Breaking Barriers: Treating Individuals with Alzheimer’s Disease
By: Ashleigh Trapuzzano, DPT Student
Nicole Dawson, PT, PhD, GCS University of Central Florida, Doctor of Physical Therapy Program
Alzheimer’s disease is the most common form of dementia – an umbrella term for a decline in cognitive abilities that interfere with daily life and function. As of 2018, 1 in 10 older adults over the age of 65 are living with Alzheimer’s disease in the United States. This growing population makes it inevitable that rehabilitation professionals working with older adults will evaluate and/or treat an individual with Alzheimer’s at some point in their career. Most importantly, it is vital that we understand that these individuals can benefit from rehabilitation interventions just as much as individuals without Alzheimer’s. Evidence supports the benefits of physical activity and exercise, mentally stimulating activities, and social engagement in this population. Understanding relevant symptoms of the disease and its effect on function, appropriate treatment strategies to implement, and the illness experience of the individual reduces the barriers and challenges commonly thought to be associated with Alzheimer’s disease.
Barrier #1: Limited understanding of the signs and symptoms of the disease
Alzheimer’s disease is an irreversible, progressive disease. It can impact many facets of the individual’s health and quality of life:
- Cognitive symptoms include short term memory loss, confusion, language and visual-spatial difficulties, and difficulties with executive function and processing speed (i.e. planning, reasoning, judgement, attention, inhibition).
- Functional symptoms include difficulties completing day-to-day activities such as household chores, managing finances, shopping, toileting, dressing, eating, and grooming. Difficulties with IADL’s such as keeping track of monthly bills is more typical in the early stages of Alzheimer’s with ADL’s being affected later in the disease progression.
- Behavioral symptoms include agitation, outbursts, mood fluctuations, and sleep-wake disturbances. “Sundowning” is common in the moderate to severe stages and involves an increase in confusion or agitation later in the day. Consider treating patients with Alzheimer’s earlier in the day.
- Social and emotional symptoms include social withdrawal, apathy, loss of self, depression, and anxiety
Barrier #2: Limited understanding of the cognitive domains unaffected by the disease
Alzheimer’s disease primarily affects the brains explicit processes, that is, declarative memory and processing that requires conscious, intentional effort. On the other hand, implicit processes that are unconscious and automatic are well protected.
- Procedural memory includes implicit long term memory for well-practiced skills, habits, and motor memory. For example, playing an instrument, getting up from a chair, tying your shoes. Functional tasks such as chair stands, walking on uneven surfaces, or functional reaching tasks are much easier to complete and understand than unfamiliar tasks, such as open-chain exercises.
- Emotional memory includes the ability to retrieve emotionally relevant memories. While an individual with Alzheimer’s may not remember your name or who you are, they can still experience a favorable or unfavorable reaction towards you.
- Long term memory including general world knowledge and personal memories from young adulthood or childhood
- Focused attention remains intact. This involves simple, non-competing tasks. This is largely influenced by interest level and motivation on the task requiring attention.
- Language, including production and comprehension, remain intact until later stages of the disease.
- Reading skills remain relatively intact allowing therapists to use for compensation of short-term memory and other deficits.
Barrier #3: Limited understanding of effective communication and treatment strategies
- Approach: Remember, individuals with Alzheimer’s can remember if their experience with you was favorable or unfavorable. Approach them with a smile, make eye contact, get at their physical level, and explain the purpose of what you’re doing.
- Keep it short and simple: Avoid unnecessary cues and details when giving directions. For example, “get to the edge of the chair, now get your nose over your toes, use your hands to push from the chair, and now lift your butt from the chair to stand up” requires a great deal of cognitive processing. Individuals with Alzheimer’s have been standing up and sitting down for their entire life. Keep it simple and simply say, “stand up”.
- Narrowing choices: Avoid open-ended questions when a specific answer is needed. Provide choices to facilitate decision-making. For example, “would you rather go to the therapy gym or walk around outside?”. Give 2-3 intervention options. This strategy includes the individual as an active participant in their care and makes therapy an enjoyable experience.
- Spaced-Retrieval: A method of learning and recalling information over increasingly longer periods of time. Learning new information is difficult for individuals with Alzheimer’s, but this technique can be an effective strategy to help the individual remember simple information by converting it to their implicit, procedural memory. For example, say you want your patient to remember to push from the chair rather than the walker to stand up. Train the task, then ask the patient, “where do you push from?”. If the correct response (the chair) is given, wait 10 seconds and then ask them again. Increase the time interval at each session. If the patient answers incorrectly, give them the correct response, ask for recall, and then ask for recall again after the longest successful time interval.
- Learning by observation or modeling: Use visual demonstration and visual feedback by modeling how to do an activity. This taps into implicit memory processes.
- External memory aids: Using signs, calendars, and lists that are accessible, bright, and with adequate explanation can reduce cognitive load. For example, a written visual sign with hip precautions and functional based pictures is more effective than verbal instructions.
- Environment: Structure the environment to facilitate cognitive processing by limiting environments that are over-stimulating and those that are under-stimulating.
Barrier #4: Limited Understanding of the Illness Experience
While many older adults are diagnosed with Alzheimer’s disease, they each have their own personal reactions to their symptoms and the way they perceive their symptoms. Some may feel very frustrated about their memory deficits while others are more concerned about the impact of the disease on their interpersonal relationships. Understanding the illness experience involves recognizing and acknowledging the positive and negative implications of an individual’s personal factors, social support, and coping style. This understanding can facilitate intervention for psychosocial factors (ex: depression, anxiety) as necessary to improve the individual’s quality of life.
The Strength Based Approach focuses on three central tenets:
1) Identifying strengths and abilities rather than deficits and limitations
2) Including individuals as active participants in the treatment process
3) Emphasizing current possibilities and options rather than past events and performance
These tenets emphasize the importance of building a strong rapport through investigation of the interests of the individual so that they remain engaged in their care. Like many older adults, individuals with Alzheimer’s are fearful of losing their independence; thus, it is important that they feel included as active participants when designing a plan of care and writing goals. Building a strong rapport with the individual is also easier when strengths and abilities are expanded upon. Help the individual recognize their remaining abilities, remind them of their progress often, and capitalize on their remaining long term memory processes, language skills, and reading abilities. Emphasizing current possibilities of the individual and helping caregivers recognize these possibilities is vital for successful outcomes of a progressive disease. In summary, individuals with Alzheimer’s disease must be viewed through a person-centered lens that is much more than their cognitive or functional impairments.