#PTonICE Daily Show – Wednesday, October 18th, 2023 – Cluster approach to dementia care

In today’s episode of the PT on ICE Daily Show, Modern Management of the Older Adult lead faculty Jeff Musgrave discusses the significant issue regarding the lack of individualization and care for older adults with cognitive impairments. Jeff points out that many older adults on their caseloads are at different stages of cognitive impairment, but this often goes unnoticed until it progresses to advanced dementia. The problem lies in the one-size-fits-all approach to treating cognitive impairments, where individuals with mild impairments are grouped together with those with severe impairments, or they are treated the same as the general population without screening for cognitive impairments.

This lack of individualization and care for older adults with cognitive impairments is also evident in nursing homes. Jeff mentions a study from Germany that examined a population of nursing home residents. The residents were grouped based on their cognitive and physical impairments. However, the study found that there was a lack of personalized care, as a more diverse group was randomly assembled with varying levels of cognitive and physical function, and they all received the same basic intervention.

Jeff emphasizes the need to tailor care to the individual’s cognitive capacity, just as their physical capacity is considered. He uses the analogy of coaching a peewee football league, where practice would not be taken to the local NFL team if the capacity is not appropriate. Similarly, individuals with cognitive impairments should not receive interventions that are beyond their cognitive abilities. However, in the current state of rehabilitation for those with cognitive impairments, interventions are often not matched to their cognitive abilities. This lack of individualization and care for older adults with cognitive impairments is a significant problem that needs to be addressed.

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

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Welcome to the PT on Ice Daily Show. Good morning, my name is Dr. Jeff Musgrave. Super excited to be with you this morning, talking about a topic that’s really important to me, but also reviewing a research article eight days off the press, a new technique called clustering to give better care to those with dementia on our caseloads. But before we get into that, if you’re looking to up your Geri game, we are available. We’ve got some extra seats in our New Jersey course in Matawan, New Jersey this weekend. If you want to hop on that train, we’d love to have you. We’ve got space for just a few more. Next weekend, if you want to join us for live, we’ll be in Annapolis, Maryland or in Central South Carolina. Last cohort of Essential Foundations just kicked off. We’ve got our first live meetup, so sorry if you missed it. We will be up in full force in January 2024. There is still time to catch advanced concepts if you want to sign up for that. The last cohort is about to begin, so grab those seats.


So team, man, I’m so excited to get to talk to you about this topic. There are so many older adults on our caseloads in various stages of cognitive impairment. And this oftentimes goes unrecognized until it becomes advanced dementia. when things are a bit harder to turn the tide, but also there’s a severe lack of individualization and care for those that have cognitive impairments. A big problem in general practice is this one size fits all. In geriatrics in general, whether we’re talking about physical impairments, but unfortunately we see the same problem when it comes to cognitive impairments. We see those with cognitive impairments get treated the same regardless of how advanced those symptoms are. So we see one of two big problems here. We either see those with very mild cognitive impairments grouped with those with very severe impairments, Or we just see them treated the same because no one’s screened or picked up on the fact that there’s a cognitive impairment on board and they’re treated just like the general population which is also not appropriate. So neither of those are a good look. So this study out of Germany was looking at a population of residents in nursing homes and what they did is they clustered them based on their cognitive as well as their physical impairment. So they used a clustering approach to try to get homogeneous groups of people based on not only their physical function but their cognitive function. So all these residents were 65 and up. They had mild to moderate dementia and were living in a skilled nursing facility. The physical measures that they used were the six minute walk test, the timed up and go, 30 seconds sit to stand. But the biggest place where they saw variation that dictated their function was on their mini mental state exam. So their cognitive impairment did a lot to dictate their function. So what they found at the end of this was that those that had more advanced cognitive impairments were not able, even if they had the physical function, to participate in as high level balance training as those that had more severe cognitive impairments. So those with more mild cognitive impairment were not able to participate at the same level, in particular when it came to balance challenges.


The interventions for this study unfortunately the link did not go through that I could see all the details but what they what they were doing was some form of strength training either seated if there was lower physical function versus standing or dynamic movement in standing if they had higher physical function. So lower to higher physical function and then they gave also a cognitive layer to their interventions while they were doing balance or strength training. So that allowed them to scale the intervention to those who, to make it more appropriate. So they had a higher and lower physical function, higher and lower cognitive function group, and they scaled the cognitive load as well as the instructions So one big thing that’s missing is the environment and the type of cues that we give typically in clinical practice for those with cognitive impairments also need to be scaled. They can’t be as complex of cues with multiple sentences in the same duration of time. We’ve got to really scale that to the person in front of us and individualize that care based on their cognitive capacity, just like we would their physical capacity. The way I kind of think about this is if you were coaching a peewee football league and practice is going really well, you would not march them over to the local NFL team for practice. Their capacity is not appropriate. But we do the same thing with cognitive impairments where we’ve got someone who has more advanced cognitive impairments, getting a much higher level of training than what they should be and it’s no surprise when the results aren’t as good and that’s also what was found in this study was the experimental group had the matched physical and cognitive and then there was a more heterogeneous group that was just kind of randomly put together with higher and lower cognitive and physical function, and they all got this lowest common denominator intervention, which we commonly see, especially because this was looking at group training in skilled nursing facilities. What typically happens is we’ve got this big group of people, and we find the person with the lowest cognitive and physical function, and we give everyone that. So the person that has the lowest physical and cognitive function gets an appropriate challenge. Everyone else has lots more ability that is not tapped into and is not being challenged. So it’s no surprise once you hear that’s what’s happening, which unfortunately is the state of rehab for those that have cognitive impairments in general, is it’s not being matched to their cognitive ability. So those that were not matched based on their cognitive and physical function showed decline in their mental function by the time the study was complete. So those with matched physical and cognitive challenge to their actual, their functional level, They did great. They were able to maintain their cognitive level in this skilled setting. And those that were not matched showed cognitive decline in even a short period of time. This is pretty wild.


So some big takeaways here. Are we screening? Are we screening cognition in our older adults? The research says that the sooner we can screen people, the better chance we have to change their life and help them maintain their cognitive function and sometimes actually improve their cognitive function. There is a mountain of research that shows exercise is beneficial for cognition, especially if we’re pushing into the fitness realm. and we’re pushing people at high intensity and we’re asking them to lift heavy things, we’re asking them to learn new novel tasks. So we want to make sure we’re doing that with older adults, not only for their physical function, but for their cognitive function. But we need to get a baseline of where they are to make sure that we’re scaling these things appropriately. The tool that was used in this study was a mini mental state exam, which unfortunately is not great at screening for mild cognitive impairment, which is kind of that first phase before there is problems with activities of daily living, like once we get into more advanced forms of dementia. Tools like the MOCA, the Montreal Cognitive assessment may be more appropriate for catching signs of mild cognitive impairment. Also the SLUMS, the St. Louis University Mental State Exam. However, with that one, it’s good to be aware that that can trigger automatically a local referral once it is complete. So you want to make sure that your patient, if there’s any family members involved with care, that they’re all aware that that will happen. And if this is like, man, I am not comfortable with this cognition stuff, this feels like way out of my depth, that’s fine. You don’t have to be the expert on everything, but you do need to be accountable to having resources in your area. Who is the SLPs, maybe outpatient, Or on your team if you are in a skilled environment that you can send for a cog referral. Or OTs, we have lots of OTs that are great at screening and intervening cognition and giving you an idea how many step commands, what type of environment, what type of cues are appropriate for this patient. but we have got to meet them where they are for cognition, just like we do for our physical interventions. So if you’re not screening, start there. We’ve got to do more than alert and oriented times three. We’ve got to be getting these screening tools in use, or we’ve got to start making those referrals to people that are able to help get a baseline and make sure that our interventions are appropriate. So if you are screening, awesome, you are ahead of the curve. So now your job is to make sure that these interventions are appropriate, just like we’re outlined in this study.


So what we want to make sure that we’re doing is we want to know that there are things like cognitive processing delays, where it may take someone with more advanced dementia symptoms two minutes to process our commands. That was just five seconds of silence from me. If you can imagine two minutes of silence after your cues made this mistake so many times with this population. In two minutes, we’ve said a thousand things. and they’re still processing the first thing that we said. So want to be mindful as we pick up on these symptoms. Cognitive processing delays can be up to two minutes. More mild forms, it could be five, 10, 15 seconds. It may feel a little more natural. Likely your skin’s going to crawl, but it may be a very appropriate communication. It’s going to look way different in this population. We want to make sure that the more advanced the cognitive impairment is, the more familiar the tools and the exercise interventions that we’re using. We can’t give a 40 point intervention and biomechanical explanation on a beautiful trap bar deadlift with an older adult. who has advanced dementia, we may be better off to use their purse and add some stuff to it, or add just grocery bags with food in it, and just ask them, pick this up. Once they do that, let’s walk, walk 20 feet, or walk over to this area of the gym. No more cues, no more instruction, set it down. That may be a very skilled, very appropriate set of cues for an older adult with advanced dementia. So we want to keep in mind the tools. We also want to keep in mind the scenario. Can we control the environment? That is a skilled scaling tool. How loud is it? How busy is the environment? Is there lots of interaction? Are we at prime time in the clinic, out in a busy clinic where there’s people throwing balls on a rebounder or the music’s blaring? There’s lots of laughter and fun. That may be a completely overstimulating environment for someone who has more advanced dementia. So the complexity… of the environment, the amount of noise, background noise, all those things are scaling options. So if we start in that quiet environment, we may eventually scale in to more advanced and complex environments where there are more distractions, where it is more like real life. But that’s gotta be an intentional choice. That doesn’t need to be an accident. We need to be very skilled with our interventions and that is part of it. How we choose to practice is also very important. Are we going to do random practice where we’re jumping between tasks to task? That’s going to be way less on the ability for someone with more advanced cognitive impairments. We may need to do block practice where we spend a big chunk of time, maybe 15 minutes, working just on a sit to stand. We may never get to a squat with a bar. That’s fine. But if we can make it practical, we can meet people where we are, that may be where we need to stay. 15 minutes here, 15 minutes on the next thing, that may be our whole session. Or maybe it’s something like a simple obstacle course. Pick this up, carry this, and follow me. That could be it. So I wanna keep these things in mind. If we are screening, we are getting a sense of what the cognitive ability level is of our clients, then our job is to scale it appropriately, and then you guessed it, then progress it as we’re able. So we wanna use all those leveraging tools. So my advice to you, we’re gonna switch gears, so that should be relevant to everyone. Now, if you are training in a group setting, kind of like this study outlines, where you’re in a skilled facility, and you’re doing group training, you can start with this lowest common denominator approach, but what you have to add in are easy scaling options. You’ve got to think about, we’ve kept everyone safe, but then for those that have the cognitive ability to do more advanced balance, or they’re safe to do more advanced strength training, What can we do to scale it up for those individuals? So we’ve got everyone moving, everyone’s safe. Now, how do we scale it up? Go heavier. Have heavier weight options available. Maybe instead of sitting, those people that have more advanced functional and cognitive impairments, they’re going to be standing. Or maybe they’re doing a dynamic movement. Maybe we’re going to add some type of vestibular component where we’re going to ask them to fixate and move their head side to side or up and down with the fixation point or maybe without a fixation point. Maybe we’re having them close their eyes and head turn side to side or up and down. We can add that vestibular layer. We can add a cognitive component as well where we can ask preference questions like everyone, someone shout out, you can think to yourself or shout out loud some of your favorite foods. or name as many states as you can, or name things that are green. We can go very simple up to more complex counting tasks where maybe we’re subtracting by 7 from 300 for someone that has a very mild cognitive impairment. Those things may still be on the docket. Those still may be very appropriate. But if we’re doing group training, we can start with that lowest common denominator and then just offer scale up options. Another easy one that was even outlined in this study that they found to be beneficial was even just having a little piece of compliant foam for those that were already doing standing. Everyone in the group was mostly doing standing. They added the compliant foam in and that was a great option to scale up balance training. Everyone’s getting instruction on the same movement, but there’s not really a whole lot of extra instruction to change the surface. All right team, I got super fired up about this. Treated lots of people with cognitive impairments. If you’re treating this population, I would love to hear any tips and tricks. Drop those in the comments. Thoughts? I will be dropping the article citation for you. The study was a new approach to individualized physical activity interventions for individuals with dementia. Cluster analysis based on physical and cognitive performance. I hope you enjoyed it. I hope you have a wonderful rest of your day and we will catch you next time.


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