Assessing and Addressing Mobility and Fall Risk in Dementia

Julie Hardy, PT, MSEncompass Home Health

We have an aging population with multiple co-morbidities, compounded by a staggering

increase in cognitive impairment, and limited

resources.

Our payment models have transitioned to:

-Value based-Outcome driven-Person centered-Evidence based

So why are we still doing low intensity, generalized

exercises, and (2w8) with so many of our patient?

PT’s/PTA’s must be better prepared to develop and carry out plans of care that are:

-evidence based -strongly rooted in

-current exercise science and -psychosocial learning theories

for older adults of all cognitive abilities.

Transforming society by optimizing movement in

order to enhance the human experience.

(? UNLESS there is cognitive impairment?)

What if your next performance review was

based on these questions:

1. How many of your patients were admitted/re-admitted to the hospital?

2. How many of your patients can better manage their own health at discharge?

3. How many health care dollars have you SAVED this year?

Don’t just make a visit.Make a difference!

Objectives:The learner will be able to:1. Utilize standardized norms to quantify

fall risk and frailty in the older adult.2. Appropriately prescribe a high intensity

functional exercise program for an older adult with or without cognitive impairment.

3. Develop and manage or carry out an effective and comprehensive plan of care for a person with cognitive impairment.

Alzheimer’s Facts and Figures 2017• Only disease in top 10 leading causes of

death in the US that cannot be prevented, slowed, or cured

• 1 in 6 people age 65 and older has Alzheimer’s (1 in 3 age 85 and older)

• Since 2000, deaths from heart disease decreased by 14%; deaths from Alzheimer’s disease or related dementia increased by 89%.

• Every 66 seconds….

2050 Projections

Dementia and Medicare $$• Beneficiaries with dementia cost three

times as much as other beneficiaries -$13,207 vs. $4454 (Avg annual cost)

• Beneficiaries with dementia are in the hospital 3.4 times more often than other elderly beneficiaries, at 3.2 times the cost to Medicare

Alzheimer’s Disease and Chronic Health Conditions: The Real Challenge for 21s t Century Medicare. AlzheimersAssociation

Assessing fall risk and mobility in dementia

How do we assess mobility in the cognitively impaired population??

Risk of death and NH placementGuralnik et al, 1994

• EPESE (Established populations for Epidemiological Study of the Elderly)

• LE performance battery: gait speed, chair rise, and, balance tests

• Predictive value of gait speed alone similar to LE performance battery in determining risk of death and disability

• LE performance battery showed higher correlation with hospitalization in VA; tandem stand and chair rise may be discriminating factors in hospitalization risk

Timed Up and Go Fall Risk

• ≥ 12.6 seconds associated with future falls. Kojima G, et al (2015)

• ≥13.5 seconds indicating risk of falls in community dwelling adults). Shumway-Cook 2000.

30 Second Chair Stand Test

www.rehabmeasures.org

Tandem Stand norms

El Kashlan et al 1998

rehabmeasures.org Addressing fall risk and mobility in dementia

How do we address mobility in the cognitively impaired population??

Frail older adults receiving high intensity strength training produce improved performance measures and reduced risk of health events. Falvey 2015

Intensity of ExerciseHow much is too much?How much is enough?How do I know what is just right?

ACSM FITT Principle Frequency: 3-5 x/week; min of 3x/week, ideally 5-6

sessions/week

Intensity:

Cardiovascular: 60-85% of max HR for 20-60 minutesStrength: 70-85% of 1 RM 8-10 reps/set 1-3 sets

Time: Cardiovascular: 30-60 min in bouts of at least 10 min.

Type: Up to the individual. A challenge in persons with dementia

High Intensity Functional Exercise in Dementia Telenius 2015

• People with mild to moderate dementia living in NH are capable of high intensity functional exercise.

• High intensity functional strength and balance exercises were effective to improve balance and strength and reduce apathy and aggression.– 50-60 minutes – 12 RM for strengthening ex– Balance: “highly challenging”

High Intensity Functional Exercise in Dementia Littebrand 2006

A high-intensity functional weight-bearing exercise program is applicable for use, regardless of cognitive function, among older people who are dependent in ADL’s, living in residential care facilities, and have a minimum of 10 on MMSE. Littbrand et al (2006)

Physical Activity (PA) in Persons with Dementia Stubbs 2014

• Faster gait speed and improved function positively associated with PA.

• Higher HRQOL and social functioning, reduced apathy positively associated with PA

• Polypharmacy, calls and lower ADL function negatively associated with PA

• Increasing age and lower global cognition did not influence PA participation.

Physical Activity in PWD Heyn 2004

• Exercise training:– 2020 subjects in 30 trials– Increased fitness– Increased cognitive function– Increased positive behavior

….in people with dementia and related cognitive impairments

Physical Activity and Cognition• Negative correlation between PA and Aß

deposition.• Exceeding AHA guidelines correlates with

significantly lower Aß deposition than controls.

PA decreases pathological Aß deposition in the brain during normal aging and the early stages of AD.

Phillips 2015

What are the barriers to increasing physical

activity when cognitive impairment

is present?

Overcoming barriers

1. Know the disease.2. Know the patient.3. Know how to communicate.4. Know what works.

Know the disease

Dementia: Impaired Cognition

Multiple cognitive deficits, manifested by:Impairment of memory and at least one of the following:

– Language impairment (aphasia) – Purposeful movement (apraxia)– Interpretation of sensory information (agnosia)– Planning and organizing ability (executive function)

CMS Program Memorandum Transmittal AB-01-135

Dementia: Impaired Cognition

FACT: Alzheimer’s is one form of dementia

FACT: Age related memory loss is part of

normal aging

Dementia : Top 3 Diagnoses

Alzheimer’s

Lewy Body

Vascular (Multi infarct)

1. Difficulty learning/remembering new information 2. Spatial orientation3. Word finding/language4. Executive function: reasoning, judgement,

abstract thinking, problem solving5. Processing sensory information6. Long term memories7. Basic functions: breathing, swallowing

General Progression of ADRD

confidential & proprietary 38

Know the patient

Beyond History• Medical history

-vision, hearing, DJD, co-morbids• Social history

– Hobbies– Vocation– Family– Traumas– Significant past events can play a role

Examination• Screen and stage if cog impairment

suspected– Mini-Cog– GDS, Allen– alz.org “Stages of Alzheimer’s”

Know how to communicate

Communication alz.org

• Speak directly to the person • Give the person time to respond. • Take into account possible sensory

impairments: visual, hearing, tactile• Use visual cues to give clues to your

meaning • Avoid talking down• Avoid arguing

Communication alz.org

• Make and maintain eye contact• Speak slowly and clearly• Minimize distractions (TV, family,

common areas)• Correct in a positive way• Give clear, step by step instructions• Ask yes or no questions if possible

Functional Outcome Measures• Clear, slow speech• Friendly facial expression• Make and keep eye contact• Short instructions with 1-2 step

command• Repeat instructions while modeling• Diminish distractions

Caregivers are key van Alphen 2016

• Caregivers play key role in promoting PA (physical activity)

• PA in persons with dementia will increase if service providers become familiar with health benefits of PA, characteristics of PA program, methods of delivery, and concepts of how such programs can be personalized and synchronized with patients’ individual needs.

Know what works

Explicit and Implicit Systems• Explicit/Declarative learning is used when

we encourage individuals to• Reflect on performance (reflection)• Sequence multiple activities within a task

(organization) • Remember and build on previous

performance (memory)• Articulate their movement processes

(language)

Explicit and Implicit Systems• Implicit/Non-declarative learning is used

when we:• Design repetitive practice within skill context

without encouraging conscious awareness or reflection on task performance (procedural learning)

• Design repetitive practice with some opportunity for association with outcomes (associative learning)

What’s different in dementia? • Explicit learning integrates awareness

attention, recall, reflection, whereas implicit learning requires no (or much less) conscious awareness of task

• Discreet neuroanatomical areas associated with explicit learning (e.g. medial temporal lobe, hippocampus) are implicated in dementia/AD

• Persons with dementia have impaired explicit and intact implicit motor-learning capacity.

Motor learning in dementia• Utilize constant (vs. variable) and

blocked (vs. random) practice sessions; consistency and repetition are key

• Train to specific and relevant functional tasks; do not expect transfer of training

• Appropriately challenge• Eliminate/minimize the possibility and or

impact of errors during learning

Errorless learning de Werd 2013, Kesselsand Hensken 2009 • Learning from mistakes (trial and error

learning) requires intact explicit memory system

• Persons with dementia don’t internally process and correct mistakes like healthy older adults, who generally benefit from “errorful” learning and need fewer external cues

• Errorless learning may result in faster automation of a procedure in dementia

Errorless Learning Strategies• Physical assistance/guidance training• Observational

training/demonstration/modeling• Forward cueing/feed forward instruction• No guessing• Stepwise training/part-whole training• Vanishing cues• Spaced retrieval

Preserved Implicit Memory Model• Unique lifetime experiences influence our

implicit memories• Unconscious effect of previous experience

on subsequent task performance (e.g. brushing teeth every day with same kind of toothbrush, with the radio on, using same toothpaste)

• Suggests that therapeutic interventions and environments should integrate:– Sensory priming with visual, auditory, tactile,

aroma input (e.g., music, objects, fragrances from the past) Harrison et al, 2007

Montessori Activity Principles• Make it enjoyable• Provide purpose & capture individual

interest• Offer choice if possible – allow control• Invite to participate• Minimize words• Make it fun!

Reach the person behind the dementia Fjellman-Wiklund, et. al. 2016

• Tailor high intensity training to the individual

• Search for information about each individual– Check current health status and interpret

body language• Create an interplay between exercise

and social interaction– Confirm the person; set up the room to

maximize participation

In health care, the overarching goal for providers, as well as for every other stakeholder, must be improving value for

patients, where value is defined as the health outcomes that matter to patients relative to the cost of achieving those

outcomes.

Failure to provide value means, well, failure.

Porter and Lee 2013

Evidence Based Resources

Evidence Based Resources Referencesde Werd MM, Boelen D, RikkertMGO, Kessels RP 2013. Errorless learning of everyday tasks in people with dementia. Clin IntervAging 8:1177-1190.

El-Kashlan, H. K., Shepard, N. T., et al. (2009). "Evaluation of c linical measures of equilibrium." The Laryngoscope 108(3): 311-319.

Falvey J, MangioneK, Stevens-Lapsley J.(2015). Rethinking Hospital-Associated Hospitalization Deconditioning: Paradigm Shift.. Physical Therapy;95:1307-1315.

Guralnik et al 1994 (1994). A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home placement. J Gerontol 49: M84-M89.Harrison BE; Son G; Kim J; Whall AL (2007). Preserved implic it memory in dementia: a potential model for care. American Journal of Alzheimer's Disease & Other Dementias (AM J ALZHEIMERS DIS OTHER DEMENTIAS), Aug/Sep2007; 22(4): 286-293.

Heyn P, Abreu NV, Ottenbacher KJ 2004. The effects of exercise training on elderly persons with cognitive impairment and dementia: a meta-analysis. Arch Phys Med Rehabil 85:1694-1704.

Kessels RP, HenskenLM 2009. Effects of errorless skill learning in people with mild-to-moderate or severe dementia: a randomized controlled pilot study. NeuroRehabilitation25 (4): 307-312.

Kojima G, et al (2015). Does the timed up and go test predict future falls among British community-dwelling older people? Prospective cohort study nested within a randomized controlled trial. BMC Geriatrics 15 (1) 1.

ReferencesPhilllips C, Baktir M, Das D, et al. (2015). The link between physical activ ity and cognitive dysfunctions in Alzheimer Disease. Physical Therapy 95:1046-1060.

Porter M, Lee T (2003). The strategy that will fix healthcare. Harvard Business Review. October 2013.

Studenski S, et al. (2003). Physical Performance Measures in the Clinical Setting. JAGS 31:314-322.

Stubbs B, et al (2015). What are the factors associated with physical activ ity (PA) participation in community dwelling adults with dementia? A systematic review of PA correlates. Archives of Gerontology and Geriatrics 59 (2), pp. 195-203.

Telenius EW, Engedal K, Bergland A.(2015) Effect of a high intensity exercise program on physical function and mental health in nursing home residents with dementia: an assessor blinded randomized controlled trial. Journal.pone.0126102. May 14, 2015.

Teri L, Logsdon R, McCurry S. 2008. Exercise interventions for dementia and cognitive impairment: the Seattle Protocols. J Nutr Health Aging. 12(6):391-394.

Van Alphen JM, Hortobagyi T, van Heuvelen MJG (2016). Barriers, motivators, and facilitators of physical activ ity in dementia patients: a systematic review. Archives of Gerontology and Geriatrics 66: pp. 109-118.