia, it can be easy to jump right to physical cueing. We want to start first with a verbal prompt. move towards a visual cue or model the behavior. We then may use a tactile cue or some physical guidance. And then lastly, physical assist. So we’re like waiting to do physical assist to the very end.

All right, the next category is motor learning. We want to encourage implicit procedural type movements and training with folks. Learn by doing is our mantra. We need to prioritize both salient and functional tasks for the patient. It’s gotta mean something to them. That’s why digging into their hobbies and their life is really important. So if we wanted to do squats with somebody, potentially doing sit-to-stands from their favorite chair may actually improve participation. When we design sessions for older adults with dementia, we want to consider using a lot of repetition, the same exercises very consistently. We want to do a lot of blocked practice. So instead of maybe programming two very unique sessions each week, we would prefer keeping the same exercises in both sessions instead of using random practice like our AMRAPs, EMOMs, supersets. We may have to focus on one exercise at a time or maybe just two. Okay, so keeping it a bit more simple. In patients with Alzheimer’s disease as well, we see that we need to set them up for a lot of success and do more exercises that encourage errorless learning as errorless learning is more superior to errorful learning or really effortful learning. So we want to get our patient to move without a lot of mistakes. Obviously, we’ll have a range of mistakes that we deem allowable, but we want to really try to cue right before an error is made and not let them error through a movement. That struggle is not as beneficial to this population.

Lastly, we want to ensure we have sufficient intensity and challenge. The article writes, I love this portion, this article writes that we can confidently and competently oversee intensive interventions and encourage patients to work hard. We find that by people feeling challenged by exercises and activities, this is a positive and rewarding experience associated with increased confidence and self-esteem in individuals with dementia. So it seems like more intense exercises actually may be better perceived by this population, right? No infantilizing exercises here. So we need to monitor for intensity. We need to look for any observable physical signs of intensity, but also, behavioral signs, cognitive signs. One of my favorite things the article goes on to talk about was excess disability. That a lot of people with Alzheimer’s disease have this excessive disability, which they’re more functionally disabled than they should be given their impairments. And this is often a result of diminished opportunity for task performance, driven by well-intentioned or time-sensitive caregiver assistance. Loss of opportunity leads to loss of skill. Loss of opportunity leads to a loss of skill. So we need to encourage our caregivers to find small pockets of opportunity for the patient during the day to help maintain their activity levels. So the caregiver relationship is a whole different podcast, but really talking with that caregiver about, hey, when you’re structuring your day, what can the patient get involved in doing? Where can we get them a little bit more activity during the day? Loss of opportunity leads to loss of skill. So that’s something I talk often about with caregivers because unfortunately they make a lot of decisions to kind of cut out the patient in the process for very good reasons. I have an 18 month old at home. I understand why people do this, but it’s having a lot of grace and trying to see where are some opportunities that we can get this person to practice more.

Now the last environment was domain. Super simple here and probably pretty intuitive. We need to be mindful of our therapeutic atmosphere to encourage success. We need to prioritize patient safety. We need to keep them comfortable. Us documenting on a computer in a really busy environment may not be it for this person. We need to keep things routine and consistent. Don’t send in Different person for therapy every time this person’s probably gonna need a very familiar face. So you’re gonna want to keep the same provider at the same time at the same place Consistency is everything we want to minimize distractions and create an atmosphere of joy. I know that sounds really simple. I But these changes in particular can make a big impact. Honestly, changing my attitude was one of the ways that’s really helped me when working with this population. I have become super joyful when I walk into the room, no matter what I am met with. I am very curious about what the patient has to offer that day, what excites them, what makes them tick. And it’s made one of the biggest impacts on my ability to care for this population. and give them meaningful sessions. So changing expectations is what we, you know, about what we should achieve. Letting our patients guide more of the session. That’s really reduced a lot of my own personal burnout and stress surrounding these interactions and sessions. I have just come to recognize and document all of these strategies that I use and what impact that they had on my ability to deliver care and to deliver movement for this population, right? I’ve recognized that these skills and these decisions that we’re making are skilled behaviors. And I value my own time and bill all of this while I’m with the person. Remember, you’re providing an opportunity for movement in this population, an opportunity for movement. I hope this article gives you just that sense and boost of motivation that you were needing to feel successful in treating these folks. You guys are out there doing an absolutely amazing job. I hope this just makes your job a bit easier. All right, y’all have a good rest of your Wednesday and we’ll talk soon.

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