Definition of terms

Intellectual impairment falls into three categories: mental retardation, delirium, and dementia. A definition of terms is necessary to ensure that all personnel use the same framework for clinical problem solving.

Psychiatric problems may be present before old age or may develop as a result of dementia and need to be assessed and treated along with the dementia. Depression, for example, can mimic dementia.

Epidemiology

Currently 5.3 million Americans are estimated to have AD. One in eight people over the age of 65 has AD.³³ Researchers estimate that by 2050 13.2 million Americans will have AD if current trends continue and no cures are found.³⁸ Half the people aged 85 years and older will have some form of dementia (9.5 million in 2050).³⁹ Disorders causing cognitive deficits are expected to continue to be a growing public health problem for at least the next 50 years. The projected statistics, assuming no cures or effective means of preventing the common causes of dementia are discovered, are that by 2040 five times more individuals with dementia will be in society as today (7.4 million Americans). This increase is partially the result of the increased life expectancy of Americans.⁴⁰ The most rapid population growth in this country is in the oldest age group, hence the increase in the prevalence of severe dementia. The prevalence of dementia rises from approximately 3% at ages 65 to 74 years to 18.7% at ages 75 to 84 years and to 47% of those older than 85 years.³⁹ The increasing number of persons older than age 85 years will be paralleled by an increase in the incidence of dementia.

More than 70 conditions are known to cause dementia.³³ Secondary behavioral problems in the patient with dementia can be interpreted as a response to somatic, psychological, or existential stress. Because memory impairments, impairments of abstract thinking or judgment, or global cognitive impairments in an elderly person may be symptoms of acute physical illness, the patient’s physical, emotional, social, and cognitive status and physical, social, and caregiver environment need to be systematically evaluated.³³

Gradual or sudden changes in intellectual capacity or memory function are not a normal part of the aging process. Any change, whether it develops slowly over time or happens suddenly, should be diagnosed, and when possible the underlying cause(s) of the delirium or dementia should be treated. Even if the cause of the dementia is untreatable, teaching the patient and significant others strategies to make the patient’s ADLs and IADLs easier to manage is always possible (see sample home program).

Physical and occupational therapists are an important part of the comprehensive evaluation, treatment, and caregiver training for patients with delirium or dementia. All treatment planning should occur as a part of a team effort in which the patient, the family or significant others, the physician, nurses, social worker, physical therapist, and occupational therapist collaborate so that a consistent treatment plan and orientation are followed. Inclusion of the day-to-day caregivers is crucial for all training because they most need to know and use the adaptations for the patient’s personal style of communication and how to facilitate functional movement for ADLs and IADLs.

Arndt-schultz principle

The Arndt-Schultz principle summarizes the differences between the abilities of the younger brain and the aged brain to discriminate or respond to stimuli⁶¹:

The implication of the Arndt-Schultz principle for clinical problem solving is that the level of a stimulus (e.g., heat, cold, sound, light, or emotional input) needs to be adjusted to compensate for the altered physiology of the aging patient. Optimal balance of the levels of sensory stimulation and emotional stimulation that is therapeutic for a young person may not be therapeutic for the older person. The stimulus may be too low so it does not reach the threshold for generating a physiological response, or it may go beyond the safe therapeutic range for the older adult and become harmful. Therefore when an elderly patient does not respond to treatment or presents an unusual physical response, the clinician needs to ascertain whether the strength of the stimulus is too strong or too weak and if modification of the stimulus is necessary because of factors associated with the aging process or the patient’s cognitive deficits (he or she may be unable to accurately report the response because of a cognitive deficit). The older person with mild or moderate confusion needs small, slow clinical input and precise monitoring of the general response (heart rate, blood pressure, respiration) as well as local response. (Clinical consideration—Use pulse oxygen meter to monitor exercise response on evaluation.) This is especially true for persons who are hearing impaired. Because the patient may not hear what is being spoken, the therapist may assume that the patient does not have the capability to comprehend what is being said. Never assume that a person does not comprehend when she or he may simply be unable to hear what is being spoken.

Law of initial values

The law of initial values is both a physiological and a psychological principle stating that with a given intensity of stimulation, the degree of change produced tends to be greater when the initial value of that variable is low at the onset of stimulation. In other words, the higher the initial level of functioning, the smaller the change that can be produced.^62,63 The law of initial values, when defined and applied to younger persons, presumes that homeostasis is a stable and consistent process. When the law is used to describe physiological and psychological responses in older persons, it cannot be presumed that homeostasis for any variable is predictable or consistent from one person to the next, or even within a 24-hour period for the same individual. For example, an older person with mild dementia may eat only sweets if left without companionship at a meal. As a result, after the meal the individual may feel unsteady and afraid to walk back to the room. (Clinical consideration—Check blood sugar for all diabetics on evaluation before exertion.) In the young, defining the average times of peak activity for most physiological processes as well as for intellectual capacity is possible. In the clinical assessment of the older persons, defining the peak times of day for awareness and intellectual capacity for each individual is necessary. For example, some patients are best able to participate in learning a new skill in the early morning, and some only in the late afternoon.

Biorhythms

The brain has a biological clock that controls all physiological functions in a precise temporal course, whether daily (e.g., secretion of some hormones), monthly (e.g., menstruation), or during a certain period of the life cycle (e.g., ability to become pregnant).^2,64,65 Before evaluating a geriatric patient with dementia or disturbance of intellectual functioning, assessment of the patient’s premorbid biorhythm is helpful. What was her or his daily schedule of activities before the medical crisis? The assessment or time study can map such things as rest periods, activities and level of exertion, sleep or rest periods, mental stimulation, emotional stimulation, eating, and elimination cycles across a 24-hour period. The patient assessment must allow for and assess the current and past variability of individual biorhythms. These biorhythms should be clearly documented and their stability evaluated and maintained as much as possible (critical if the patient will be going back to the family). For example, if a woman has worked for 40 years as a night nurse, being primarily active from 11 pm to 7 am, she will most likely be alert and best able to participate in a rehabilitation program during those hours. In most cases the patient should be allowed to choose the best time for treatment. For patients whose dementia is too severe for them to make this determination, the staff, by monitoring the patient’s behavior, can choose a time for treatment when the person is most alert. For the elderly, and particularly for those who have dementia, the time of assessment and treatment must be documented to maximize the person’s rehabilitation potential.^66,67

Sensory changes with aging

Aging can also be defined in terms of adaptation. Aging is the progressive and usually irreversible diminution, with the passage of time, of the ability of a person or body part to perform efficiently or adapt to changes in the environment. The consequence of the process is manifested as decreased capacity for function and for withstanding stresses.⁶⁸ Because the rehabilitation evaluation identifies functional problems, therapists should examine the possibility that sensory losses or disturbances (e.g., vision, hearing, touch, taste, smell, proprioception, temperature, and kinesthesia) are contributing to the functional impairments.⁶¹ A partial or total loss of one or more of the normal sensory inputs can result in disturbance of an individual’s mental status.

The more sudden the loss of a sense, the more difficult is the adaptation to the sensory disability. This is especially true for elderly persons because several mild sensory changes related to normal aging are already taxing their capacity to adapt. Adaptation to a sensory loss in one modality is typically accomplished through increased use of the other senses. For example, a young blind patient can adapt by using hearing and kinesthesia and usually learns to function well in spite of the loss of visual input. The older the patient is when blinded, however, the more difficulty she or he will have in making this adaptive crossover to other senses. At some time in any person’s life, adaptive crossover from one sense to another becomes exceedingly difficult, if not impossible. Thus psychopathological or behavioral changes may occur if a sensory impairment develops.⁶⁹ This situation becomes more likely if the disruption is caused by a central nervous system deficit with multiple and abrupt simultaneous sensory input loss, such as might occur from a stroke.

The poliomyelitis epidemics of the early 1950s demonstrated the relationship between sensory input and abnormal behavior. Patients with poliomyelitis who were placed in tank-type respirators developed intermittent disruptions in mental state, including hallucinations, delusions, and dreamlike experiences while awake. The patients were deprived of normative input to the senses (kinesthesia and proprioception) and had severely restricted vision and hearing because of the nature of the construction of and the noise that emanated from the respirator. Solomon and Shackson⁷⁰ and Solomon⁷¹ called this problem “sensory deprivation psychosis,” but this clinical situation may include cognitive changes in addition to psychotic symptoms. This type of problem often occurs today after a hip fracture when, to control the pain, a patient is given a medication that has the side effect of disrupting orientation to time and place. Until other medication can be tried to control the pain, the patient is described as “out of his or her mind,” especially at night. The patient may try to remove all clothing or call out to people for help, often a mother or father. The psychosis stops when the medication is removed. Recovery is also enhanced when consistent nurturing is provided. Note: Other common triggers can be the requirement to stay in one position (e.g., sleep on the back after surgery) or the need to have a spacer between the knees after surgery.

Sensory changes associated with normal aging can lead to the same degree of loss or distortion of significant sensory input as previously described.72–74 A bilateral loss of vision may lead to agitation and disorientation. Elderly people with hearing impairments often have grave difficulty relating to the world. Elderly persons who become deaf commonly experience some episodes of paranoid behavior.⁶⁹ The problems for hearing-impaired elderly persons are often exacerbated by health care professionals who do not know how to place a hearing aid in a patient’s ear, replace a battery, adjust the volume on the aid, remove excess ear wax from the aid, identify the need to trim ear hair, or consider the possibility of a malfunctioning aid. Finally, sensory impairments may become exacerbated by surgical or medical interventions.

Certain medications, as well as some diseases, can also distort kinesthesia or retard the activity and movement of the patient.⁶⁰ Movement is significant in the maintenance of an efficient nervous system. Anything that denies a person the ability to perform physical movement (e.g., drugs, restraints, traction, passive motion machine, positional props, or architectural designs not adapted to the elderly) hastens and increases the difficulty of adapting to functional limitations. The patient loses her or his freedom to move and may feel trapped and helpless. This can trigger memories of other trauma or violent experiences that involved feeling helpless or victimized. Movement is necessary for accurate sensation.^14,75 It has been demonstrated that if movement of the eyes does not occur properly, vision becomes ineffective. The same is true to a lesser degree for hearing. If movement does not occur in the course of the hearing process, hearing can become distorted and misrepresented at the central level.

New research on brain function in the elderly points to the following ideas for clinical consideration and possible modifications to enhance functional performance:

Cognitive changes in normal aging

The idea that cognitive decline is a necessary part of aging is a myth. This belief has been debunked by research on crystallized and fluid intelligence.^79,80 Crystallized and fluid intelligence are components of general intelligence. Crystallized intelligence involves the ability to perceive relationships, engage in formal reasoning, and understand intellectual and cultural heritage. Crystallized intelligence can be affected by the environment and the attitude of the individual.⁸¹ Crystallized intelligence can increase with self-directed learning and education as long as a person is alive. The measurement of crystallized intelligence is usually in the form of culture-specific items such as number facility, verbal comprehension, and general information.

Fluid intelligence, what has been called “native mental ability,” is the product of the brain’s information processing system. It includes attention and memory capacity and the speed of information processing used in thinking and acting.⁸² It is not closely associated with acculturation. It is generally considered to be independent of instruction or environment and depends more on the genetic endowment of the individual.⁹ The items used to test fluid intelligence include memory span, inductive reasoning, and figural relationships, all of which are presumed to be unresponsive to training. Because fluid intelligence involves those intellectual functions most affected by changes in neurophysiological status, it has been generally assumed to decline with age. Several studies have shown this to be untrue; one study noted that during middle age, scores on tests for fluid intelligence are similar to scores in midadolescence.^53,83 These changes, however, are primarily associated with processing speed and working memory and executive function.^12,84

Recent studies that have looked at the effects of cognitive changes in activities have shown that older people perform activities at a slower rate and use different areas of the brain in the process compared with younger people. Those additional areas of the brain used have mostly to do with monitoring and processing the ongoing activity.^13,85 Activities are therefore performed more in a feedback rather than a feed-forward manner, which also requires more time. So, if older adults are given time to complete tasks, they usually do well.

Botwinick³⁵ described the classic pattern of changes in intelligence with aging. In the adult portion of the life span, verbal abilities decline little, if at all, whereas psychomotor abilities decline earlier and to a greater extent (greater decline if the individual is not engaged in regular physical activity). The period between ages 55 and 70 years is a transition time, and some decreases in performance are noted on many cognitive tests. A substantial decline on laboratory tests of cognitive function is generally limited to those older than 75 years.⁴⁰ In these latter years, however, the decline in fluid intelligence is offset by the growth in crystallized intelligence for most people unless dementia is present. Although changes may be demonstrated in the laboratory, they may not be significant in the “real world,” and the elderly may be as capable as the young of participating in rehabilitation training. For elderly people to benefit maximally, however, they must control the pace of training because the tasks that are the most difficult for older adults are those that are fast paced, unusual, and complex.⁸⁶ All physical and occupational therapy treatments with older patients need to be structured to encourage the patient to set his or her own pace. The goal is to have a pace that allows ease of breathing and a comfortable, functional upright posture so that the person can enjoy the experience. Interventions should be predictable and progress by adding one new concept at a time.

“Terminal drop” is another type of cognitive change that differs from those that occur in normal aging and in those with dementia. This involves a decline in IQ scores in persons within the year before their death. This change in intellectual function is thought to result from some predeath changes in brain physiology. Research studies that show drastic decreases in intellectual function with advanced age may have a large percentage of subjects who were near death as a part of the sample.⁸⁷ Subjects who did not experience this terminal drop would then appear similar to those in studies on normal elderly persons.

Stress and intellectual capacity

Selye⁵⁵ defined stress as the nonspecific response of the body to any demand made on it. All human beings require a certain amount of stress to live and function effectively. When a stressor (stimulus) is applied, the body predictably goes through the three stages of response called the general adaptation syndrome (GAS). The first response is a general alarm reaction, a “fight-or-flight” response that mobilizes all senses in an effort to make a judgment about the response needed. The older person is at a disadvantage because collecting and processing accurate sensory data are decreased with normal aging owing to short-term memory loss. This will manifest in a patient asking the same question repeatedly during a crisis. The sensory memory in an older person lasts less than 1 second.²⁴ The next stage involves judgment and the selective adaptation to the stressor. A decision is made regarding which action is needed, and all other bodily activities return to homeostasis. The older person is slower to search and retrieve the information from storage. If the stimulus continues and goes beyond the therapeutic or functional level, then the body system or part will gradually experience physiological exhaustion. A person in physiological exhaustion is likely to manifest abnormal responses to any new stimulus. Paradoxical reactions are unusual physiological or psychological responses to stimuli (e.g., an erythematous response when an ice pack is applied or a patient becoming more agitated after receiving a sedative).

When a person is under perceived stress (whether real or imagined), a predictable set of cognitive changes can occur. These cognitive functional changes can include preoccupation; forgetfulness; disorientation; confusion; low tolerance to ambiguity; errors in judgment in relation to work, distance, grammar, or mathematics; misidentification of people; inability to concentrate, solve problems, or plan; inattention to details or instructions; reduced creativity, fantasy, and perceptual field size; decreased initiative; decreased interest in usual activities, the future, or people; and irritability, impatience, anger, withdrawal, suspicion, depression, and crying. Differentiating whether the patient is having a stress reaction or has dementia is critical. If the changes occur with a sudden onset, they are probably related to a medical or pharmaceutical problem and may be reversible.

With aging, the brain undergoes physiological changes that make the older person less physiologically efficient in her or his response to stressors. The general alarm reaction is poorly mobilized and takes longer to become activated (Arndt-Schultz principle). The stage of resistance should yield a series of responses that allows the body to economize in its response to stress. In persons of all ages who receive too many different stimuli and in the elderly who experience normal levels of stimuli, the body becomes less efficient at turning off the general alarm response and replacing it with more appropriate and limited responses. When a person is overwhelmed by this type or level of stress, the individual may demonstrate mild global or specific cognitive impairments, especially mild short-term memory loss.⁸⁸

The historical clinical data become the only means of establishing a diagnosis because no tests are currently available to distinguish acute dementia from emotional exhaustion. In cases of domestic violence that have been kept secret for years, this can be a difficult problem. For example, a 90-year-old man had beaten his wife a few times early in their marriage. They later came to an agreement and their marriage had continued with only verbal abuse and no physical abuse. As he approached 85 years of age, however, he again began to get violent and would shove her during arguments. At one point she fell, broke her hip, and ended up in a nursing home for 8 weeks. Another time he was bringing her to therapy and on the way he became angry and let go of the wheelchair, and it ran into a wall. The wife chose to do nothing and say nothing. The only sign was that she always cried in physical therapy when she started to relax. The client eventually confided to the physical therapist and was referred to a crisis counselor to determine how to proceed. She saw the counselor weekly for more than 4 years. Another incident happened in which the wife was hurt and protective services were called. The patient refused to press charges and returned to the home, stopped all counseling, withdrew in embarrassment, and within several weeks became confused. The husband placed her in a nursing home and she was given the diagnosis of dementia and placed on haloperidol (Haldol). No other therapeutic services were offered. Access to one-on-one counseling and family therapy is critical. What if support had been offered? Could this situation have turned out differently? If the person had been 36 years old, a psychiatric evaluation would likely have been made and treatment could have reversed the confusion that masked the severe depression.

The assessment of an elderly person, with or without dementia, must include a determination of the type, number, and severity of the patient’s current stressors. Positive life events (e.g., marriage or the birth of a grandchild) are also stressful life events. Scores that rate stressful life events can identify patients who are at greatest risk of physiological and emotional exhaustion.⁸⁹ Developed in the 1970s, the Holmes-Rahe Social Readjustment Rating Scale is still a commonly used life stress evaluation tool (see www.stresstips.com).⁹⁰ Elderly patients, with their numerous psychosocial problems and chronic and acute illnesses, are likely candidates for physiological and emotional exhaustion and the development of psychopathology. Thus the environment and process of rehabilitation care need to be modified to counteract the effect of stress on the intellectual capacity of the older patient. Any action that modifies stress so that a deterioration of intellectual function is stopped or reversed is an efficient and cost-effective part of the total rehabilitation effort.

Mini-mental state examination and other cognitive scales

The Mini-Mental State Examination (MMSE) was developed as a result of a study noting that 80% of cognitive disorders among elderly people were not detected by the general practitioner.^20,91 It appears to be the most predictable test but is only helpful if all caregivers can monitor the cognitive state of the older patient. All caregivers must be part of the team effort to get a real 24-hour picture of the cognitive capacities of the patient. Although training is improving in this area, most professionals on the rehabilitation team (physicians, nurses,^92,93 physical therapists⁹⁴ and social workers⁹⁵) are likely to have had only minimal specialty training in gerontology and the unique symptoms and needs of the elderly.

The MMSE provides a screening test for identifying unrecognized cognitive disorders in the elderly (Figure 27-1).^21,96,97 The MMSE assesses only cognition and does not examine other aspects of the traditional mental status examination such as mood, delusions, or hallucinations. The test can identify whether the patient is oriented; remembers (short term); and can read, write, calculate, and see and reproduce in drawing the relation of one object or figure to another. The examination is used to screen for cognitive dysfunctions, much as a measurement of blood pressure or blood sugar is used to screen for significant medical disorders. The MMSE also may be used in a serial fashion to quantify changes in a patient’s cognitive status over time. This examination can be used as a springboard for planning how to carry out the traditional rehabilitation evaluation of a patient who has some intellectual dysfunction.^98,99

The MMSE has been standardized for elderly persons living in the community. The scores on this test correlate significantly with the Wechsler Adult Intelligence Scale and the Wechsler Memory Test. The MMSE is reported to have a high test-retest reliability for both normal and psychiatric sample populations with r = 0.89 or greater. It has been found that when a cutoff score of 24 is used for the detection of dementia, the MMSE had a sensitivity of 87.6% and a specificity of 81.6%.⁹⁶ Several studies have noted that interviews with informants are highly consistent with elderly persons’ scores on the MMSE.¹⁰⁰

The examination takes only a few minutes to administer, is scored immediately, and can be administered by any member of the rehabilitation team. The entire examination grades cognitive performance on a scale from 0 to 30. A score of 24 or less usually indicates some degree of cognitive dysfunction, but some patients with dementia may score above 24 and some with depression or delirium may score significantly below 24. A low score on this examination can mean that the patient probably has dementia, delirium, mental retardation, amnestic syndrome, or aphasia. A low score on the MMSE can indicate the areas of specific cognitive impairment and gives the rehabilitation team data about how to best communicate with the patient. MMSE scores are also correlated with educational level, with scores dropping 10% to 20% for people with an eighth-grade education or less if older than 70 years.¹⁰¹ A shortened version of the MMSE has been developed that uses only 12 of the 20 original variables. Although the original study suggested that the shortened version of the MMSE is equally as effective as the full MMSE in identifying elderly patients with cognitive deficits, more recent studies have questioned these findings. Another test recently developed to screen for cognitive deficits is the Mini-Cog. It is reported to have higher sensitivity and accuracy of classification because it is not biased by language or educational level.¹⁰²

Older persons may show changes in mental abilities immediately after surgery, after hypoxia (low oxygenation), with delayed care after a fall, or after hitting the head during a fall or other trauma. The Glasgow Coma Scale and the Rancho Los Amigos Cognitive Scale can be used in many ways to assess the cognitive status of an individual, especially if brain injury results from an impact to the head or severe whiplash, for example. First, the extra testing helps staff choose which patients can live safely and compatibly in the same unit. The Rancho Los Amigos Scale can help identify the need to segregate the patients who are prone to screaming incomprehensible words over and over. The coma state may be temporary as a result of medication, anxiety, or anesthesia. Test scores may be used to create a patient group that allows calm and functional use of the shared living space. Another purpose in using these additional tests is to create small groups where patients at level 4 (confused, agitated, alert, active, aggressive or bizarre behaviors, nonpurposeful motor movement, short attention span, inappropriate verbalization) are segregated from those at level 5 (agitated by too much stimulation, require continual redirection) to allow level 5 clients to live and function to their full capacity and allow level 4 patients to have room to move and express. A level 4 patient may become upset and cry on a unit that has mostly level 5 and a few level 3 (inconsistent response to commands, turns toward or away from sound) patients. The biggest factor is to use the test scores to target activities and recreation to a specific cognitive level so that satisfaction and social comfort are possible.

Sensory and perceptual changes with dementia

Patients with dementia may have specific problems that inhibit the integration of sensory input. Aphasias and disruption of association pathways may inhibit the patient’s ability to integrate accurately perceived sensory information in a meaningful way. Bassi and colleagues¹⁰³ and Fozard¹⁰⁴ have demonstrated that patients with AD, multiinfarct dementia,¹⁰⁵ and alcoholic dementia may demonstrate disturbances in visual acuity, depth perception, color differentiation, and differentiation of figure from ground when compared with normal age-matched control subjects and normal younger subjects.

An assessment of specific sensory systems is necessary when a person demonstrates cognitive losses. The challenge in rehabilitation is to design a process and environment of care so that compensation and modification maximize the ability of the elderly patient with sensory deficits to adapt to most life situations. The example of visual deficits is a case in point. One of every two blind persons in the United States is older than 65 years (see www.afb.org/ and click on AFB senior site).¹⁰⁶ Techniques of environmental adaptation and special measures to organize care to help elderly blind people have allowed many of them to live independently in the community.¹⁰⁷ However, many elderly people with visual impairments are not blind. Some of the structural changes that result in mild to moderate deficits of vision include yellowing; uneven growth, striation, and thickening of the lens; increasing weakness of the muscles controlling the eye; alteration in the perception of color (especially fine distinctions in tone and brightness); and slower adaptation to light.¹⁰⁴ Modifications of the environment can include adequate effective lighting (including adequate intensity and controlling of reflection), dark and clear large-print, low-vision aids (e.g., magnifying glass), verbal orientation and escort by persons accompanying patients in a new environment, consistent furniture placement, explanation when changes occur, clear hallways, a systematic storage system for clothes and toilet articles, and the use of consistent contrasting colors to identify doors, windows, baseboards, and corners.^{77,92,104,108}

Older adult learning styles and communication

Learning occurs throughout life.⁸⁶ In physical and occupational therapy, habilitation occurs when the client learns new skills, and rehabilitation occurs when the person relearns old adaptive skills. As with intelligence, the learning process does not change abruptly when an individual reaches old age, but differences in performance have been reported. One challenge for rehabilitation therapy is to find ways to improve the efficiency of learning by the older person.

Botwinick³⁵ has noted that learning and performance are not the same. Poor performance on a learning task may mean that insufficient learning has occurred, that learning has not transferred to a new environment or task, or that the performance does not accurately reflect the extent of learning achieved.⁹ The key variables that affect a person’s ability to participate in a learning task can include intelligence, learning skills acquired over the years, and flexibility of learning style. Noncognitive factors also can have a strong bearing on an individual’s performance. The noncognitive factors include visual and auditory acuity, health status, motivation to learn, level of anxiety, the speed at which stimuli and learning are paced, and the meaningfulness to the individual of the items or tasks to be learned. Research has shown that learning styles change over the life span and that people learn better when instructional approaches are matched to their learning style.²⁵ Therefore a rehabilitation assessment needs to include a review of the preferred learning style of the patient. This is particularly important before discharging a patient from a rehabilitation program. The rationale is that a lack of progress may not reflect the patient’s lack of capacity for rehabilitation, but rather may reflect a dissonance between the patient’s learning style and skills with the presentation of materials in the treatment program (e.g., verbal input has not been adapted to match the level or pace of comprehension of a person who may have a strong preference for visual learning and slower pace).

Interference

Interference can make the learning process less efficient in two major ways.¹⁰⁹ First, interference can result from a conflict between present knowledge and the new knowledge to be learned. Second, if the task to be learned has two or more components, secondary components may interfere with the learning of the primary components. This is particularly true if secondary components overlap in time or use the same sensory modality.⁸² The elderly have special difficulties if they must concentrate on intake, attention, and retrieval processes at the same time. Therefore the process and therapeutic environment of rehabilitation for the elderly patient must not be disturbed by background noise, other stimuli in the environment, or anxiety. When learning a new task, the elderly patient may require a quiet room with no stimuli other than that offered by the therapist. The need to rid the environment of distractions is particularly important when working with an elderly patient with dementia because this patient will have greater difficulty filtering out irrelevant sensory inputs compared with elderly patients without dementia.

Pacing

The pacing of therapeutic intervention is a significant variable in helping an elderly person learn. Elderly persons (with or without dementia) perform best if they are given as much time as they need and when learning is self-paced.³⁵ The major drawback of a fast pace (as perceived by the patient) is that the elderly person generally chooses not to participate rather than risk making a mistake. A lack of response by the patient is often interpreted as apathy, poor motivation, or “confusion.”¹¹⁰ Patient participation is increased when extra time to complete a rehabilitation task is offered. After the individual assessment, group work (where concepts can be presented, reviewed, and examined at leisure) also can be used to reduce the psychological pressure of faster paced one-on-one learning. The details of therapy must be planned carefully, including how questions are asked (this involves asking clear and precise questions in nonmedical language) and, most important, setting aside enough treatment time so the patient can respond at a manageable pace.

Organization

If data are organized in the brain as part of the learning process, the retrieval of these data becomes easier. Older persons are less likely than members of other age groups to organize data spontaneously to facilitate learning and later retrieval (memory) of that learning.³⁷ Elderly people who are highly verbal show fewer weaknesses in the ability to organize stimuli. Elderly persons with poor verbal skills show significant improvement in data retrieval when strategies for organization of data are provided by others (e.g., the therapist). Older learners have difficulty following content because they cannot anticipate what will be taught and do not see the “whole picture” of what is being presented.¹¹¹ This is an example of how organization may influence the learning process.

Organizing therapy by beginning with an overview in outline form of the entire lesson is helpful. This presents the patient with a conceptual map of the upcoming experience. The use of purposeful organizing also can help bridge the gap between what the older person knows and the new information or task to be learned. The use of neurolinguistic programming (NLP) is especially effective with elderly patients and patients with cognitive deficits because it builds consciously—through language, kinesthesia, and visual input—a picture of a new concept from a known and familiar frame of reference.¹¹¹

Inefficient learning, and at times an inability to learn, occurs in the older adult if material is presented in one way and the older person is expected to apply it in some other way. Instructions need to be provided in the format and context in which they are to be used. If possible, one piece of new data should be presented at a time. A conscious transition needs to be made by the therapist from the patient’s current frame of reference to the understanding of the new data, and the pace needs to be set by the patient.

Several other strategies exist for maximizing the efficiency of older adult learners based on awareness of normal age-related changes. Some of the more frequently used techniques are summarized in Box 27-1.

Communication

Therapists can begin by inquiring into what the reality of the patient looks like. The first goal should be to communicate with words, gestures, positioning, and so on so that stimuli bring out functional responses in the patient. All people have an ongoing internal dialogue. As a healthy adult, the therapist chooses to notice his or her own dialogue, hear the content, and then pursue the goals and commitments that enhance interaction with the patient.

The interaction with the patient needs to be grounded in the present moment. The power for action lies in the present moment. The patient will bring his or her authentic self to the conversation or the interaction. The therapist needs to be sensitive to the entire communication—what is said and what is withheld. The patient with cognitive problems may not understand the content, but many patients still have the ability to sense and respond to the therapist’s affective state at the moment. When beginning communication, be clear of all previous concerns and bring no extra or extraneous emotions into the interaction. Caregivers and therapists bring into the conversation the power of intention to create a therapeutic interaction and the choice to stay on task. Patients bring their own sets of concerns at any particular moment. Knowing something about the patient’s concerns helps the process.

Therapists and caregivers need to be self-aware. What is the therapist’s favorite strategy for communication? What is the therapist’s favorite sentence structure? Our habitual forms of presentation need to be assessed with regard to whether they are effective, because the patient needs to be the focus of attention. Honoring the communication habits of the patient is necessary if effective communication is to occur with a person with cognitive deficits. If the therapist chooses to speak to the patient as if there were no cognitive deficits, consistent results will not occur and the patient may be upset or agitated. The patient could be approached as if he or she were a person from another culture that has its unique customs, norms, and ways of communication. The patient-therapist interaction becomes an inquiry in which success is measured by the achievement of functional outcomes that are needed and wanted (e.g., the patient transferring into bed and feeling safe).

Now the question becomes what is the specific process of interaction with which the patient appears to be most comfortable and feels safe? Every patient is different, and it may depend on the time of day or whether the patient is tired or feeling threatened. Persons commonly respond best to one particular style of communication and are predictably upset or agitated by another style. If a patient wants to joke around and be playful, this should be a cue to staff that this is a workable style of communication. Another patient smiles whenever the tone of the conversation is soft, nurturing, and tender, and if staff is willing, this is where ease of relating can occur. Other patients relate best to rules and need predictable structures and boundaries. They love to know what is coming next. Still another category is people who can relate and communicate when definite admiration and respect are built into the conversation or when patient and therapist can agree to disagree. Each patient with cognitive problems needs to have caregivers develop a chart of what works to create a sense of relatedness and ease in communication. A challenge here for caregivers is that the patient’s abilities can change; guidelines for communication when new caregivers are introduced to the patient can also be helpful. Someone who is familiar and enjoys interacting with the patient should introduce new staff to the patient.

For persons with cognitive disturbances, familiarity and rituals are keys to ease of adaptability. The basis for rituals is well-organized documentation to which all caregivers have access and contribute on an ongoing basis. This information needs to be filtered and organized so that each shift can see what is working for the patient today. Even a nonverbal patient can relate effectively to bathing if a ritual exists regarding dressing and undressing (e.g., the socks always come off first). Mace and Rabins⁹⁹ spelled out the details of the importance of caregivers being aware of the power of familiarity and rituals. Mintzer and colleagues¹¹² reinforced the same idea in their research on the effectiveness of alternative care environments for agitated patients with dementia. Another detail that requires staff or caregiver attention, evaluation, and adaptation in daily care is ideational apraxia. LeClerc and Wells¹¹³ described this as “a condition in which an individual is unable to plan movement related to an object because he or she has lost the perception of the object’s purpose.” This is especially important in relation to feeding, dressing, toileting, and bathing. The authors described a tool that can help caregivers assess ideational apraxia and problem-solving compensations to prevent unnecessary agitation or disability and take actions to preserve existing abilities. Savelkoul and colleagues¹¹⁴ emphasized the importance of effective communication between staff and patients and the importance of routines for patient care to maximize functional behaviors for institutionalized elderly living in residential homes. Another key point noted was that staff corrected and tested residents too often, which can create agitation and anxiety. This appeared to be related to lack of training and information on the part of the staff about the dementia and cognitive status of patients as well as a lack of support from other staff.

As a patient goes through gradual deterioration of cognitive status, as is common in AD, staff, family, and caregivers must be trained in nonverbal, positional, and manual cues and emotional communication techniques. Many patients come to a place in their lives with dementia when words are a source of confusion. Other strategies to communicate should then be used. Sign language is initially a possible tool until the associative functions begin to disappear. Accurate assessment needs to create adaptations in communication. It may be necessary to use hand-guided communication, in which the patient is led through a task or parts of a task to get his or her cooperation. At this stage of communication, ease and trust are the most important goals. It may take 5 minutes of tenderly holding a patient’s hand before the patient is ready to walk to the dining room or bathroom. This requires much patience on the part of caregivers. Positional communication can be used as well as simple touch. As patients begin to feel safe with their state of being, they will relax and choose to participate. At times patients have unique needs, such as only wanting to be cared for by a female caregiver or a male caregiver. Honoring patient needs is critical because the cognitively impaired may not be able to learn or adapt to the demands of the staff member because of previous trauma (assault or incest, real or imagined).

As a way to summarize the considerations about communication with a person with cognitive impairment, therapists may find it useful to examine their own intentions from moment to moment. “What is my goal in this interaction?” “Who am I being at this moment?” The task may be important and the “doing” of it may be critical. For the patient with cognitive disturbance, therapists must provide life-enhancing stimuli on the basis of the patient’s perceptions. If in the zeal to “do,” the patient is accidentally scared, intimidated, or bullied, the damage may not be able to be undone. The cognitively impaired patient presents a unique challenge if a threat has been created, because reestablishing their trust is often difficult. Often the patient may be afraid of the therapist and simply needs the therapist to leave the room for some time. The saving grace for many patients is that their short-term memory is poor so they may not remember the incident tomorrow. The problem with agitation occurs when other cognitively impaired clients in the area also get upset.

The solution to the crisis moment, when a breakdown in communication has occurred, is to redirect communication and the focus of the present moment effectively. For example, a staff member could purposely bump into a chair and knock it over, drop a cup of water or a book, start to sing, whistle loudly, or clap his or her hands. At that moment a distraction is created. If the distraction works, then the patient’s attention is pulled away from his or her old thought and focused to a new topic. At that moment the staff needs to be intentional. The new focus needs to offer comfort or nurturing or a predictable sense of well-being (e.g., helping to clean up, eating some food, looking at a picture of a favorite thing, holding a favorite item, touching a favorite comfort object, hugging).

The research findings and techniques previously discussed describe many of the aspects of the Feldenkrais approach to learning.^1,14 The Feldenkrais Method has been applied to the needs of elderly persons with good results. The principle that learning needs to be pleasurable is especially applicable to elderly clients (with or without dementia) because they are often under more stress and have fewer supportive resources to cope with a crisis. Despite changes in learning style, the older person (with or without dementia) can be helped to learn more efficiently through well-planned instruction. The use of techniques to increase learning efficiency in the elderly has been demonstrated to decrease the stress that at times may result in emotional or cognitive overload and abnormal cognitive reactions.

Ann¹¹⁵ notes that because habits and procedural memory (behaviors learned by doing) are two of the last areas of the brain affected by AD and dementia, individuals with these diseases can often walk around after they are no longer able to be aware of their surroundings, consistently communicate, or reason. The Feldenkrais Method taps into an individual’s habits, producing positive and lasting results through the capacity of the individual to still use procedural learning (even though she or he is not able to describe verbally or be consciously aware of the learning that is achieved). One example of how the Feldenkrais Method taps into procedural memory follows. Lee, a man of age 92 years with advanced dementia, was able to achieve changes in his behaviors, even though he was worked with while he was sleeping, which changed his behavior while he was awake. Because of Lee’s constant walking and potentially combative behavior, working with him initially was difficult. When he was asked to sit or lie down, he complained loudly and told the therapist to get away. Instead, the therapist worked with him during his frequent naps. He walked bent over with his feet and legs turned out and a wide stance. He held both arms close to his sides, with his elbows bent and no arm swing. He was unable to move isolated areas of his torso; he therefore did not turn his head to look at something next to him. Instead, he turned his whole body. Lee would decide to sit down without looking to see if a chair was behind him, partially because he did not have safety awareness and partially because he did not have the capability to rotate his body. Immediately after waking up or finishing a meal, he would start to walk. As a result of these limitations and actions, Lee was constantly falling. Lee needed to learn how to differentiate the movement pattern of turning his head separate from his trunk. Lee had a pattern that was “un”differentiated in which he moved his head and trunk as a single unit; he had no choice to do anything else. Through gentle movements while Lee was lying on his back or side, the first several sessions involved exploring passive movement of his pelvis and spine. The focus was to explore with Lee his capacity to move in diagonal patterns and to create a kinesthetic relationship between his right shoulder and his left hip and vice versa, the sensation of elongating his spine and learning to twist his torso. He began to demonstrate the capacity to breathe by allowing his chest to expand in the lower rib area. The passive movement explorations involved exploring upper torso rotation, including head turning, shoulder blade differentiation, and the ability to move the shoulder blades independently of his ribs, and connecting movements of the ribs and chest to flow with the movements of the upper spine. After the third session, Lee stopped falling while walking. Although he still exhibited rigid movements and difficulty moving his arms away from his body, he shifted weight a little more easily and demonstrated minimal trunk rotation for walking in both directions. Lee did not fall for several months until he stopped walking because of a sore on the ball of one foot. Lee gradually discovered how to allow the therapist to work with him and the protest stopped. This ability to learn to allow the therapist to sit next to him and touch him is an example of learning through use of emotional memory, another type of memory that seems to work in conjunction with procedural learning. Both procedural and emotional memory are preserved long after other memories are lost. Even without cognitive recognition, emotional memory capabilities in persons with AD allow them to communicate and establish trust with another human being and learn new functional ways to balance in gravity.

Another example is Dina, an 83-year-old with advanced AD, Parkinson disease, depression, and cataracts. The Feldenkrais sessions with her demonstrated the power of focusing the communication and interaction on keeping the activities pleasant and working within the comfort zone of the patient. The chief problem was that the patient had swollen knees and had not been able to straighten her knees past 90 degrees for the previous 2 years. Dina had received traditional physical therapy in which the intervention included attempting to straighten the knees by placing a weight on top of them. Dina cried during this treatment and reported pain. She could not propel her own wheelchair, and it took two staff members to transfer her to and from her wheelchair. Her reaction to their attempt to transfer her was to lift her legs off the floor and give them her entire weight. She did not rest her feet on the floor, even in sitting. Dina had difficulty lying in all positions. When on her back, her lower body twisted to the side. She stayed where she was placed and in the position she was placed in. Dina was unable to specifically point to a body part and say it hurt her. The focus of the first session was to explore how to help her rest more comfortably. The first efforts were to try to enhance mobility in her ribs and spine. After the first session, she was able to rest more fully on one side. After the second session she was able to rest more fully on both shoulder blades and on her pelvis evenly. After the fourth session, Dina began wheeling herself in the wheelchair with her feet, and staff reported that later in the day they saw her stand up from the wheelchair for about 1 minute by herself. None of the sessions had involved direct work with her legs, and the progress in her ability to participate in her life points to the fact that movement deficits are not always the root of problems. The capacity to feel safe and allow touch and other physical and social communication can create improvements in the ability to live in gravity and assist caregivers with the chores of life. The Feldenkrais Method is an example of effective, functional communication, manual therapy, and neurological rehabilitation that enhances daily living skills in people with AD and other dementias.^1,14,115

Transplantation shock

Some elderly persons seem to function well in a familiar environment but become severely disoriented and unable to perform ADLs if taken out of their own homes. As a general rule, these persons have mild symptoms of dementia that are not readily apparent when they remain in a structured, familiar, stable environment and maintain a consistent daily routine. When faced with the need to adapt to a new environment and bombarded with multiple unfamiliar sensory stimuli, however, their limited brain capacity is unable to make sense out of the large volume of new stimuli. If a patient was oriented before admission to an institution and then becomes disoriented, the patient’s cognitive functioning will likely return to its baseline level of functioning on return to the familiar environment. Therefore all moves by a patient from one hospital room to another or from one institution to another, and all changes in a treatment regimen, need to be carefully planned. If a change is anticipated, the patient should be involved in the decision making. If the change is a permanent move, the patient needs to have a chance for one or two trial visits before the actual move. The patient needs to be informed of all changes well in advance, and this information needs to be given repeatedly to the patient with dementia. The precautions mentioned can help the patient relocate without creating transplantation shock and the negative cognitive and emotional changes.

Alzheimer disease

The treatment of irreversible dementia is a long-term process. Recent studies have found that the average duration of illness from first onset of symptoms to death is 8.1 years for AD, 6.7 years for multiinfarct dementia,¹³⁵ and 5.6 years for Pick disease.¹²⁴ Medical and nursing care can extend the life expectancy of patients with dementia for up to 20 years or more.

In 1907, Alois Alzheimer³⁴ described the case and the neuropathology of a 54-year-old woman who developed morbid jealousy, which was followed by loss of memory, inability to read and understand, and death 4.5 years after onset of the illness. Since then, it has been noted that 50% of patients with dementia have AD.¹⁰¹ In making the diagnosis of AD, all other causes of cognitive dysfunction must be ruled out. The disease can occur at any age, but the onset of the disease is almost always after age 65 years. The prevalence of the disease gradually increases to a rate of 20% in persons older than 85 years.³³

AD can be clinically staged. The use of staging enables the family and health care team to plan ahead for the individual’s needs. Staging helps the family prepare longitudinally for the process of interacting with the patient. It allows the treatment team to plan for appropriate levels of services as the individual’s abilities decline. Finally, it allows the health care team to quantify change in functional and cognitive abilities over time, which helps assess the effectiveness of the patient’s treatment plan and establish evidence-based practice. The use of staging requires an accurate description of the patient’s behavior (without the use of jargon) as well as an assessment of the patient’s mental state.

Traditionally the symptoms of AD have been thought to progress in three stages.

Stage 1 lasts from 2 to 4 years and involves loss of functional skills or orientation, memory loss, and lack of spontaneity. The patient is often aware of the losses and is, in many cases, able to cover up the cognitive losses by talking around the issues. During this stage the patient and family may need to deal with the issue of giving up a job, hobbies, or other types of meaningful activity because of the patient’s inability to carry them out safely and independently. The patient begins to lose the ability to handle money and a personal budget, drive a car safely, and tell time. The family or significant others may have to come to terms with the question of whether the patient can live alone. Depression is common during this stage of the disorder.¹³⁰

Stage 2 is characterized by progressive memory loss and the presence of a variety of neurological symptoms. Aphasias, apraxias, wandering, repetitive movements and stereotypical behavior, increased or decreased appetite, constant movement, and a peculiar wide-based gait can manifest. Psychotic symptoms (especially paranoid delusions and hallucinations), agitation, violent behaviors, and uncontrollable screaming are common symptoms during this stage of the disorder.

In stage 3 the patient develops vegetative symptoms. The patient may become mute, stop eating, and become incontinent of bowel and bladder. Muscle twitches or jerks, spasms of the diaphragm, and an inability to walk generally occur. The patient may develop seizures, and emotional responsiveness, if present, is at a primitive level. Eventually the patient dies from the disease.

The MMSE also may be used as a staging tool. Scores of 26 or more are generally associated with minimal, if any, dementia; scores of 21 to 25 are associated with mild dementia, scores of 15 to 20 with moderate dementia, scores of 10 to 14 with severe dementia, and scores of 9 or less with profound dementia. The severity of most other symptoms correlates well with the MMSE score.

There is wide agreement now on a seven-stage scale to describe the progression of Alzheimer’s (see www.alz.org/alzheimers_disease_stages_of_alzheimers.asp). This scale is probably the most accurate staging system for AD and correlates more closely with the progression of different sets of symptoms through the course of the disease.

The barthel index

The Barthel Index (Table 27-1) is a profile scale that rates 10 self-care, continence, and mobility criteria.¹³⁶ The specific rating guidelines used in scoring are presented in Appendix 27-A. The advantage of the Barthel Index is its simplicity and usefulness in evaluating patients before, during, and after treatment. It is functionally oriented and may be best used when accompanied by a clinical evaluation.⁸⁷ The scale allows documentation of functional changes over time. It is useful when discussing with families the need for help for the patient who cannot manage self-care (ADLs and/or IADLs). Work continues to develop more effective and reliable scales for assessing function and status in people with AD.¹³⁷

Supporting families and caregivers with their own sense of loss, frustration, and helplessness

Family, significant others, and caregivers go through their own coping and adaptive process as the patient experiences gradual or sudden cognitive disturbances.¹³⁹ These people have a history with the patient and have expectations about what the relationship and communication should be. As cognitive disturbance occurs, they experience a series of losses because the patient is no longer able to respond and interact as he or she has in the past. With progressive cognitive decline, family and friends experience ongoing losses because the patient is continually changing and less able to relate. For many patients with cognitive disturbances, at the final stage all communication disappears and the family is left with only nonverbal communication or no communication at all. Staff who work with a patient over a period of time also face their own personal reactions of loss, unfulfilled expectations, and a continual need to reassess how to relate effectively to the patient. The responsibility for creating a positive relationship falls on the people who are interacting with the patient. The family and caregivers themselves need training and ongoing support in learning how to nurture and maintain an ongoing relationship with the patient. This requires that caregivers and family members be aware that they are in a healing process as they relate to the loss of the relationship that previously existed.

Nonlinear learning

Nonlinear learning begins with the posing of a question. Then data and information are collected, and additional questions are generated that are related to the first question. At some point an “Aha!” moment or insight occurs. A new relationship is suddenly made possible that was not possible before. Nonlinear learning is not about small gradual steps of progress but occurs as learning balance occurs when riding a bicycle—one minute balance is impossible, and the next is the breakthrough moment. Nonlinear training offers precise strategies that can enhance communication with someone who has cognitive deficits. Nonlinear learning is built on scientific communication that operates on the basis of verifiable facts at the present moment. Nonlinear learning invites each person to examine all strategies for communication to be sure that problems are not occurring as a result of misinterpretation of the facts. Communication can occur without verbal language, and fear does not need to be present. When a patient has cognitive deficits, the art and science of human interaction need to be precise so that caregivers do not speak in words that are not understandable to the patient. Which caregiver prejudgments are brought to the interaction with the patient needs to be understood: experiencing the stage of awe, sharing joy in the moment, or suffering because the person is “difficult”? The care and therapy provided to a person with cognitive disturbances need to be created based on the facts of the moment and carried out in a state of gratitude, vulnerability, and nurturing for the staff and the patient.

Role of the physical therapist: development of interventions and caregiver training

All persons with cognitive losses should have access to caregivers who are trained to manage emotional responses in order to provide precise strategies for communication with those with dementia. A gracious and secure existence is possible even when cognition is diminished if the caregivers are committed to adapting the environment and its demands to match the capacity of the patient. The challenge for health care is designing training programs that truly prepare families and caregivers to be effective, empowering communicators. All caregivers need training to create this experience for a person with cognitive deficits.

As a part of the rehabilitation program, caregiver training for this group of patients needs to emphasize reassurance, hands-on interventions, and communication to allow treatment to proceed at a pace perceived as reasonable by the patient.⁶⁷ In the early and middle stages of all dementias, physical therapy intervention usually can prolong the ability to move with ease in ADLs and IADLs and maintain the ability to participate in some social activities. This is extremely important for caregivers because deficits in the patient’s ability to perform ADLs and IADLs often relate to the inability to physically perform these activities under supervision.⁴⁷ The ability to walk is lost late in most dementias, but gait and coordination disturbances are common and can benefit from physical therapy.^144–146 Therapeutic intervention to assist the patient and train the caregivers involves facilitation of ease of movement and motor planning and developing or refining environmental and cognitive cues to assist in carrying out complex tasks. Ultimately, caregivers require training in how to move, lift, and otherwise assist the patient.

Although not able to reverse the progressive cognitive decline, the exercise intervention that the physical therapist can develop may improve the level of function, confidence, vitality, and safety of the patient and ease the burden of care for the caregivers. Research is beginning to establish an important role for exercise in maintaining physical activity^147,148; contributing to general health and slowing of cognitive decline^149–152; as well as maintaining strength and aerobic conditioning.¹⁵³ Guidelines for exercise prescription include aerobic, strength, balance, coordination, and flexibility activities determined by direct assessment, and suggestions for motivational and problem-solving strategies. The Seattle Protocols are an important contribution in this area.^154,155 Research shows that exercise not only increases strength, coordination, and aerobic capacity but also creates beneficial changes in brain plasticity.^156–158 Further studies need to be done to work out more clearly what types of exercise are beneficial in what ways for what populations.¹⁵⁹

Cognitive impairment is a key limiting factor in the performance of ADLs and IADLs as well as a limiting factor for participating in rehabilitation. Accurate assessment and training by the therapist helps the caregiver provide only the help that is absolutely needed, with patients continuing to perform for themselves as many ADLs as possible. For example, when brushing the teeth, the patient needs to be able to remember the command to brush, must recognize the toothbrush, and must perform a complex but repetitive motor action. The patient may only need the help of someone placing the toothbrush in his or her hand and slowly guiding it to the mouth to be able to safely brush the teeth.

The accurate assessment of IADLs and ADLs is more reliable than medical diagnosis for predicting the amount of assistance and interaction a person will need in a nursing home (see Table 27-1 and Appendix 27-A).¹³⁶ The first goal of rehabilitation for patients with dementia is to create a supportive emotional and physical environment. In other words, the environment must actively work to compensate for the patient’s cognitive and functional losses as they occur. The ultimate goal is to help patients feel they are capable so that they will continue to try to do those things for themselves that they can do safely, whether they remain in their home or live in an institution. Orientation and training of significant others is also important so they feel comfortable allowing the patient to participate safely in activities and basic self-care tasks modified to their cognitive level.

The Alzheimer’s Association ([800] 272-3900; www.alz.org) is a resource for professionals and caregivers of people with dementia. The goals of the association are the following:

The Alzheimer’s Association promotes the provision of humane care to the patient with dementia or related disorders throughout the course of the illness. Other support groups have been tried in communities in which spouses have worked to develop ongoing respite care.¹⁶⁰

As a member of the rehabilitation team, the physical or occupational therapist can conduct an inventory of services as a part of the annual review of the quality of care that is provided for a patient with dementia. Surveys of persons caring for patients with dementia listed the following services in their perceived order of importance^83,161:

In the home care category, information about the availability of services and government programs and various forms of respite care were also ranked high in the survey. Overall, caregivers (family and friends) of the patient are often able and willing to provide care for the patient throughout the illness if appropriate professional consultation can help them cope with problematic situations and if adequate respite time is provided to the caregiver(s).

Not mentioned in this chapter was the need for psychological support for caregivers. The stress on caregivers is extreme, and symptoms of anxiety and depression are common. Because of the relative lack of counseling services for caregivers, however, the use of (and probable abuse of and dependence on) psychotropic medications by caregivers is high.^60,162 Because these medications may impair the cognitive functioning of caregivers, the risk of harm to the patient with dementia is also high.