Alzheimer’s and other dementias are neurological diseases
Cognitive impairment in early stage Alzheimer’s disease limits a physical therapist’s ability to accurately assess motor skills, muscle tone, and strength. Because therapists typically use traditional fact-finding approaches like question/answer and verbal commands, Alzheimer’s patients can be dismissed as “within functional limits” or “not appropriate for therapy” due to the inability to follow instructions. But physical therapists are well equipped to assess patients with other brain dysfunction like CVA or TBI, who may or may not present with obvious motor issues. It is important that therapists look at Alzheimer’s and other dementias through the same lens. Alzheimer’s is a neurodegenerative disease. PT’s need to work around behavior or personality issues, confusion, denial, and resistance and look for ways to improve strength, mobility, and access to the environment- at all stages of decline. Target areas should include balance, vestibular disturbances, and awareness of barriers and hazards in the environment.
Procedural memory trumps working memory
I couldn’t train my son to pitch a baseball by simply telling him how to do it. Just because a person can understand the instructions you give and remember them long enough to tell them back to you does not mean that he or she can physically perform the motions correctly. If you expected your son or daughter to be able to throw a baseball that way, your child would have failed T-ball! Procedural Memory is solidified by repetitive performance, and it is not dependent on the conscious awareness of actually doing the action. Practice breeds performance. It’s true with our kids sports and it’s true with our dementia clients trying to stand. So just because a person with Alzheimer’s cannot see the value in multiple sit to stands, or cannot sequence proper hand and foot placement with verbal cues, does not mean that the task is unlearnable. Repetition with consistent approaches over a period of weeks will result in motor learning. The same principle holds true for strengthening, using an assistive device, or locating the bathroom or dining room.
The visual and motor cortices are the secret back doors
In most dementias caused by neurodegenerative disease, the visual cortex is left largely intact until the later stages of the disease. Language, memory, and reasoning are usually affected early on, resulting in the impairment of the ability to follow conventional learning approaches. The visual and motor cortices are fairly well preserved. “Functional” or meaning that non-traditional approaches can be an effective way to elicit desired activity. The take-home message: use demonstration for instruction and repetition for learning. And remember, stay in their visual field. They need to “see you” do the task.