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Journal of Geriatric Physical Therapy:
Case Report

Fall Management in Alzheimer‐related Dementia: A Case Study

Mirolsky‐Scala, Gail PT, DPT1; Kraemer, Theresa2

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Author Information

1Ledgeview Living Center, West Paris, ME

2University of New England, Portland, ME

Address correspondence to: Gail Mirolsky‐Scala (GailRunner@aol.com).

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Abstract

Background and Purpose:: Nursing home residents with dementia are at an increased risk of falls. This case report describes a physical therapist's approach to fall management in a patient with Alzheimer's disease in a long‐term care facility.

Case Description:: An 85‐year‐old female with Alzheimer's disease began to experience impaired balance and weakness resulting in gait deviations and falls. The combination of clinical findings, scores on several clinical measures, and fall history classified her as being at high risk for future falls.

Intervention:: The physical therapy fall management program included lower extremity and core therapeutic exercise, balance, gait, and assistive device training, and caregiver instruction in the form of a functional maintenance program (FMP) with focus on activities that activated the implicit memory system while emphasizing aspects of communication that are typically preserved in patients with dementia.

Outcomes:: After 4 weeks of twelve 30 minute sessions, the patient's Tinetti Assessment Tool score increased from 8/28 to 16/28 and Berg Balance Scale score from 7/56 to 19/56. The number of documented incident reports related to falls decreased from 2 to 0 in a 4‐week period of time. On the International Classification of Functioning, Disability, and Health, the patient improved in 4 areas of the Impairments of Body Functions domain, in 12 areas of the Activity Limitations and Participation Restriction domain, and in 3 areas of the Environmental Factors domain.

Discussion:: Positive functional outcomes were achieved through a modification of typical fall prevention interventions that took into consideration the patient's decreased cognition, communication deficits, and behavior problems.

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INTRODUCTION

It is estimated that 42% to 72% of residents of nursing homes have dementia; this diagnosis carries with it a high risk of falling.1–5 The most prevalent type of dementia in nursing home residents is Alzheimer's disease (50–60%) followed by vascular dementia (25–30%).3 The clinical signs and symptoms of dementia include pyramidal system impairment, parkinsonism, apraxia, gait impairment, memory impairment, and altered behavior patterns.6–9 In addition to falling more frequently than residents without cognitive impairment, those with dementia are three times more likely to be seriously in‐ jured in a fall.1,2,10 Those with Alzheimer's disease will fall at least once in a year.11

The gait dysfunction and balance disorders common in mid to late stages of dementia are important risk factors for falls. Residents with Alzheimer's disease demonstrate a cautious gait pattern12 with decreased step length, step height, cadence, heel strike, and arm swing, visual‐spatial deficits, a wide base of support, difficulty turning, and a flexed posture.13 These gait deviations increase in frequency and severity as the disease progresses.12 Chong et al suggest that balance disorders in persons with Alzheimer's dementia stem from the inability to process sensory information in an unstable physical environment, rather than as a result of poor motor control or impaired vision or vestibular functioning.11 Residents with Alzheimer's disease have difficulty diverting attention away from conflicting visual cues when situations require concentration to maintain balance.11

Other factors thought to contribute to fall risk in patients with dementia include: environmental hazards, multiple comor‐bidities, use of restraints, certain medications (antidepressants, nonsteroidal anti‐inflammatory drugs, vasodilators, antianxiety agents), postural hypotension, improper footwear, vision and/or hearing loss, impaired cognition, cardiovascular disorders, wandering, and ambulation assistive device use.1,2,13 Additional predictors of falls in long term care residents with dementia include impairment in activities of daily living (ADLs), falls in the 2 weeks prior to admission, and scores below 20 on the Mini Mental State Exam (MMSE).13,14 Physical therapists can identify risk factors and predictors that may contribute to falls, provide prevention services to reduce or eliminate future falls and health care costs, restore function, reduce impairments, and limit the degree of disability.15

Physical therapy interventions for residents of long term care facilities who fall include: family and nursing caregiver training, environmental modification, bed mobility, transfer, and gait training, balance training, therapeutic strengthening exercise, and restraint reduction.13,16–19 These interventions are most efficacious if a multidisciplinary (physician, nursing, physical therapist, occupational therapist, pharmacist, ancillary services) approach is used that also considers communication strategies, medication management, socialization, activities/recreation participation, and ADL retraining.13,20

Physical therapists examine, evaluate, and provide risk reduction and primary prevention interventions for individuals with loss of balance and history of falling.15 Physical therapy plans of care designed to reduce falls in older individuals and specifically for residents with dementia focus on improving endurance, balance, strength, and locomotion. In community living older adults, fall prevention interventions that include progressive muscle strengthening, balance training, ambulation, and environmental hazard assessment can significantly reduce risk of falling. There is little evidence specifically examining the use of a fall management program in older adults with Alzheimer's disease in a long‐term care facility.

A variety of approaches have been used to improve balance and reduce fall occurrence among aging adults living independently in the community or assisted‐living facilities.22 Those that produce statistically significant improvements included resistance exercise targeting muscle performance, practice responding to perturbations, and voluntary movements designed to improve control of the individual's center of mass within his or her base of support during functional activities that challenge postural control.22

There is a negative misperception among clinicians about potential to effect positive change in persons with dementia of the Alzheimer's type.16 While the cognitive impairment, communication difficulties, and behavioral problems associated with this diagnosis can and do create challenges for participation in rehabilitation, positive functional outcomes can be achieved.16 Physical therapists can use evidence from the clinical research literature to modify interventions to the needs of these patients.23

The foundation for effective fall management interventions for residents with dementia is the establishment of a method of communication that works for that patient, that takes into account the degree of expressive and receptive language difficulty, perseveration, illogical topic changes during conversation, and difficulty initiating speech that the patient experiences.24 Many individuals with dementia desire to communicate socially, maintain the ability to understand and use nonverbal communication and use humor, and have normal conversation structure.25 Attending to these aspects of communication facilitate establishment of rapport with the patient. Recommended strategies include the use of gestures, simple verbal cues and facial expressions, using a quiet voice and short sentences, providing positive feedback, speaking slowly, and allowing extra time for processing of commands.2

No studies, to date, have described best practice for fall management in patients with Alzheimer's dementia. This case report describes physical therapy interventions used to improve balance, strength, and functional status and reduce risk of falling for a long‐term care resident with Alzheimer's dementia who had begun to experience falls.

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CASE DESCRIPTION

History

The patient was an 85‐year‐old, Caucasian female admitted as a permanent resident to a long‐term care facility following the death of her spouse (her primary caregiver) 35 days prior to referral to physical therapy. Her primary diagnosis on admission was Alzheimer's disease, with a Clinical Dementia Rating (CDR) Scale score of 3, indicating severe dementia. Past medical history included: hypertension, coronary artery disease (CAD), inferior wall myocardial infarction, pernicious anemia, hyperlipidemia, reflux esophagitis, recurrent urinary tract infections, and anxiety. With a height of 63 inches, and weight of 135.2 pounds, her body mass index (BMI) was 23.9. Medications26 upon admission are listed in Table 1. Two days after the physical therapy evaluation, the patient's primary care physician reduced her Risperdal dosage to 1 Mg bid in an attempt to reduce akathisia or restlessness which may have been causing her to experience the urgent need to move and not sit down.

Table 1
Table 1
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The patient was a retired beautician whose previous hobbies included knitting, gardening, and reading novels. She was a nonsmoker and rarely drank alcoholic beverages. Prior to admission, she required minimal assistance from her spouse with basic ADLs. She did not use an assistive device, but required supervision with all mobility‐related activities. She had not fallen at home, prior to admission. While she was homebound in her single‐family, rural home, caregivers were able to take her to medical appointments. All care was provided by her spouse without home health assistance. She had no previous care from physical therapists.

The patient was referred to physical therapy for evaluation and intervention 35 days after admission, following 2 noninjurious falls. The first fall, unwitnessed, occurred in the living room area of the facility at 10:35 AM, 9 days prior to the physical therapy evaluation. Urinalysis done the day after the fall ruled out a urinary tract infection (UTI) as a possible cause of the fall. The second fall, 7 days after the first, occurred in the patient's semi‐private room while she was attempting to walk around her bed at 3:10 PM. Nursing reported the patient wandered throughout the day, often to the point of exhaustion. Nursing staff verbally prompted her to sit or lie down to rest frequently during the day, as she was unable to recognize the need to do so on her own. As many as 8 times a day, facility staff observed her falling asleep while standing holding the hallway railings or leaning on furniture.

Nursing staff and primary care physician noted that the patient became agitated and anxious, and had tried to leave the facility several times to look for her husband, not remembering his death. At other times, with no signs of agitation, she willingly took part in group activities (coffee socials, musical programs, pet therapy, and visits with children's groups) and received daily one‐on‐one visits from the activities director. She enjoyed weekly visits from her 3 daughters and sons‐in‐law and many grandchildren.

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Examination

Upon the initial physical therapy examination, the patient was alert and oriented to person and place, and consistently followed 1 step verbal commands. She had no verbal complaint of pain (using a numbering rating scale for pain intensity27) and demonstrated no grimacing or wincing upon examination. When asked about her perception of her general health, the patient responded “pretty good.” In sitting, radial heart rate was 79 bpm, respiratory rate 18 bpm, and resting blood pressure 100/68 mmHg. Passive and active range of motion of all extremities was grossly within functional limits.28 Upper and lower extremity strength was grossly rated 3/5 per the protocol described by Kendall et al.29 Core strength was rated as 3/5; posture was kyphotic. Static and dynamic sitting balance was rated as good; static balance in standing balance fair, and dynamic balance in standing poor per protocol described by Reinisch.30 There was no edema of the lower extremities. Light touch was intact in all extremities per examination protocol described by Gould et al.28 Finger‐to‐nose and heel slide coordination tests were performed smoothly, but slowly.31 Proprioception appeared to be intact, per procedures described by O'Hanlon‐Nichols.31 She was able to roll independently in both directions, without pulling on the bedrail. Transitions including supine to sit and sit to stand, bed to chair, and toilet transfers required supervision to minimal assistance of one person, depending upon level of fatigue. Because of distractibility, she required minimal assistance of one person with dressing, bathing, grooming, and hygiene. She was able to eat without the need for adaptive equipment, but required supervision to complete the meal.

The patient walked in lace up walking shoes with no assistive device, but required supervision to minimal assistance of one person due to fatigue and loss of balance. She was frequently observed to “furniture walk” or hold the hallway railing for support, walking on her own. During ambulation, she took short steps, made initial contact with her entire foot, remained in slight knee flexion during stance, and had a consistently kyphotic posture and forward head throughout the gait cycle. With fatigue, knee flexion in stance increased from approximately 10° to 35°, and forward thoraco‐lumbar flexion of the trunk increased from 15° to 30°. She was able to ambulate for 200 feet across the carpeted hallway, before taking a 2‐minute standing rest break holding onto the hallway railing while speaking with another resident. Although she responded “yes” when asked if tired by staff noting signs of fatigue, the patient did not recognize the need to rest or initiate sitting or lying down unless prompted by staff. The patient's room was free of clutter, well lit, and the walkways were clear.

The Mini Mental State Exam (MMSE) was used to assess cognitive status.32,33 MMSE scores can range from 0 to 30; those between 0 to 10 represent severe dementia, 11 to 17 moderate dementia, and 18–23 mild dementia.33 Items on the MMSE evaluate orientation, registration, attention and calculation, recall, and language. This patient scored a 5/30 on the MMSE during the initial examination.

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Outcome Measures

Four functional tools were used to objectively quantify the patient's functional status and to evaluate change in function and rate of falling following physical therapy intervention: the International Classification of Functioning, Disability, and Health; the Performance Oriented Mobility Assessment (POMA), the Berg Balance Scale (BBS), and facility‐generated incident reports.

The International Classification of Functioning, Disability, and Health (ICF)34 was used to assess the patient's functional abilities. The ICF is a scientific tool that reports consistent, internationally comparable information about a patient's health and disability. At the individual patient level, it assesses the patient's level of functioning, determines what treatments or interventions can maximize functioning, evaluates the outcomes and usefulness of treatment interventions, and enhances communication among different health care providers by using a standard language to describe health and health‐related states.34 Reliability and validity for this measure has not been established. Only those items that pertained to the long‐term care setting were selected for each measurement. Evaluation was performed by the same physical therapist at the same time of day during each assessment. The results of the ICF assessment for this patient are summarized in Table 2.

Table 2
Table 2
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The POMA35,36 is a comprehensive assessment of balance and gait that involves performance‐oriented evaluations of multiple tasks. Gait and balance elements are scored separately, but can be combined to achieve a maximum score of 28. This tool can be used for many different medical diagnoses, and testing can be done with or without an assistive device. The measure's validity, reliability, sensitivity to change, and predictive validity has been evaluated and established.35–37 On initial examination, the patient's POMA score was 8/28 (5/16 balance score, 3/12 gait score); this indicates high risk of future falls. The patient's immediate balance upon standing was steady only with support, she required support to maintain standing, staggered during the sternal nudge, demonstrated discontinuous steps and staggering during a 360° turn, demonstrated hesitancy during gait initiation, experienced discontinuity between steps, and had a mild to moderate deviation in excursion.

The Berg Balance Scale (BBS) is a reliable and valid tool that objectively quantifies levels of balance in older adults for a broad range of pathologies.38–40 The tool evaluates 14 mobility and balance tasks and scores each task using a 0 to 4 scale with 56 the maximum score attainable. A score of 36 or below indicates an 100% risk for falls.38–40 On the initial evaluation, the patient's BBS score was 7/56 indicating that she was at high risk for falling and dependent in mobility. While completing the BBS assessment, the patient demonstrated an inability to stand unassisted for more than 30 seconds with eyes open or closed, was unable to stand with feet together for more than 15 seconds, could not stand with one foot in front of the other or on one leg without a loss of balance, and experienced a loss of balance with reaching forward or picking an object up from the floor.

The POMA and BBS link the physical therapy examination to intervention strategies by directing the fall management training program to target each patient's specific impairments and, thus, enhance the effectiveness of the fall management intervention. Such measures are useful in pinpointing gait and balance impairments for residents of nursing homes, which in turn, have lead to better outcomes of physical therapy interventions.20,40

The POMA and BBS were used as outcome measurements because of their emphasis on functional tasks. Strategies to facilitate communication were employed during testing; these included the use of gestures and visual cues along with verbal command, slowing the pace of the examination, providing reassuring touch to decrease fear and anxiety, incorporating familiar, functional tasks, and providing a low stimulation environment. Instruments that measure time to complete tasks are inappropriate for persons with Alzheimer's disease, because of the likelihood of perseveration, decreased attention span, and delayed processing of commands.2

Incident reports, mandated by the U.S. Department of Health and Human Services, are used to track occurrence and outcomes of falls in long‐term care settings.1 Prior to the start of physical therapy intervention, the patient had 2 documented incident reports related to falls.

Given the results of the examination findings, clinical tests and patient's recent history of falls, physical therapy intervention in the form of a fall management program including therapeutic (strengthening) exercises, balance training, gait training, and instruction to nursing staff in a functional maintenance program (FMP) was warranted.

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Diagnosis, Prognosis, and Plan of Care

The problems and needs identified in the initial examination fall within 3 practice patterns described in the Guide to Physical Therapist Practice:15'Neuromuscular Patterns 5A (primary prevention/risk reduction for loss of balance and falling) and 5E (impaired motor function and sensory integrity associated with progressive disorders of the central nervous system) and Musculoskeletal Pattern 4C (impaired muscle performance). Because the patient was cooperative, friendly, followed simple verbal commands well, was able to be easily redirected, was willing to participate in physical therapy and had involved, attentive caregivers in the facility's nursing staff, her prognosis for improving strength, balance, safety, and function and reducing fall risk was determined to be good, despite the presence of cognitive impairment. Based on results of the examination, the ICD‐9 code 781.2 (abnormality of gait) was chosen for the physical therapy diagnosis. The goals of physical therapy were to decrease her risk of falling as evidenced by:

1. an increase in core strength to 4/5;

2. an increase in lower extremity strength to 4/5;

3. improvement in balance and gait indicated by a POMA score 15/28 (balance 8/16 and gait 7/12) within 2 weeks;

4. improvement in balance and gait indicated by a POMA score of 20/28 by discharge;

5. improvement in balance indicated by BBS of 15/56, specifically demonstrating the ability to turn 360° safely, stand unassisted with feet together, and pick up an object from the floor from a standing position;

6. a decrease in the number of falls as documented on incident reports to 0 in a 4 week time period; and

7. resumption of safe, supervised ambulation within the facility with the appropriate assistive device for 300 feet (the distance from the patient's room to the dining and living room areas) with a normalized gait pattern, continuous steps, and an upright posture within 4 weeks.

The patient could not articulate her goals for physical therapy; however, the patient's family's goals were to prevent future falls and to “make her steadier on her feet.” Frequency of physical therapy intervention was set at 3 times per week for 4 weeks duration, consistent with the expected number of visits per episode of care in the practice patterns from the Guide to Physical Therapist Practice.15 Current Procedural Terminology (CPT) codes used during this physical therapy episode of care were 97001 (physical therapy evaluation) for the initial evaluation; and 97110 (therapeutic exercise), 97112 (neuromuscular reeducation), and 97116 (gait training) for intervention sessions.

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Intervention

A fall management program plan of care was initiated to address the patient's bilateral lower extremity and core muscle weakness, balance deficits, gait impairments, and lack of awareness of appropriate response to fatigue. Care was provided in the patient's room on the dementia unit.

The fall management program had 4 components: therapeutic exercises, standing balance activities, gait training, and a functional maintenance program (FMP) for nursing staff. The therapeutic exercise component consisted of open and closed chain lower extremity and trunk strengthening exercises in supine, sitting, and standing. These activities were selected based on evidence from studies by Hostler et al41 and Galvao et al42 that demonstrated that improvement of strength, endurance, and functional gains were possible using small increment progressive resistive exercise (PRE). Cuff weight resistance around both ankles was systematically increased during the 4 week program as outlined in Table 3. Manual and visual cues were provided to ensure safe and proper form during exercise sessions. Simple, one‐step verbal cues were provided, and positive feedback was given when the patient completed the exercises appropriately. The therapist stood or sat in the patient's direct line of vision to establish and maintain eye contact during exercise sessions.

Table 3
Table 3
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Standing balance exercises included marching in place, tandem walking, balancing on one leg with eyes open and closed, reaching for cones, side stepping, walking on toes and heels, and functional tasks such as opening and closing dresser drawers and doors, putting clothes away in the closet, and making the bed. Reassuring touch and calm tone of voice while guarding the patient were used to dispel the patient's fear of falling during these activities. Parallel visual cues were given with the therapist performing the exercises alongside the patient.

Gait training included trying various assistive devices in an attempt to improve the patient's gait pattern and safety during ambulation. During the first session, the patient was introduced to a straight cane (SC); however, she tended to carry the cane instead of using it for support or safe ambulation. In sessions 2 and 3, the patient used a front wheeled walker (FWW). Initially, the FWW promoted a more effective swing phase, as well as better knee extension during stance. The patient was inconsistent in positioning the walker, allowing it to roll too far forward, increasing her tendency to assume a forward flexed posture, and leading to loss of balance in an anterior direction, and assistance from the therapist to prevent a fall.

During the fourth treatment session a Merry Walker® (Merry Walker Corporation, Mundelein, IL) was considered. This is considered a form of a physical restraint because patients are unable to open and close the front gate without assistance. For this patient, however, the device was a justified enabler; it allowed the patient to walk as she wished and supported her in sitting, thus reducing risk of falls when she did not recognize the need to take action when fatigued. The Merry Walker® allowed her to ambulate independently without a caregiver, encouraged appropriate rest breaks, allowed her to interact socially and seemed to decrease her anxiety and agitation. In the device, the patient was able to attain a consistent, upright posture, take longer steps with an appropriate heel strike, and achieve a more stable extended knee extension in stance. The tactile cues from the Merry Walker® seat against her lower extremities when she stopped walking prompted the patient to sit and rest. It also reduced the need for staff to redirect the patient to a chair or her bed when she began to lose her balance or demonstrate other signs of fatigue from excessive wandering. Guidelines for use of the device included a duration of no more than 2 hours, with release during meals, family visits, and supervised activities.

The patient was cared for by a single physical therapist and the time and order of interventions, as well as verbal and nonverbal cuing was consistent across sessions. This provided effective reinforcement of what was being taught and maintained a constant practice condition.43 Whatever the patient became interested in doing during the session was incorporated, as a means of fostering her cooperation. Incorporating familiar tasks into intervention sessions for patients with Alzheimer's disease improves efficacy, but also requires the physical therapist to be flexible, creative, and have patience.44 For balance and gait training, the patient performed purposeful and familiar tasks, such as putting away her clothes in the closet or delivering her dirty laundry to the soiled utility room. These activities helped to improve her ability to turn, her anticipatory postural control, her ability to initiate gait, and her ability to maintain an upright posture. The patient did have difficulty focusing when the environment was visually complex or stimulating, demonstrating loss of balance when distracted by conflicting visual cues.

A functional maintenance program (FMP) designed to maintain lower extremity strength, preserve standing balance, and prevent a decline in function and future falls was put into place for nursing staff to use with the patient. Nursing assistants were instructed how to effectively assist the patient perform a daily, comprehensive exercise program. This program included functional exercises consistent with those she did during physical therapy. Nursing staff were instructed in how to assist the patient in and out of the Merry Walker® appropriately.

To ensure carryover and maintenance of the functional abilities gained during the episode of physical therapy care, it was essential to instruct the patient's caregivers about strategies that had been effective for this patient. This ensured the staff knew how to safely position the patient in the Merry Walker®, how to appropriately communicate with the patient, and how to successfully carry out the FMP with the patient. By establishing a consistent routine with the patient in a low stimulation environment and using strategies that activated her implicit memory system, the patient's fall risk was reduced and safe mobility around the facility was facilitated. The patient's family was pleased with the intervention outcome of elimination of falls and improved safety during mobility.

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OUTCOMES

The physical therapy episode of care included 12 intervention sessions of 30 minutes each, provided 3 times per week for 4 weeks. On discharge from physical therapy, the patient demonstrated improved scores in the objective and subjective outcome measures established to decrease her risk of falling. Strength increased to a rating of 4/5 in both lower extremities and 3+/5 for her core. Static standing balance improved to a grade of good and dynamic standing balance to a grade of fair. She demonstrated the ability to safely ambulate with a more effective gait pattern and upright posture throughout the facility with supervision in the Merry Walker® for 300 to 400 feet before she would sit to rest without prompting from staff. The results on the International Classification of Functioning, Disability and Health34 are summarized in Table 2.

The POMA score increased from 8 to 16 out of a possible 28 (7/16 balance score, 9/12 gait score), with a corresponding drop in risk level from high to moderate risk. The greatest improvements were in her ability to turn 360° steadily, achieve bilateral swing through and foot clearance with each step, and demonstrate continuous stepping during walking.

The patient's Berg Balance Scale score increased by 12 points from 7 to 19 out of a possible 56, well beyond the minimal clinically important difference of 6 reported by Stevenson et al.45 She demonstrated greatest improvement in her ability to stand independently while using her hands to assist, sit by using the back of her legs against a chair to control the descent, and placing her feet together in standing and holding the position for 30 seconds. A comparison of the pre‐ and postintervention scores for each task assessed is in Table 4.

Table 4
Table 4
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There were no documented incident reports for falls while on physical therapy caseload for 4 weeks. Upon follow up during patient care conferences, the patient was free of falling at 60 days following discharge from physical therapy and the FMP was being carried out compliantly and without difficulty by the nursing assistants.

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DISCUSSION

Advanced age, visuospatial impairments, cognitive decline, and use of psychotropic drugs have been associated with decreased clinical performance on balance testing, especially among individuals with dementia.46–48 Physical therapists can play a vital role in the screening, prevention, treatment, and management of falls, especially among older individuals with dementia, through the use of a falls management program.15 Most of the current literature involves physical therapy interventions to assess and treat balance and gait disorders and falls in patients without Alzheimer's dementia, but little information is available on rehabilitation of those with Alzheimer's disease or other dementias who experience falls, weakness, and balance and gait impairments.

The procedural and therapeutic interventions used for this patient with Alzheimer's dementia were based upon evidence about fall prevention in older individuals through strengthening, balance training, and used of an appropriate ambulatory assistive device, which for this patient was a Merry Walker. Problems with transfers and bed mobility were thought to be related to the patient's fatigue from wandering; when rested she could accomplish these activities with supervision, however, she required assistance for safety when fatigued.

This patient's medications were evaluated by a coordinated, interdisciplinary approach, found to provide maximum benefit to the patient for reducing morbidity and mortality and maintaining independence and quality of life.16,20 Specifically, addressing high‐risk medications such as Risperdal may have lasting and relatively‐immediate beneficial consequences on a patient's behavior and subsequent safety.

Very often, physical therapists are under the impression that improvements in function and strength cannot occur in patients with dementias, especially in the late stage of the disease process. They assume that patients with Alzheimer's dementia are unable to participate in a rehabilitation program due to their inability to follow directions and to remember instructions.2,16 This belief however is erroneous.16,43 Loss of functional abilities occurs early in the disease process, but the relationship between functional ability and dementia stage is not linear.43 In fact, the patient described in this case report had severe dementia but did participate willingly and cooperatively with physical therapy intervention, achieving improvements in core and lower extremity strength as well as in standing balance, required less assistance during ambulation, improved endurance, and ultimately reduced her risk of future falls.

In dementia of the Alzheimer's type, the implicit (procedural, nondeclarative) memory system is preserved despite impairment of explicit (declarative) memory in patients with Alzheimer's dementia. The implicit memory system involves unconscious, unintentional recall and effects of previous experiences on various task performance via priming (improved speed and accuracy in processing what an object is used for and what its physical features are) and motor skill learning (performance improvement in a task that occurs with practice). Explicit memory involves conscious and intentional recollection of specific information and previous experience. Individuals with Alzheimer's disease are able to improve and sustain function if interventions focus on use of the implicit, not explicit, memory system.43,50,51

For those with cognitive impairment typical of Alzheimer's disease, acquisition and improvement of motor skills occurs best when a task is practiced repeatedly, under constant conditions, in a familiar, low stimulation environment.25,43 This is why the physical therapy interventions were provided at bedside in the patient's room on the dementia unit. It was thought that, had intervention taken place in the busy rehabilitation department, the patient would have experienced more of the acute anxiety to which she was prone. The ability to process and learn is affected by sensory ability, cognitive function, age‐related changes in the central nervous system, as well as the disease process of dementia. Because sensory processing is thought to activate implicit memory, reassuring touch (an aspect of nonverbal communication) may help to dispel anxiety or fear, allowing a patient with dementia to better focus on a task. Parallel visual cueing (in which the physical therapist sits or stands alongside the patient demonstrating a task) combined with slow gestures and prompts, is more effective than mirror‐image cuing (with the therapist positioned in front of the patient).2,43 Gentle manual cues used to guide movement in the desired direction are less likely to stimulate resistance in patients with Alzheimer's disease.2 These techniques worked particularly well in facilitating function during intervention with the patient described in this report. Her participation was substantially facilitated by use of the Merry Walker®. The visual cue of the seat and the tactile cue of the pressure of the seat behind her legs when she stopped ambulating, prompted her to sit down to rest when she was fatigued, eliminating the need for staff to redirect her to a chair or her bed to rest. Having the therapist walk alongside her demonstrating the desired gait pattern may have helped the patient to attain the appropriate response. During therapeutic exercises, the patient was able to consistently participate in lower extremity and core strengthening exercise with the visual cues of the therapist performing the same exercises next to her. This was further facilitated by the use of simple verbal instructions and tactile guiding of the limbs in the appropriate direction.

This patient experienced gains in lower extremity strength, core strength, and functional ability as measured by manual muscle testing following physical therapy. This is similar to studies that have demonstrated these benefits of exercise at any age in people without dementia.

The ICF was chosen as an outcome measure because it addresses a patient's function, health, personal, contextual, and environmental factors when assessing a patient and developing a fall management intervention.52 Communication with families improves because terminology, related to function, is easier to understand.53,54 The use of multidisciplinary problem solving forms based on the ICF model assist health care providers to formulate patient‐centered hypotheses, care, anticipated outcomes, as well as patient compliance if care is focused according to targeted problems.52,54 This multidisciplinary approach facilitates the success of a fall management program.16,20

When communicating with patients with Alzheimer's dementia, “going with the flow” of the conversation is less likely to trigger agitation than efforts to reorient the patient. The use of gestures, simple verbal cues, facial expressions, extra time allowance for the processing of commands, a quiet voice, short sentences, positive feedback and speaking slowly all worked well with the patient in this case report. Making and maintaining eye contact, at the pateint's eye level, fosters trust and cooperation; in contrast, standing above the patient who is seated or lying may be intimidating and trigger agitation or resistance to participation. Many persons with Alzheimer's disease are unable to formulate and verbalize concerns or complaints; because of this, it is imperative to monitor nonverbal signs of pain and fatigue (eg, grimacing, shortness of breath, agitation, loss of balance, and altered gait patterns) during intervention.

Although the physical therapy intervention described in this case report may have contributed to reducing the incidence of falls, the impact of change in medication must also be considered. The improvements in strength could be due either to the small increment PRE program, the practice effect involved with motor skill learning, or a combination of both.25,43 It is recommended that all strengthening interventions establish an accurate, objective baseline through the use of a repetition maximum to prescribe the appropriate resistance that will provide an overload and thus adaptive response. It is also important to note that MMT is a subjective measure prone to bias and a ceiling effect. Examination of strength using a hand held dynamometer would have more effectively quantified strength. Likewise, the balance and gait improvements may have occurred through the practice effect and sensory cueing.2,43

The selection of the interventions for the patient in this case report was based upon the author's clinical experience working with patients with Alzheimer's dementia as well as evidence from the research literature about fall management, rehabilitation of patients with dementia, communication, and memory research. Further research is necessary to ascertain the effectiveness of fall management interventions in patients with dementia related to Alzheimer's disease. In addition, there is a need to determine the barriers and facilitators of these fall management interventions that influence the extent to which they are effective with this population of patients.

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ACKNOWLEDGEMENT

Dr. Mirolsky‐Scala provided concept, design, data collection, treatment, and writing and this case report was submitted in her partial fulfillment of the Doctor of Physical Therapy degree for the University of New England, Portland, ME. Dr. Kraemer provided conceptual input, writing, editing, revising, review, and approval.

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REFERENCES

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Key Words:: falls; Alzheimer's disease; dementia; physical therapy

Copyright © 2009 the Section on Geriatrics of the American Physical Therapy Association

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