Functional Independence and Dementia
The Dose-Response Relationship to Therapeutic Exercise Dementia ranks as a leading cause of disability for elderly patients, and the prevalence is expected to quadruple over the next three decades.1
While there is a worthwhile focus on the cognitive decline associated with dementia, it may be less appreciated that dementia causes rapid physical decline. This results in problems with coordination, balance, posture, and gait.2
These challenges exacerbate reductions in quality of life, reduced caregiver wellbeing, and increased healthcare costs.1-4 To make matters worse, patients with dementia typically receive fewer rehabilitation services, not more.4,5 The reduced utilisation of rehabilitation may stem from a combination of increased focus on the cognitive aspects of dementia and from the increased difficulty in accessing healthcare caused by dementia. It is well established that in dementia, therapeutic exercise can slow functional decline, improve balance, and reduce fall risk.6-8 However, given the increased rate of physical decline caused by dementia, standard geriatric rehabilitation plans may or may not be adequate.
To explore this question, Cheri LeDoux and colleagues analysed Medicare’s data on patients with a primary diagnosis of dementia who received therapeutic exercise visits.9 All subjects had detailed assessments submitted at start of care, at discharge, and (if care lasted longer than 60 days) every 60 days. Assessment information included details about independence with various activities of daily living (ADLs), including grooming, upper-body dressing, lower-body dressing, bathing, toilet transfers, toileting hygiene, bed/chair transfers, ambulation, feeding, meal preparation, and telephone use.
LeDoux et al. matched changes in these scores to visit records. Their data affirms that therapeutic exercise improves ADLs in a dose-dependent way and over & above improvements available through consultation and care planning. They observed the following associations between number of supervised-exercise visits and probability of ADL improvements: consultation without exercise (0 exercise visits) – 60%, 1-5 visits – 69%, 6-13 visits – 81%, 14 or more visits – 89%. The data provides considerable encouragement for primary care practitioners to assess ADL independence among elderly in general and among patients with dementia. Prescribing therapeutic exercise to reverse loss of independence promises to improve patient safety as well as quality of life for both the patient and the family caregiver.
References
1. Arrighi HM, McLaughlin T, Leibman C. Prevalence and impact of dementia-related functional limitations . . ., 2001 to 2005. Alzheimer Disease & Associated Disorders. 2010 Jan 1;24(1):72-8.
2. Poulos CJ, Bayer A, Beaupre L, Clare L, Poulos RG, Wang RH, Zuidema S, McGilton KS. A comprehensive approach to reablement in dementia. Alzheimer's & Dementia: Translational Research & Clinical Interventions. 2017 Sep 1;3(3):450-8.
3. Pressley JC, Trott C, Tang M, Durkin M, Stern Y. Dementia in community-dwelling elderly patients: A comparison of survey data, Medicare claims, cognitive screening, reported symptoms, and activity limitations. Journal of Clinical Epidemiology. 2003 Sep 1;56(9):896-905.
4. Weber SR, Pirraglia PA, Kunik ME. Use of services by community-dwelling patients with dementia: a systematic review. American Journal of Alzheimer's Disease & Other Dementias®. 2011 May;26(3):195-204.
5. Cations M, Laver KE, Crotty M, Cameron ID. Rehabilitation in dementia care. Age and Ageing. 2018 Mar 1;47(2):171-4.
6. Telenius EW, Engedal K, Bergland A. Long-term effects of a 12 weeks high-intensity functional exercise program on physical function and mental health in nursing home residents with dementia: a single blinded randomized controlled trial. BMC Geriatrics. 2015 Dec 1;15(1):158.
7. Jensen CS, Hasselbalch SG, Waldemar G, Simonsen AH. Biochemical markers of physical exercise on mild cognitive impairment and dementia: systematic review and perspectives. Frontiers in Neurology. 2015 Aug 26;6:187.
8. Lam FM, Huang MZ, Liao LR, Chung RC, Kwok TC, Pang MY. Physical exercise improves strength, balance, mobility, and endurance in people with cognitive impairment and dementia: a systematic review. Journal of Physiotherapy. 2018 Jan 1;64(1):4-15.
9. LeDoux CV, Lindrooth RC, Seidler KJ, Falvey JR, Stevens‐Lapsley JE. The Impact of Home Health Physical Therapy on Medicare Beneficiaries With a Primary Diagnosis of Dementia. Journal of the American Geriatrics Society. 2020 Apr;68(4):867-71