dementia types, assessment, scales, physiotherapy, management, recent advance

1. DEMENTIA
Seminar presentation –
Syed Adil – MPT 1

2. CONTENTS
• Introduction
• Causes
• Types
• Pathophysiology
• Clinical features
• Assessment (outcome measures)
• Physiotherapy rehabilitation
• Recent advance

3. DEFINITION
Dementia can be defined as
an acquired decline in memory
and in at least one other
cognitive function sufficient to
affect daily life in an alert
person.
Narinder Kaur Multani, Satish Kumar Verma, Principles of Geriatric Physiotherapy, 1st edition 2007

4. • Dementia is a syndrome – usually of a chronic or progressive nature –
leads to deterioration in cognitive function (i.e. the ability to process
thought) beyond what might be expected from the usual consequences
of biological ageing. It affects memory, thinking, orientation,
comprehension, calculation, learning capacity, language, and
judgement.
https://www.who.int/detail/dementia

5. INTRODUCTION
It is most severe type of cognitive impairment
Gradual onset
Continue decline
Prevalence
• In India it is reported to be 2.7%.
• As the age increase, prevalence of dementia increases, nearly 20% of
people above 80 suffer from dementia.
http://nhp.gov.in/disease/neurological/dementia 16-09-2016

6. CAUSES OF DEMENTIA
Alzheimer’s disease accounts for 60-70 percent cases of dementia.
Following Correctable conditions accounts for 15-30 percent cases of
dementia -
• Drug complications
• Infectious diseases
• Metabolic and nutritional disorders
• Subdural hematoma
• Normal-pressure hydrocephalus

7. TYPES OF DEMENTIA
• Alzheimer's disease
• Vascular dementia
• Dementia with lewy bodies
• Fronto-temporal dementia
• Mixed dementia

8. PATHOPHYSIOLOGY WITH CLINICAL FEATURES
Alzheimer’s disease
• Stages of Alzheimer disease –
1. Preclinical stage – ( before the onset of sign and symptoms)
2. Early stage – (Between 1 and 3 years from onset of symptoms)
3. Middle stage – (Between 2 and 8 years from onset of symptom)
4. Late stage – (Between 6 and 12 years from onset of symptoms)

9. Deposition of beta-
amyloid and
neurofibrillary tangles
loss of synapses and
neurons
Gross atrophy of the
brain
Dementia
Pathophysiology

10. Preclinical Stage of Alzheimer’s
Disease
Early stage of Alzheimer’s Disease
Delayed paragraph recall Slow reactions
Frequent repetitions of the same
questions or stories
Slowness in picking up new
information
No functional impairment Disorientation for date
Mild language or executive
dysfunction
Recent recall problems
Missed appointments
Mild difficulty copying figures
Naming difficulties
Reduced participation in social
functions

11. Middle Stage of Alzheimer’s Disease Late Stage of Alzheimer's disease
Disorientation to date, place Nearly incomprehensible verbal
output
Trouble recognizing familiar people Loss of remote memory
Impulsive actions Inability to recognize self or family
members
Difficulty with perceptual motor skills No longer grooming or dressing
Late afternoon restlessness Incontinence
Illegible writing Reduced ability to walk or get around
Loss of ADL skills Motor or verbal agitation
Overreaction to minor events
Delusions, agitation, aggression

12. Vascular Dementia
• Impairment of cognitive function caused by conditions that block or
reduce blood flow to various regions of the brain, depriving them of
oxygen and nutrients.
• Sudden onset of dementia after a stroke or stepwise gradual decline
due to multiple micro-strokes.

13. CLINICAL FEATURES OF VASCULAR DEMENTIA
5- 10 percent cases of dementia
Focal neurological findings
Behavioral and psychological problems same as AD
Less severe memory impairments and recall problems than AD
More severe depression than AD.

14. Dementia with Lewy Bodies
Abnormal deposition of group of proteins called Lewy bodies which
leads to damage to the brain cells.
CLINICAL FEATURES
5-10 percent of dementia
Parkinsonism is seen that is manifested primarily by rigidity and
bradykinesia rather than tremor
Onset is insidious and nature of disease is progressive similar to AD.
Visual hallucinations are more commonly found than AD

15. Frontotemporal Dementia
• Abnormal deposition of group of proteins called tau which leads to
impairment in synaptic conduction and damage to the brain cells in the
frontal and temporal lobe.
• Less common type
• Develops at a relatively young age

16. CLINICAL FEATURES
Early changes in personality and behavior with relative sparing of
memory
Executive dysfunction
Primary progressive aphasia
Sparing of visuospatial abilities

17. Mixed dementia
• Mixed dementia is a condition in which brain changes of more than
one cause of dementia occur simultaneously.
• Studies are ongoing to determine how having mixed dementia affects
symptoms and treatments.

18. ASSESSMENT AND DIAGNOSIS
 History
• Duration of symptoms: Since how long the symptoms have been
present ?
• Type of onset: Whether the symptoms started gradually or suddenly?
• Rate and nature of decline in cognitive function: Whether the decline
was stepwise or continuous?
• Social history may help to assess recent memory: For example, How
often do you visit your relative?

19. • Medical history may give idea about remote memory: For example,
Where you operated for fractured femur?
– Language problems: This can be primarily assessed while talking to
patient.
– (Family members or caregivers should be involved to obtain complete
information)

20. NEUROMUSCULAR EXAMINATION:
• The presence of rigidity, bradykinesia and tremor indicates dementia
with Lewy bodies.
SENSORY EXAMINATION:
• There may be disturbances in visual acuity, depth perception, color
differentiation
GAIT AND BALANCE:
• Modified performance-oriented mobility assessment (POMA) is used
for the assessment of balance and gait.

21. LABORATORY TESTING:
• CBC, TSH, Liver and renal function tests may be recommended to
find out secondary cause or comorbid conditions in patients with
dementia.
NEUROIMAGING:
• CT scan or MRI scan to rule out the secondary cause of dementia such
as subdural hematoma or normal-pressure hydrocephalus.

22. ASSESSMENT OF FUNCTIONAL STATUS
• ADL scale
• IADL scale
MENTAL STATE AND COGNITIVE FUNCTION
• Mini Mental Scale Examination (MMSE)
• The Mini-Cog assessment instrument
• Geriatric depression scale (GDS)
Dementia Severity Rating Scale (DSRS)

23. Katz Index of Independence in Activities of Daily Living
Activities
Points (1 or 0)
Independence
(1 Point)
NO supervision, direction or personal
assistance.
Dependence
(0 Points)
WITH supervision, direction,
personal assistance or total care.
BATHING
Points:
(1 POINT) Bathes self completely or needs
help in bathing only a single part of the body
such as the back, genital area or disabled
extremity.
(0 POINTS) Need help with bathing
more than one part of the body, getting
in or out of the tub or shower. Requires
total bathing
DRESSING
Points:
(1 POINT) Get clothes from closets and
drawers and puts on clothes and outer
garments complete with fasteners. May have
help tying shoes.
(0 POINTS) Needs help with
dressing self or needs to be
completely dressed.
TOILETING
Points:
(1 POINT) Goes to toilet, gets on and off,
arranges clothes, cleans genital area without
help.
(0 POINTS) Needs help transferring to
the toilet, cleaning self or uses bedpan
or commode.
TRANSFERRING
Points:
(1 POINT) Moves in and out of bed or chair
unassisted. Mechanical transfer aids are
acceptable
(0 POINTS) Needs help in moving from
bed to chair or requires a complete
transfer.
CONTINENCE
Points:
(1 POINT) Exercises complete self control
over urination and defecation.
(0 POINTS) Is partially or totally
incontinent of bowel or bladder
FEEDING
Points:
(1 POINT) Gets food from plate into mouth
without help. Preparation of food may be done
by another person.
(0 POINTS) Needs partial or total help
with feeding or requires parenteral
feeding.
TOTAL POINTS: SCORING: 6 = High (patient independent) 0 = Low (patient very dependent

24. LAWTON - BRODY
INSTRUMENTAL ACTIVITIES OF DAILY LIVING SCALE (I.A.D.L.)
Scoring: For each category, circle the item description that most closely resembles the client’s highest functional level (either 0 or 1).
A. Ability to Use Telephone E. Laundry
1. Operates telephone on own initiative-looks up and dials
numbers, etc.
2. Dials a few well-known numbers
3. Answers telephone but does not dial
4. Does not use telephone at all
1
1
1
0
1. Does personal laundry completely
2. Launders small items-rinses stockings, etc.
3. All laundry must be done by others
1
1
0
B. Shopping F. Mode of Transportation
1. Takes care of all shopping needs
independently
2. Shops independently for small purchases
3. Needs to be accompanied on any shopping trip
4. Completely unable to shop
1 1. Travels independently on public transportation or drives own car
2. Arranges own travel via taxi, but does not otherwise use
public transportation
3. Travels on public transportation when
accompanied by another
4. Travel limited to taxi or automobile with assistance of
another
5. Does not travel at all
1
0 1
0
1
0
0
0
C. Food Preparation G. Responsibility for Own Medications
1. Plans, prepares and serves adequate meals independently
2. Prepares adequate meals if supplied with ingredients
3. Heats, serves and prepares meals, or prepares meals, or
prepares meals but does not maintain adequate diet
4. Needs to have meals prepared and served
1 1. Is responsible for taking medication in correct dosages at
correct time
2. Takes responsibility if medication is prepared in advance in
separate dosage
3. Is not capable of dispensing own medication
1
0 0
0 0
0
D. Housekeeping H. Ability to Handle Finances
1. Maintains house alone or with occasional assistance (e.g.
"heavy work domestic help")
2. Performs light daily tasks such as dish washing, bed
making
3. Performs light daily tasks but cannot maintain
acceptable level of cleanliness
4. Needs help with all home maintenance tasks
5. Does not participate in any housekeeping tasks
1 1. Manages financial matters independently (budgets, writes
checks, pays rent, bills, goes to bank), collects and keeps track of
income
2. Manages day-to-day purchases, but needs help with banking,
major purchases, etc.
3. Incapable of handling money
1
1
1
1
0
1
0
Score Score

27. Geriatric Depression Scale
(GDS) Scoring Instructions
1. Are you basically satisfied with your life?
2. Have you dropped many of your activities and
yes no
interests? yes no
3. Do you feel that your life is empty? yes no
4. Do you often get bored? yes no
5. Are you in good spirits most of the time? yes no
6. Are you afraid that something bad is going to
happen to you? yes no
7. Do you feel happy most of the time? yes no
8. Do you often feel helpless? yes no
9. Do you prefer to stay at home, rather than going
out and doing things? yes no
10. Do you feel that you have more problems with memory than most?
yes no
11. Do you think it is wonderful to be alive now? yes no
12. Do you feel worthless the way you are now? yes no
13. Do you feel full of energy? yes no
14. Do you feel that your situation is hopeless? yes no
15. Do you think that most people are better off than
you are? yes no
A score of > 5 suggests depression Total Score

31. PHYSIOTHERAPY REHABILITATION
Education to caregivers
• Explain the importance of touch as the means of communication.
• Try to know about the interests of patient such as hobby, favorite game
or favorite food.
• Use the way of communication that patient enjoys most.
• Avoid the activity that patient does not like to participate in.

32. Environmental Modifications
Goals :-
• To compensate for cognitive loss.
• Safety
• To orient them to time, the place, and care-giver identity by constant
reminders
• To improve the level of independence

33. • Music during meals and bathing
• Simulate family member’s presence with video or audio tapes
• Good, nonglare lighting
• Quiet room with no distractions such as background noise
• Low-vision aids such as magnifying glass
• A systematic storage of clothes and toilet articles
• Contrasting colors for identifying doors, windows, cupboards and
corners

34. To improve physical function (mobility, strength,
coordination)
Strength training : Resisted exercises : 10 -15 repetitions of 8-10
exercises using TheraBand, weight cuffs, light weight dumbells
Traditional Stretching Techniques:
(15 – 30 seconds hold 3-5 repetitions)
• Gentle stretching of elbow flexors,
• Hip, knee flexors and ankle plantar flexors.
PNF – Hold relax PNF technique
Physiotherapy In Dementia Jaswinder Kaur, Shweta Sharma, Jyoti MittalDepartment of Physiotherapy, Dr.
RML PGIMER & Hospital, New Delhi - 110001

35. To reduce the risk of falling and improve Gait
Balance training
• Reaching activities
• Activities on Swiss ball
• Perturbations in sitting and standing
• Heel-toe standing,
• Partial wall squats and chair rises,
• Single limb stance with side kicks or back kicks
• Marching in place

36. To improve urinary incontinence
• Pelvic floor strengthening exercise 10 reps 4-5 times per day
• Electrical stimulation
• Biofeedback

37. RECENT ADVANCE
The Effect of Electrical Muscle Stimulation on Muscle Mass and
Balance in Older Adults with Dementia
Yuichi Nishikawa et.al
Journal : Brain sciences, March 2021
CONCLUSION
These findings suggest that EMS is a useful intervention for increasing
muscle mass and maintaining balance function in olderadults with
dementia.

38. REFERENCES
• Narinder Kaur Multani, Satish Kumar Verma, Principles of Geriatric
Physiotherapy, 1st edition 2007
• Andrew A. Guccione, PT, PhD, FAPTA, Geriatric Physiotherapy 2nd
edition 2000
• Physiotherapy In Dementia Jaswinder Kaur, Shweta Sharma, Jyoti
Mittal Department of Physiotherapy, Dr. RML PGIMER & Hospital,
New Delhi – 110001
• http://nhp.gov.in/disease/neurological/dementia 16-09-2016

39. • https://www.alz.org. 2022
• Yuichi Nishikawa et.al The Effect of Electrical Muscle Stimulation on
Muscle Mass and Balance in Older Adults with Dementia Journal :
Brain sciences, 03-2021

40. Thank you