Vol. 18 Issue 13
Subacute and Long-Term Care
Treating Patients With Advanced Dementia
Patients with advanced dementia are one of the most difficult populations with whom to work. By advanced dementia, I'm referring to patients at a late stage or end stage of the dementia progression. In the long-term care setting, physical therapists and PT assistants are often asked to become involved in the care of patients at this stage of dementia.
Whether the therapist is providing direct treatment, setting up a restorative or maintenance program or asked to consult, it is important to understand the profile of the patient at an advanced level of dementia. Our focus should be on what the patient is still able to do and treatment should be tailored to optimizing these abilities.
Profile of Late-Stage Dementia
The abilities of patients in late-stage dementia would be equivalent to that of a 1- to 2-year-old child. At this stage, the patient in general is dependent or requires maximal assistance for most functional abilities. At the lowest level in the late stage of dementia, patients still can sit up, lean forward and sit unsupported for brief periods of time.
Patients can spontaneously stand and sense when they are losing their balance. They can name some body parts when touched and perform reciprocal movements like walking and marching. They mainly respond to visual and tactile cues and respond little to verbal cues. They will wave and clap to communicate and sometimes use one-word phrases (i.e., yes or no).
At their highest level during this stage, patients can walk to familiar locations, use their upper extremities to push and do hand-to-mouth feeding. Floor contrasts can be confusing and may cause patients to stop walking.
Holding onto an object can be distracting, so assistive devices for gait can become increasingly difficult to use. In addition, patients are slow to release their grasp, familiarly known as a "death grip."
It is necessary to use more visual and tactile cues although patients still respond to some verbal cues. Patients can sing, reminisce and name one-word familiar locations (i.e., bedroom). Response time is slowed and it is important to wait for response after cueing (as long as 30 seconds in some cases). Treatment of patients at this stage can include:
Sitting training on a mat;
Scooting in sitting;
Transfer training for sit-to-stand and stand-to-sit;
Use of rails and bars to assist in transfers;
Active range of motion; the patient needs continual tactile cues to initiate and sustain movements;
Active resistive exercise with cueing;
Gait training on flat surfaces, to highly familiar locations and up and down steps;
Caregiver instruction and restorative/maintenance program development.
Profile of End-Stage Dementia
At this stage, the patient in general is dependent for most functional abilities. At the lowest functional level at end stage of dementia, the patient responds to various stimuli and needs primarily sensory cueing.
This patient also is non-verbal but demonstrates attention through non-verbal arousal to voices and facial expressions. The patient may withdraw from noxious stimuli but positively respond (i.e., turn the head) to strong but pleasant olfactory stimuli. Patients respond to touch and massage, turn their heads to track moving colors, music and whistles.
At the highest level during this stage, patients demonstrate the ability to move body parts. They spontaneously move in bed and can begin to assist in sitting up and rolling in bed. They can sit in a secure chair for brief periods. They can become involved in active assistive range of motion. They often need 50 percent assistance to maintain sitting on a mat. Patients respond to visual and tactile cueing but need continuous cueing to sustain actions. Treatment options include:
Positioning in bed and in a chair;
Passive range-of-motion of all extremities;
Active assistive range of neck and upper extremities;
Sensory stimulation to promote facial and neck movements, clearing of secretions and interaction with environment;
Recognizing the typical functional abilities of the patient with advanced dementia will allow therapists to more appropriately tailor their treatment plan to the patient's abilities. Further, I believe it will help to alleviate frustration for some who find this population to be challenging.
Reisberg, B. (1986). Dementia: A systematic approach to identifying reversible causes. Geriatrics, 41, 30-46.
Warchol, K. (2007). Dementia Care Specialists Inc.
Bob Thomas is a geriatric physical therapist who currently serves as the president of Infinity Rehab, a provider of rehab in subacute, long-term care and outpatient settings in seven states. He lectures nationally on rehab for the frail older population for Great Seminars and Books Inc. and is an adjunct professor in the physical therapy program at Pacific University in Hillsboro, OR.