The document provides information on physical therapy for patients with dementia. It begins with definitions of dementia and discusses the different types, including Alzheimer's disease and Lewy body dementia. It describes the stages of dementia and tools to assess cognitive function, such as the Mini-Mental State Examination and Global Deterioration Scale. Treatment options discussed include cholinergic medications to increase acetylcholine in the brain as well as other drugs and therapeutic interventions.

1. PHYSICAL THERAPY SUCCESS
IN THE PRESENCE OF
DEMENTIA
Dr. Stacy Millar PT, DPT, GCS

2. WHAT IS DEMENTIA?
"Properly defined, dementia is
characterized by persistent
observed cognitive changes
resulting from an illness." (1)
Click to add text

3. REVIEW OF BRAIN SECTIONS AND
FUNCTION
http://ib.bioninja.com.au/options/option-a-neurobiology-and/a2-the-human-brain/brain-sections.htmlto add

4. BLOOD SUPPLY
Clihttp://www.medicalrf.com/The-circle-of-
willis-image_RF000027326.htmlck to add text
Clichttps://www.alz.org/alzheimers-
dementia/what-is-alzheimers/brain_tourk to
add text

5. NERVE CELL
https://www.alz.org/alzheimers-dementia/what-is-alzheimers/brain_tourk to add text
"An adult brain contains
about 100 billion nerve
cells" (2)
Branches form the pathways for
communication between neurons
Signals travel along
branches to synapse with
communicating neurons

6. SYNAPSE
thttps://simple.wikipedia.org/wiki/Neuron#/media/File:Neuron.sv
g
https://en.wikipedia.org/wiki/Chemical_synapse#/media/File:Chemical_synapse_s
chema_cropped.jpg

7. PLAQUES
https://www.flickr.com/photos/nihgov/3868650325
Amyloid: protein fragments
abnormally formed by bone marrow
Beta Amyloid: protein fragment from
amyloid precursor protein (APP)
Healthy brain will break down and
excrete
Alzheimer's brain cannot break down
and therefore accumulates and forms
plaques

8. TANGLES
Consist of a protein called Tau of
which is a component of a
microtubule
Altered chemical messages cause Tau
proteins to detach from microtubules
Creates insoluble twisted fibers inside
brain cells causing neurofibrillary
tangles

9. http://essays.biochemistry.org/content/56/99.figure
https://health-innovations.org/2015/03/25/harmonized-neuroimaging-protocol-for-
measuring-early-sign-of-alzheimers-has-been-developed/
https://www.neuroscienceassociates.com/reference/diseases/approac
h-ad/

10. TYPES OF
DEMENTIA
Vascular
Reversible
Pseudodementia
Alzheimer's Disease
Lewy Body

11. VASCULAR
DEMENTIA
Multi-Infarct Dementia
 "...additive effects of small and large infarcts that
produce a loss of brain tissue." (1)
 Signs specific to dementia related to multi-infarcts
 Abrupt onset
 Step-by-step deterioration
 Fluctuating course
 Emotional lability
 Common Disturbances:
 Problems with memory
 Abstract thinking, judgement, impulse control,
and personality

12. REVERSIBLE
DEMENTIA/
DELIRIUM
Cognitive dysfunction that can be corrected
"Estimates show that 10% to 30% of those
presenting with dementia symptoms can be
treated to correct a metabolic or structural
condition, also resulting in restoration of
intellectual function." (1)
Conditions that can mimic dementia:
 Drug complications
 Infection
 Nutritional, psychiatric, and metabolic disorders
 Trauma

13. PSEUDODEMENTIA
"...term used when dementia-like behavior is
actually the result of a major depressive
episode." (1)
Defining characteristics:
 Psychomotor retardation
 Flattened affect
 Disinterest in events around them

14. LEWEY BODY DEMENTIA
• "Lewy body dementia (LBD) is a disease associated with abnormal
deposits of a protein called alpha-synuclein in the brain." (4)
• 2nd most common form of progressive dementia (5)
• Effects more than 1 million individuals just within the US (4)
• Typically begins around age 50 (4)
• Lasts an average of 5-8 years from time of diagnosis until death (4)
https://www.nia.nih.gov/health/what-lewy-body-

15. SIGNS & SYMPTOMS
• Visual hallucinations (differing factor from other
dementias)
• Movement disorders that mimic Parkinsonian
mobility
• Poor regulation of bodily functions (autonomic
nervous system)
• Cognitive problems
• Sleep difficulties
• Fluctuating attention
• Depression and Apathy
*True diagnosis can only be made via autopsy
• Severe dementia
• Aggressive behavior
• Increased risk of falls
• Worsening Parkinsonian symptoms
• Death
COMPLICATIONS
LEWY BODY DEMENTIA(4)

16. DEMENTIA OF ALZHEIMER'S TYPE (14)
• "Early Onset Familial Alzheimer's"
• Caused by genetic defects on chromosomes 21,14,
and 1
• Autosomal dominant
• Occurs in 50% of first degree blood relatives
• Occurs before age 60
• Accounts for only 5% of AD cases
Click to add text
https://www.alz.org/alzheimers-
dementia/research_progress/earlier-diagnosis

17. DEMENTIA OF ALZHEIMER'S TYPE (14)
• "Late Onset Alzheimer's"
• Most common form of AD
• Occurs in people 65 or older
• Particular gene involved called APOE
(apolipoprotein E)
• Has 3 normally occurring alleles
• APOE-4 = risk factor for the disease
• APOE-2 = protective factor

18. TYPICAL PATTERN OF
PLAQUE FORMATION
• "The hierarchical pattern of
neurofibrillary degeneration among
brain regions is so consistent that a
staging scheme based on early
lesions in the entorhinal/perirhinal
cortex, then hippocampal Ammon
subfields, then association cortex,
and finally primary neocortex is well
accepted as part of the 1997 NIA-
Reagan diagnostic criteria (NIA-RI
Consensus 1997)."(27)
https://www.alz.org/alzheimers-dementia/what-is-

19. HEALTHY BRAIN VS. ALZHEIMER'S BRAIN
http://www.noticias.com.ve/contaminacion-aumenta-
riesgo-de-padecer-alzheimer/
https://www.dementiacarecentral.com/video/video-brain-
changes/

20. STAGES OF ALZHEIMER'S
Mild/Early Stage
Moderate/Middle Stage
Severe/Late Stage

21. MILD/EARLY
STAGE (6)
Mild forgetfulness
Difficulty concentrating
May still live independently
Difficulty making plans
Difficulty staying organized
Trouble managing money
Begin to notice their memory lapses

22. MODERATE/MIDDLE
STAGE (6)
Typically longest stage
Increased difficulty in remembering events
Problems learning new things
Trouble reading and writing
Recognize familiar individual but cannot remember name or relationship
Lose track of time and place
Begin having trouble with activities of daily living
Personality changes with paranoia, moodiness, and/or become withdrawn
Become restless, agitated, anxious, and tearful particularly in late afternoon/night time
(sundowning)
Tend to wander
Difficulty sleeping

23. SEVERE/LATE
STAGE (6)
Lose physical abilities such as sitting,
walking, eating
Loss of bowel and bladder control
Able to voice some words but unable to
carry on a conversation
Unaware of surroundings or recent
experiences
More likely to become afflicted with
infections

24. 7 A'S OF
DEMENTIA
(11)
• Anosognosia: no knowledge of illness
• Amnesia: loss of memory
• Aphasia: loss of language
• Agnosia: loss of recognition
• Apraxia: loss of purposeful movement
• Altered Perception: loss of visual
perception
• Apathy: loss of initiation

25. ANOSOGNOSIA
• Particularly likely to occur if
pathology is in tempero-parietal
lobe
• Poor judgement and problem-
solving
• Resistance to care
• STM is most important as it allows for
information to be maintained long enough
to get into long-term storage
• Without STM, patient with dementia can no
longer consciously learn
• Declarative – experienced over time
• Procedural – all tasks learned
AMNESIA
7 A'S OF DEMENTIA (11)

26. APHASIA
• Often still recognizes non-verbal
communication
• Expressive aphasia – associated with frontal
lobe
• Person able to comprehend speech but
unable to produce language
• Receptive aphasia – associated with temporal
lobe
• Person has deficit in comprehending
language
• Loss of recognition to
• Visual – objects and faces
• Auditory – sounds
• Somatosensory – touches
AGNOSIA
7 A'S OF DEMENTIA (11)

27. APRAXIA
• Loses ability to plan, sequence,
and execute each step within a
task
• Visuo-spatial discrepancies
• Depth perception
ALTERED PERCEPTION
7 A'S OF DEMENTIA (11)

28. APATHY
• Typically occurs with damage to
medial frontal lobe
• Over time, will not initiate
conversations or activities
without cueing
7 A'S OF DEMENTIA (11)

29. PREVENTION
• Exposure to bright light (go
outside/sit by window)
• Exercise
• Daytime rest (not too late in the day)
• Being overly tired
• Unmet needs such as hunger or
thirst
• Depression
• Pain
• Boredom
CAUSES
SUNDOWNING (13):
"...RESTLESSNESS, AGITATION, IRRITABILITY, OR
CONFUSION CAN OCCUR OR WORSEN AS DAYLIGHT
BEGINS TO FADE."

30. SUNDOWNING (13)
• Coping Strategies:
• Decrease noise, distractions, too
many people, etc
• Distract person with a favorite
activity, snack, video, tv show
• Quiet and calm time in the evening
close to bed time
• Minimize shadows so not to cause
confusion (draw curtains or turn on
lights)
• Listen and respond calmly

31. MMSE
• Use the Mini Mental State Examination to determine where patient is in ability to
function and learn
• "... assessment of an older adult’s cognitive status is instrumental in identifying
early changes in physiological status, ability to learn, and evaluating responses to
treatment." (7)
• "The Mini Mental State Examination (MMSE) is a tool that can be used to
systematically and thoroughly assess mental status. It is an 11-question measure
that tests five areas of cognitive function: orientation, registration, attention and
calculation, recall, and language. The maximum score is 30. A score of 23 or
lower is indicative of cognitive impairment. The MMSE takes only 5-10 minutes
to administer and is therefore practical to use repeatedly and routinely." (7)

32. SCORING
• 24-30: Normal range
• 18-23: Moderate
cognitive impairment
• 0-17: Marked
cognitive impairment

33. GLOBAL DETERIORATION SCALE
Stages 1-3 =
Pre-dementia
stages
Stages 4-7 =
Dementia stages
Stage 5 = Person
dependent upon
caregivers

34. LEVEL 1
• No cognitive decline • Very mild cognitive decline
• Age associated memory
impairment
• No noticeable deficits in
employment
LEVEL 2
GLOBAL DETERIORATION SCALE (12)

35. LEVEL 3
• Mild Cognitive decline
• Earliest evidence of deficits
• Decreased performance in
social settings
• Level of denial high
• Anxiety high
• Moderate Cognitive
Decline
• Unable to perform
complex tasks
• Flat affect
• Withdrawal from
challenging situations
LEVEL 4
GLOBAL DETERIORATION SCALE (12)

36. LEVEL 5
• Moderately Severe Cognitive
Decline
• Must have assistance with
daily tasks
• Disorientation to time
• Severe Cognitive Decline
• Personality and emotional
changes occur
• Delusional behavior
• Cannot carry out purposeful
action
LEVEL 6
GLOBAL DETERIORATION SCALE (12)

37. LEVEL 7
• Very Severe Cognitive Decline
• Verbal abilities lost
• Incontinent
• Generalized rigidity
• Only basic pyschomotor skills
GLOBAL DETERIORATION SCALE (12)

38. TREATMENT
OPTIONS
Medications
Therapeutic Interventions

39. • Alzheimer's is primarily a disease with
deficiencies in the brain's cholinergic
systems
• http://psychiatricdrugs.com/neurology/acetylcholine/
• Medication research is focused on either
increasing available acetylcholine
(cholinergic agent), preventing its
destruction (cholinesterase inhibitors), or
by minimizing damage to the nerve cells
due to effects of oxidation and
inflammation
https://study.com/academy/lesson/cholinergic-drugs-mechanism-of-
action.html
https://www.medscape.com/viewarticle/705284_2

40. CHOLINE
• Component of various foods but can
be found in capsule form
• Associated with only modest
improvements and that was in those
in the earlier stages of illness
• May increase alertness and awareness
• Works best when used in
combination with other drugs
• Naturally found dietary substance in
foods such as egg yolks, meat, fish,
and soybean products
• Shows greater ability to slow down
disease progression than choline
• Can be found in capsule form;
however, the amount needed to
provide beneficial effects would be
impossible to ingest in this form
LECITHIN
CHOLINERGIC AGENTS( 1 4 )
KNOWN TO IMPROVE AVAIL ABILITY OF ACETYLCHOLINE IN THE
BRAIN, ENHANCE SYNTHESIS, AND INCREASE RELEASE IN THE
SYNAPSES BET WEEN NEURONS

41. CHOLINESTERASE INHIBITORS( 1 4 )
• Tacrine:
• Higher potential for liver toxicity thereby increased
blood testing
• May slow cognitive impairment by 6-12 months
• Galantamine:
• Extracted from the bulb of a daffodil species
• Works in a more unique way than the others in
that is stimulates a specialized ACh receptor on
neurons known as nicotinic receptors
• Stimulation of nicotinic receptors enhance
learning, memory, and inhibits build up of beta
amyloid
• Benefits lasted 12 months
• Aricept (Donepezil):
• Indicated for mild to moderate
dementia
• May slow disease progression for 6
months or more
• Physostigmine:
• Can cross blood brain barrier
• Very narrow dose range between being
effective versus being toxic
• Short half-life
• Exelon (Rivastigmine):
• Works by inhibiting both
acetylcholinesterases and
butrylcholinesterases
• Indicated for moderately severe to
advanced dementia

42. CHOLINERGIC RECEPTOR AGONISTS(14)
• Stimulate the receptors that receive acetylcholine
• Benthanechol Chloride:
• Produced decreased confusion, increased initiative, and enhanced productive
activity
• Delivered via a drug infusing pump implanted into the abdominal wall and is
connected to an intracranial catheter allowing the drug to cross the blood
brain barrier
• Arecoline and RS-86
• Produced little or no significant improvement

43. NEUROPEPTIDES
• Short chains of amino acids that have
strong interactions on the nervous
system
• Enhance communication between
body cells, tissues, and organs
• Produced in studies reversal of
memory impairment, enhanced
cognitive abilities, improved
neurotransmission in memory and
learning, decreased depression,
increased energy, attention, and
concentration
• Utilized and studied as a nasal spray
• Helped memories appear more
quickly
VASOPRESSIN
OTHER MEDICATIONS(14)

44. GLUTAMINERGIC AGENTS
• Memantine:
• Acts on glutaminergic
neurotransmission
• Aids in decreased loss of a specific
glutamate receptor known as NMDA
receptor
• NMDA receptor noted to be found in
the deterioration found in Alzheimer's
disease
• Slowed progression of symptoms in
moderately severe to severe Alzheimer's
• Provides neuroprotection as well as
symptom relief
• Currently awaiting its production within
• Hormone that help nerve cells survive
by preventing damage from
inflammation and oxidation
• Promotes growth of cholinergic
neurons
• Stimulates neurite growth and
synapse formation
ESTROGEN
OTHER MEDICATIONS (14)

45. ANTIOXIDANTS
• Oxidative stress results when
antioxidant defenses are overwhelmed
by free radical formation
• Protect neurons from this oxidative
stress
• Vitamin E:
• Traps free radicals and interrupts the chain
reaction that damages cells
• Prevents cell death caused by glutamate
and beta-amyloid proteins
• Selegiline (Deprenyl):
• Known as a scavenger of free radicals
• Slows progression of disease
• Increased risk of Alzheimer's disease
with high cholesterol
• High cholesterol and fat increase
amount of beta-amyloid in the brain
• Beta-amyloid and cholesterol stimulate
an inflammatory response causing
vessels to constrict
• Thereby, statins modulate immune
responses by decreasing inflammation
STATINS
OTHER MEDICATIONS (14)

46. TRICYCLIC ANTI-DEPRESSANTS
• Amitriptyline & Doxepin:
• Higher potential for side effects of
increased confusion and memory loss
• Desipramine or Nortriptyline:
• Decreases potential for cognitive
impairment as compared to above listed
• Prevent nerve cells from eliminating
serotonin
• Zoloft, Prozac, Paxil, Celexa, Luvox,
Effexor, & Wellbutrin
• Aids in treating verbal agitation, anxiety,
fear, panic, restlessness, depression
• Trazodone & Citalopram
• Greatest risk for postural hypotension
• Remeron & Serzone
• Might aid sleep at night but coud carry
over to drowsiness next day
SELECTIVE SEROTONIN REUPTAKE
INHIBITORS (SSRIS)
ANTI-DEPRESSANTS(1 4 )
"RESULTS ARE MIXED, BUT THE USE OF ANTIDEPRESSANTS IN
TREATING BEHAVIORAL SYMPTOMS SEEN WITH AL ZHEIMER'S
DISEASE IS ENCOURAGING."

47. SIDE EFFECTS
• Elderly have lower tolerance than younger
• Brain impairment increase effects and/or
interfere with effectiveness of medications
• Hypotension
• Dry mouth, blurred vision, dilated pupils,
constipation, urinary retention, nasal congestion,
and increased heart rate
• Extrapyramidal reactions
• Slowed movements, muscle rigidity, resting
hand tremor, shuffling gait, drooling, and
mask-like face
• Tardive dyskinesia
• Involuntary lip and tongue motions,
writhing movements of arms and legs
• Haldol
• Navane
• Prolixin
• Loxitane
EXAMPLES
OTHER MEDICATIONS(14)
MA JOR TRANQUILIZERS

48. SIDE EFFECTS
• Can build up in the body over time
• Drowsiness
• Nervousness
• Dizziness
• Headache
• Irritability
• Fatigue
• Blurred vision
• Valium
• Lorazepam
• Xanax
• Restoril
• Librium
EXAMPLES
OTHER MEDICATIONS(14)
MINOR TRANQUILIZERS

49. ANTIPSYCHOTICS
• More favorable side effects
• Used to treat behavioral and
psychological symptoms of dementia
• Risperidone (Risperdal)
• Quetiapine (Seroquel)
• Olanzapine (Zyprexa)
• Valproic Acid (Depakote)
• Carbamazepine (Tegretol)
MOOD STABILIZERS
OTHER MEDICATIONS(14)

50. "ISOLATION OR RESTRAINT
MUST NOT BE IMPOSED IN
ANY FORM AS A MEANS OF
COERCION, DISCIPLINE,
CONVENIENCE OR
RETALIATION BY STAFF."(15)
https://publications.tnsosfiles.com/rules/0940/0940-03/0940-03-06.p

51. WHY SHOULD THERAPY BE INVOLVED?
"Existing empirical evidence indicates that
physical disability, depressed mood, and sleep
and behavioral disturbances, may be
ameliorated by combining an exercise training
program with caregiver education and
problem solving." (8)
"Acute PE [physical activity] increases cardiac
output, leading to increased cerebral blood
flow, which triggers various neurobiological
mechanisms in the brain tissues. The regular
(repeated) increases in cerebral blood flow
associated with regular PE probably contribute
to increases in angiogenesis, neurogenesis,
synaptogenesis, and neurotransmitter
synthesis in the different cerebral areas
involved in cognition (e.g., memorization) and
mobility" (9)

52. WHY SHOULD THERAPY BE INVOLVED?
"Multicomponent exercise training
[comprising balance, aerobic exercise
(generally walking), and strength
training] was shown to be particularly
effective for improving postural and
motor functioning and reducing the risk
of falling in AD subjects." (9)
"Research with AD subjects has shown
that walking plus conversation has a
better preventive effect than walking
alone, suggesting that the “socialization
effect” of exercise is an important aspect
for this population. In another
controlled exercise trial, the practice of
walking combined with bright light
exposure improved sleep among AD
patients." (9)

53. CIRCULATING INSULIN-LIKE
GROWTH FACTOR ENHANCED VIA
EXERCISE FOR BRAIN INSULT
PROTECTION(16)
"Our findings also indicate that exercise is
neuroprotective because of increased
passage of circulating IGF-1 into the brain
because when this passage is blocked,
exercise is no longer neuroprotective,"
"An additional mechanism involved in IGF-
1 mediated exercise neuroprotection is
likely related to enhanced neuronal
glucose metabolism. Improved glucose
metabolism is essential for neurons to be
able to survive to injury, and increased
glucose consumption is a typical response
to brain injury."
"Brain uptake of blood-borne IGF-1 is
essential for exercise-induced increases in
the number of newly formed hippocampal
neurons and in widespread c-Fos
expression in neurons."
https://www.frontiersin.org/articles/10.3389/fneur.2011.00028
/full

54. WHY SHOULD THERAPY BE INVOLVED?
"The exercise-carrousel program is easily applicable in hospital dementia care and
significantly reduces neuropsychiatric signs and symptoms in patients suffering from
predominantly moderate stages of dementia."(17)
"...a 2-week exercise program with multiple short-bout exercise sessions per day is an
innovative and feasible approach for structured physical activation in acute dementia care
leading to clinically significant improvement of neuropsychiatric signs and symptoms."(17)

55. THERAPEUTIC APPROACH
It is our responsibility as therapists
working with those with dementia to
meet them where they are at

56. THERAPEUTIC
TREATMENT
OPTIONS(18)
• "Similarly, the application of TG
[therapeutic gardens] has been
shown to reduce behavioral problems
(e.g., fear and anxiety) during post-
stroke rehabilitation procedures,
improve ambulation, promote
positive reminiscences, stabilize
sleep-wake cycles and reduce stress,
suggesting this treatment option as a
complementary therapy for dementia
patients dwelling in aged-care
facilities."
https://depts.washington.edu/hhwb/Thm_Healin

57. USE OF THERAPEUTIC
GARDENS(18)
• "...exposure to natural environments
improved inappropriate behaviors in
patients with dementia. Research has
shown that a wander garden resulted in
increased feelings of freedom, improved
quality of life, and reduced agitation,
including the number of falls and the need
for high doses of antipsychotics in dementia
patients."
• "...older adults with AD derive benefits
from exposure to gardens in that they foster
walking, socialization, and higher self-
esteem while reducing depression and
aggressive behaviors, including isolation
and vulnerability."
http://gardendesignseibao.blogspot.com/2017/06/dementia-garden-

58. CANINE-ASSISTED THERAPY(19)
• "This approach includes animal-assisted therapy, defined as an
intervention in which an animal is incorporated as an integral part
of the treatment process, in order to promote an improvement in
physical, psychosocial, and/or cognitive functioning of the person
treated."
• "Our study provides evidence of the significant benefits of
canine-assisted therapy for quality of life in people with
Alzheimer's disease."
• "...a higher quality of life is associated with lower levels of
depression, a decrease in the presence of neuropsychiatric
symptoms, and less dependence on activities of daily life."
https://www.samvednacare.com/blog/2017/09/11/6-benefits-of-pet-therapy-for-

59. ESSENTIAL OIL USE FOR
TREATMENT OF AGITATION IN
DEMENTIA( 2 0 )
• -Scent detection relies on immediate memory
• -Scent recognition is more delayed memory
processing
• -Fragrances can evoke strong memories of earlier
times
• -Limbic system's amygdala governs emotional
response
• -Hippocampus is involved in retrieval of memories
surrounding scent
https://www.dreamingearth.com/blog/essential-oils-

60. ESSENTIAL OIL USE FOR
TREATMENT OF AGITATION
IN DEMENTIA(20)
• Lemon balm is a more recent scent
• More effective in people without dementia due
to being too potent
• Less familiar scent
• May have a more clinical or pharmaceutical
basis
• More effective in reducing agitation in people
without dementia
• Lavender was a popular herb in
earlier 20th century
• Grown in gadens
• Used as perfumes & disinfectants
• Older people with dementia would recognize it
and be comforted by it
• More effective in reducing agitation and
physical non-aggressive behavior in people
with dementia https://www.facebook.com/lemonandlavendeo

61. FREQUENCY OF FAMILY VISITS INFLUENCES
SYMPTOMS( 2 1 )
• "Stimulation of cognitive activity is important for reducing cognitive decline, and
communication is one of the important stimuli for this."
• "It was clear that family contact was associated with the maintenance of psychological
functions in aged people with moderate dementia."
• "This result suggests that family visits in a nursing home are useful for prevention of
aggravated dementia in subjects with a slight level of dementia, and as a cure for
subjects with a moderate level of dementia."
• "This study demonstrates that the frequency of family visits is associated with
suppression of BPSD [behavioral and psychological symptoms of dementias], and is
particularly effective for subjects with moderate dementia."
https://www.caring.com/senior-living/assisted-
living/

62. IMPACT OF GROUP
ACTIVITIES AND
THEIR CONTENT
WITH DEMENTIA(22)
https://www.flickr.com/photos/135633694@N04/2054688406
0/

63. - "Active participation levels were highest for the exercise, music,
and art groups."
- "Wellbeing was observed to be lower during unstructured time
compared to the activities."
- "Wellbeing was also higher for reminiscence therapy than for
general group activities"
- "The most successful group activities were games and choral
singing, whereas the least successful were story-telling and poetry,
with other topics being in between or having a greater impact on a
specific outcome, such as exercise impacting active participation."
(22)

64. MUSICAL MEMORY AND THERAPY
Can be very calming for the dementia patient,
particularly when it allows rememberance and
famililarity
https://mageerehab.org/about-us/care-team/music-therapy

65. MUSICAL MEMORY PRESERVED IN
ADVANCED ALZHEIMER'S DEMENTIA( 2 3 )

66. "The results showed a crucial role for the caudal anterior
cingulate and the ventral pre-supplementary motor area in
the neural encoding of long-known as compared with
recently known and unknown music."
"Interestingly, the regions identified to encode musical
memory corresponded to areas that showed substantially
minimal cortical atrophy (MRI) and minimal disruption of
glucose metabolism (PET) as compared to rest of brain."
"Musical memory also appears to represent a special case
in Alzheimer's disease, in that it is often surprisingly well
preserved especially implicit musical memory, which may
be spared until very late stages of the disease."
(23

67. APPROPRIATE APPROACHES
• Avoid criticism
• Consistent but simple commands
• Give sensory cues
• Provide demonstration
• Allow resting periods
• Tasks should be repetitive
• Involve family and direct caregivers
• Break tasks into simple tasks
• Clear and calm cues
• One word commands
• Make task as functional as possible
• Allow time for their response
• Speak normal
• Do not slow down sounds or over-
exaggerate the words or increase
volume

68. APPROPRIATE APPROACHES(14)
• Maintain a routine for daily activities
• Always request the desired behavior
in the same setting ( i.e. eating in the
dining room, dressing in bedroom or
bathroom)
• Possibly try checklists
• Be encouraging
• Decrease stimuli
• Eat with the patient
• Leave a light on in the bathroom
• Label the important rooms ( i.e.
bathroom, bedroom, dining room)
• Label with pictures
• Place stop sign at doors you don't
want them to go through

69. APPROPRIATE
APPROACHES
When assisting patient's with
more fine motor activities,
maintain your position from
behind the patient to allow
appropriate motion,
sequencing, and visual input
rather than assisting patient
from the front that can further
confuse the embedded
program
https://www.aota.org/Practice/Productive-Aging/Alzheimers-
Dementia.aspx

70. TREATMENT ENVIRONMENT
• Free of clutter
• Free of distractions
• Well-lit areas
• Appropriate temperature per patient
• Low volume
• Safe
• Avoid patterns on floor if possible
 Figure-ground
• Tread on stairs
• Bright tape on stairs
 Visual-spatial perception
http://www.psicologosenlallama.com/2013/06/aprobar-atencion-y-percepcion-
con-m-j.html
http://www.canelaysal.com/teoria-de-la-
gestalt/gestalt/

71. THERAPEUTIC
APPROACH
Examples:
Homemaker – set up
a clothes line;
sweep/mop; putting
objects on shelves
Construction worker
– carry objects of
different weights;
use hammer on a
busy board;
Secretary – deliver
stacks of paper to
various locations;
taking notes in
standing
Enjoyed
baking/cooking -
cut putty in standing
to place in pots;
Gardener – bring
potting plants and
soil to plant flowers
or herbs; have
flower boxes outside
and walk patient
outside to work in
Find out what their prior
occupation(s) and hobbies were
to utilize for generalized therapy
with a functional task approach

72. "HOW DO PHYSICAL THERAPISTS
REPORT (BILL) TIME SPENT DELIVERING
PATIENT EDUCATION?"
• No designated code for reporting
patient education
• Time reported of providing the skilled
service of patient education depends
upon the therapist's intended
outcome
• Reflect intent, detailed instructions for
the patient, comments, and
observations of patient's/caregiver's
success in learning
• Must relay the skilled service
delivered and how it relates to the
plan of care
"WHAT SHOULD BE INCLUDED IN
DOCUMENTATION ABOUT PATIENT
EDUCATION?"
BILLING & DOCUMENTATION
Q&A(24)

73. SKILLED MAINTENANCE(25)
• Coverage of a maintenance program
is based on assessment by the PT of
the patient's condition and the need
for skilled care to carry out a safe and
effective maintenance program
• Covered in cases of therapeutic
interventions requiring a high level of
complexity
• "Medical necessity" is required for all
services covered by Medicare
• Services covered can be rehabilitative,
maintenance, or slowing of decline
• Physical therapist must be able to
justify services are reasonable and
necessary
• Considered skilled to instruct
caregivers and occasionally review
outcome

74. SKILLED
MAINTENANCE(25)
A maintenance program
can be created directly
from an initial evaluation
Documentation must
reflect the need for skilled
therapy to maintain
function or prevent/slow
deterioration
It is not required to have a
rehabilitation/restorative
therapy before initiating a
maintenance program
Establishing the home
exercise program and
teaching the caregiver how
to adequately provide the
service is considered skilled
and billable therapy
Frequency of visits for the
maintenance program is
determined by physical
therapist's justification via
documentation
The goals of a maintenance
program are to maintain
the patient's current
functional status or to
prevent/slow further
deterioration

75. HOME HEALTH
• The 13th, 19th, and 30th reassessment
requirements are still required for a skilled
maintenance program
• Assessment to reflect why services are skilled and
why the skill of a physical therapist is required to
maintain function or prevent/slow decline
• Functional measures should be utilized to track the
status within the patient's condition to decipher
reasonable expectations
• Medicare requires plan of care be physiian re-
certified every 90 days
• Even a maintenance program must be certified by a
phyician within 30 days of the initial treatment date
as well as recertified every 90 days or when plan of
care duration has expired (whatever comes first)
OUTPATIENT
SKILLED MAINTENANCE(26)

76. STATISTICS (14)
Prevalence of the disease doubles every 5 years beyond age 65
Estimated that 360,000 new cases will occur each year in the US alone
By 2040, 14 million people in the US are expected to have AD
Incidence is higher in women than men
Life expectancy reduced by approximately one-third after development of AD
People with AD live an average of 8-10 years after diagnosis
Disease can last up to 20 years
4th leading cause of death in US, killing more than 100,000 anually
(But respiratory conditions, congestive heart failure, and infections, which develop
in the late stages of the disease, are often given as the cause of death)

77. PERSONAL
REFLECTION
THROUGH EACH
STAGE
2005-No symptoms at
all
2012-End of Early Stage
2013-Mid Stage 2014-Late Stage

78. You treat a disease, you
win, you lose. You treat a
person, I guarantee you,
you'll win, no matter what
the outcome.
-Patch Adams

79. Our job is improving the
quality of life, not just
delaying death.
-Patch Adams

80. WORKS CITED
1. Guccione, Andrew. (2000). Geriatric Physical Therapy, United States of America: Mosby.
2. Alzheimer's Association. (2018). Retrieved from https://www.alz.org
3. Bright Focus Foundation. (2015, July 1). Amyloid Plaques and Neurofibrillary Tangles. Retrieved from
https://www.brightfocus.org/alzheimers/infographic/amyloid-plaques-and-neurofibrillary-
tangles
4. National Institute on Aging. (2018, June 27). What is Lewy Body Dementia?. Retrieved from
https://www.nia.nih.gov/health/what-lewy-body-dementia.
5. Mayo Clinic. (2017, August 9). Lewy Body Dementia. Retrieved from
https://www.mayoclinic.org/diseases-conditions/lewy-body-dementia/symptoms-causes/syc-
20352025.
6. Johns Hopkins Medicine. (2018, August 9). Stages of Alzheimer's Disease. Retrieved from
https://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/stages_of_alzheimers_disease_134,64.

81. WORKS CITED
7. Kurlowicz, Lenore. & Wallace, Meredith. (1999). The Mini Mental State Examination (MMSE). The
Hartford Institute for Geriatric Nursing, (3). Retrieved
from https://www.mountsinai.on.ca/care/psych/on-call-resources/on- call-resources/mmse.pdf.
8. Teri, Linda, Logsdon, Rebecca, & McCurry, Susan. (2008). Exercise Interventions for Dementia and
Cognitive
Impairment: The Seattle Protocols. J Nutr Health Aging, 12(6), 391-394.
9. Paillard, Thierry, Rolland, Yves, & de Souto Barreto, Philipe. (2015). Protective Effects of Physical Exercise in
Alzheimer's Disease and Parkinson's Disease: A Narrative Review. Journal of Clinical Neurology,
11(3),
212-219.
10. van Halteren-van Tilborg, Ilse, Scherder, Erik, & Hulstijn, Wouter. (2007). Motor Skill Learning in
Alzheimer's

82. WORKS CITED
11. Puxty, John, Abbott-McNeil, Deanna, & Murphy, Susanne. (2009). Brain and Behaviour: The 7 A's of
Dementia
[PowerPoint Slides].
12. Reisberg, Barry. (2005, September 14). Global Deterioration Scale. Retrieved from
http://geriatrictoolkit.missouri.edu/cog/Global-Deterioration-Scale.pdf
13. National Institute on Aging. (2017, May 17). Tips for Coping with Sundowning. Retrieved from
https://www.nia.nih.gov/health/tips-coping-sundowning
14. Gruetzner, H. (2001). Alzheimer's A Caregiver's Guide and Sourcebook. New York, NY: John Wiley & Sons,
Inc.
15. (n.d.). https://publications.tnsosfiles.com/rules/0940/0940-03/0940-03-06.pdf.
16. Carr, Eva, Treo, Jose Luis, Busigina, Svetlana, and Torres-Aleman, Ignacio. (2001). Circulating Insulin-Like
Growth
Factor 1 Mediates the Protective Effects of Physical Exercise against Brain Insults of Different
Etiology

83. WORKS CITED
17. Fleiner, Tim, Dauth, Hannah, Gersie, Marleen, Zijlstra, Wiebren, and Haussermann, Peter. (2017). Structured
physical
Exercise improves neuropsychiatric symptoms in acute dementia care: a hospital-based RCT. Alzheimer's
Research & Therapy, 9(68):1-9.
18. Chukwuemeke Uwajeh, Patrick, Onosahwo Iyendo, Timothy, Polay, Mukaddes. (2019). Therapeutic Gardens As a
Design
Approach For Optimising The Healing Environment Of Patients With Alzheimer's Disease And Other
Dementias:
A Narrative Review. Elsevier. 1-14.
19. Sanchez-Valdeon, Leticia, Fernandez-Martinez, Elena, Loma-Ramos, Sara et al. (2019). Canine-Assisted Therapy
and
Quality of Life in People With Alzheimer-Type Dementia: Pilot Study. Frontiers in Psychology, 10(1332):1-
6.
20. Watson, Karen, Hatcher, Deborah, Good, Anthony. (2019). A randomised controlled trial of Lavender (Lavandula
Angustifolia) and Lemon Balm (Melissa Officinalis) essential oils for the treatment of agitated behaviour
in

84. WORKS CITED
21. Minematsu, Akira. (2006). The Frequency of Family Visits Influences the Behavioral and Psychological Symptoms of
Dementia (BPSD) of Aged People with Dementia in a Nursing Home. J. Phys. Ther. Sci. 18:123-126.
22. Cohen-Mansfield, Jiska. (2018). The impact of group activities and their content on persons with dementia attending
them. Alzheimer's Research & Therapy. 10(37):1-8.
23. Jacobsen, Jorn-Henrik, Stelzer, Johannes, Fritz, Thomas Hans, et al. (2015). Why musical memory can be preserved in
advanced Alzheimer's disease. Brain A Journal of Neurology, 138:2438-2450.
24. Elliot, Carmen. (2019, September). FAQ: Coding for Patient/Client Education. Retrieved from www.apta.org.
25. APTA. (2015, October). FAQ: Skilled Maintenance: What Constitutes Skilled Maintenance? Retrieved from www.apta.org.
26. APTA. (2015, October). FAQ: Skilled Maintenance: Documentation. Retrieved from www.apta.org.
27. Serrano-Pozo, Alberto, P. Frosch, Matthew, Masliah, Eliezer and Hyman, Bradley T. (2011) Neuropathological alterations in
Alzheimer's
Disease. Cold Spring Harb Perspect Med, 1:a006189