Facilitating the use of implicit memory and learning in the physical therapy management of individuals with Alzheimer disease: a case series

Research Among People Living With Dementia or Mild Cognitive Impairment in Physiotherapy Journals: A Scoping Review

BACKGROUND AND PURPOSE

Global estimates forecast an increase in the number of people living with dementia (PLWD) or mild cognitive impairment (MCI). Physiotherapists play an important role in the delivery of care to PLWD or MCI; however, physiotherapists report less confidence when working with PLWD or MCI, citing limited educational opportunities. Our scoping review sought to quantify and assess the type of research published in physiotherapy journals related to these groups of people.

METHODS

Fifteen journals were selected based on global physiotherapy representation, indexing, and online accessibility of archives. Extraction of all articles published within a decade (2011-2021) for the selected journals was completed. Inclusion criteria: (1) research reports, reviews, case studies, or expert opinion pieces related to PLWD or MCI and (2) published in English. Each article was categorized by type of article, clinical setting, type of dementia, physiotherapy focus, and Sackett's system of hierarchy of evidence. An analysis of trends over time and a bibliometric assessment of research impact were performed.

RESULTS AND DISCUSSION

Of 11 091 articles identified, 67 were included. The most common country of origin was the United States (38.8%). Articles were mainly research reports (70.1%), from a community-dwelling setting (50.8%), with a combined physiotherapy focus (28.4%), and a level IV (37.3%) of hierarchy of evidence. Close to half of studies did not identify the underlying dementia type (43.3%, n = 29), followed by people living with Alzheimer's dementia (28.4%, n = 19), combined groups of PLWD or MCI (20.9%, n = 14), and individuals with only MCI (7.5%, n = 5). Six articles on average related to PLWD or MCI were published annually (32.7 citation per article), and no growing trend was observed.

CONCLUSIONS

Few articles published in prominent physiotherapy journals over the last decade were related to PLWD or MCI. Publication trends remained unchanged, and publication origins were from the Americas which impacts generalizability. Physiotherapists should attain complementary information on care for PLWD or MCI through more general rehabilitation journals. Physiotherapy journals should seek to promote research related to PLWD or MCI through different avenues (eg, special issues) as increased information is needed for clinicians to feel confident in providing informed care.

Interventions focusing on learning pre-transfer wheelchair manipulation in a patient with severe Alzheimer's disease: a case report

BACKGROUND

Independence of transfer is important for the daily activities of wheelchair users. A critical step in performing this transfer includes a pre-transfer wheelchair manipulation, and patients with Alzheimer's disease (AD) experience difficulties in learning these tasks. In this report, we present the results of a treatment focused on learning pre-transfer wheelchair manipulation and its learning course in a patient with severe AD.

CASE DESCRIPTION

The patient was a 92-year-old woman with severe AD during hospitalization in a long-term care ward. Since her cognitive function was highly compromised, she required assistance for pre-transfer wheelchair manipulation. Physiotherapists implemented a treatment plan that incorporated post-behavioral praise into a practice combining errorless learning and spaced retrieval training for pre-transfer wheelchair manipulation.

OUTCOMES

The patient was able to accurately perform pre-transfer wheelchair manipulation in the seventh treatment session and achieved transfer independence after 12 physiotherapy sessions.

CONCLUSION

This case report suggests that practicing combined errorless learning, spaced retrieval training, and post-behavioral praise was helpful as a treatment modality for an individual with severe AD for wheelchair manipulation learning before transfer.

Examining gait aid use and user safety by older people with dementia: Perspectives of informal carers to inform practice

PURPOSE

To determine gait aid use and decision-making related to usage in people with dementia, and examine factors influencing (1) gait aid use or not; and (2) falls in past year.

MATERIALS AND METHODS

A survey of informal carers of older people with dementia in the community. Closed questions on gait aid use, falls, timing and sources of gait aid acquisition, and advice received to support use were used. Chi-squared tests (Fisher's Exact) compared: (1) gait aid users vs non-users and carers' report of (i) unsteadiness in walking/turning, (ii) dementia severity, (iii) falls in past year, and (2) fallers vs non-fallers and (i) timing of gait aid commencement relative to dementia diagnosis, (ii) whether health professional advice was received regarding use, and iii) regularity of use.

RESULTS

Forty-seven completed surveys, 63.8% of care recipients used a gait aid; 56.9% had ≥2 falls in past year; 66.7% commenced use after dementia diagnosis; 25% acquired their aids from non-health professionals; and 37% did not receive advice regarding use. Gait aid users and non-users differed on carer ratings of unsteadiness in walking/turning (p = 0.02).

CONCLUSION

Carers reported important aspects regarding gait aid acquisition, safe gait aid use and benefits which warrant further investigation.IMPLICATIONS FOR REHABILITATIONIn our small sample, use of gait aids by people with dementia was related to the level of unsteadiness in walking and/or turning, and not associated with falling in the past year.People with dementia do not routinely receive professional advice about how to use gait aids, highlighting the potential value of maximizing health professional involvement in gait aid prescription and training.Deterioration in the ability of gait aid use after the diagnosis of dementia indicates a need for re-assessment or re-training of gait aid use over time.Clinical guidelines to facilitate decision-making regarding under what conditions gait aids are beneficial, what duration and aspects require instruction to ensure effective use by people with dementia are needed.

The Potential for Effect of a Six-Week Training Program for Gait Aid Use in Older People with Dementia with Unsteadiness of Gait: A Pilot Study

This study examined the potential for effect of a six-week gait aid training program for people with dementia on spatiotemporal gait outcomes, perception of use, and falls with gait aid use. The program utilised four 30-min physiotherapy home visits, scheduled at weeks 1/2/3/6, and was enhanced by carer-supervised practice. Falls and the physiotherapist's clinical judgement of participants achieving safe gait aid use during and after the program were described. Perception ratings at each visit were measured using Likert scales which, along with the spatiotemporal outcomes using the gait aid (Time-Up-and-Go-Test, 4-m-walk-test, Figure-of-8-Walk-Test with/without a cognitive task) at weeks 1 and 6, and at weeks 6 and 12 (6-week post-program), were examined with ordinal logistic regression analyses. Twenty-four community-dwelling older people with dementia and their carers participated. Twenty-one (87.5%) older people achieved safe gait aid use. Twenty falls occurred, and only one faller was using their gait aid when they fell. Walking speed, step length, and cadence significantly improved when walking with the gait aid at week 6 compared with week 1. No significant improvements in spatiotemporal outcomes were retained at week 12. Physiotherapists were more likely to agree that gait aid use had improved walking safety among older people with dementia with subsequent training visits. Larger studies of the gait aid training program are needed for this clinical group.

Failure to improve task performance after visuomotor training with error reduction feedback for young adults

Visual feedback that reinforces accurate movements may motivate skill acquisition by promoting self-confidence. This study investigated neuromuscular adaptations to visuomotor training with visual feedback with virtual error reduction. Twenty-eight young adults (24.6 ± 1.6 years) were assigned to error reduction (ER) (n = 14) and control (n = 14) groups to train on a bi-rhythmic force task. The ER group received visual feedback and the displayed errors were 50% of the real errors in size. The control group was trained with visual feedback with no reduction in errors. Training-related differences in task accuracy, force behaviors, and motor unit discharge were contrasted between the two groups. The tracking error of the control group progressively declined, whereas the tracking error of the ER group was not evidently reduced in the practice sessions. In the post-test, only the control group exhibited significant task improvements with smaller error size (p = .015) and force enhancement at the target frequencies (p = .001). The motor unit discharge of the control group was training-modulated, as indicated by a reduction of the mean inter-spike interval (p = .018) and smaller low-frequency discharge fluctuations (p = .017) with enhanced firing at the target frequencies of the force task (p = .002). In contrast, the ER group showed no training-related modulation of motor unit behaviors. In conclusion, for young adults, ER feedback does not induce neuromuscular adaptations to the trained visuomotor task, which is conceptually attributable to intrinsic error dead-zones.

The experiences of people with Alzheimer's dementia and their caregivers in acquiring and using a mobility aid: a qualitative study

PURPOSE

Cognitive deficits and gait and balance problems are progressive in people with Alzheimer's dementia. Yet, mobility aids are associated with an increased falls risk in people with dementia. Our objectives were to identify the perceptions of people living with mild-to-moderate Alzheimer's dementia, and their caregivers, on the use of mobility aids.

METHODS

A qualitative study using semi-structured, face-to-face interviews was conducted. Community-dwelling older adults with dementia attending a day hospital program were recruited. Thematic analysis was conducted and the text was coded into broad themes aligned with the research questions. The coded text was examined for patterns and similarities, and grouped to form inductive themes.

RESULTS

Twenty-four people (12 living with dementia and their 12 caregivers) participated. Five themes were identified: (1) acknowledgement of need; (2) protecting a sense of self; (3) caregiver oversight and relief of burden; (4) healthcare professional involvement; (5) environment and design of aids.

CONCLUSIONS

The findings suggest that people with Alzheimer's dementia and their caregivers regard mobility aid use as increasing independence. There is a role for healthcare professionals to be involved in the prescription, provision and training for use of mobility aids among people living with dementia to ensure uptake and safety.IMPLICATIONS FOR REHABILITATIONMobility aid use is regarded as increasing independence by people with Alzheimer's disease and their caregivers.Falls risk associated with mobility aid use was not well known and caregivers perceived mobility aids as a means to reduce falls.Most people do not see a healthcare professional when they acquire a mobility aid and there is a role for healthcare professionals to be involved in the prescription, provision and training of people living with dementia in the use of mobility aids in order to increase the uptake of aids and their safe use.

Physical therapy in patients with Alzheimer’s disease: a systematic review of randomized controlled clinical trials

ABSTRACT The objective of this study is to evaluate the effects of physical therapy on the cognitive and functional capacity of patients with Alzheimer’s Disease (AD). This is a systematic review of randomized or quasi-randomized clinical trials, using the descriptors: AD, dementia and physical therapy. Two studies were included with a total of 207 participants. In study 1, no statistically significant difference was found on the mini-mental state examination (MMSE) (MD 0.0, 95%CI −5.76 to 5.76), neuropsychiatric inventory (MD −4.50, 95%CI −21.24 to 12.24) and Pfeffer instrumental activities questionnaire (MD 0.0 95%CI −6.48 to 6.48). In study 2, there was no statistically significant difference on the MMSE (MD −1.60, 95% CI −3.57 to 0.37), clock-drawing test (MD −0.20, 95%CI −0.61 to 0.21) and Alzheimer’s Disease Assessment Scale - cognitive subscale (MD 1.0, 95%CI −2.21 to 4.21) after 12 months. There was no consistent evidence on the effectiveness of physiotherapeutic intervention in improving cognitive function and functional capacity of patients with AD. More studies should be conducted for better evidence.

Electrophysiological repetition effects in persons with mild cognitive impairment depend upon working memory demand

Forms of implicit memory, including repetition effects, are preserved relative to explicit memory in clinical Alzheimer's disease. Consequently, cognitive interventions for persons with Alzheimer's disease have been developed that leverage this fact. However, despite the clinical robustness of behavioral repetition effects, altered neural mechanisms of repetition effects are studied as biomarkers of both clinical Alzheimer's disease and pre-morbid Alzheimer's changes in the brain. We hypothesized that the clinical preservation of behavioral repetition effects results in part from concurrent operation of discrete memory systems. We developed two experiments that included probes of emotional repetition effects differing in that one included an embedded working memory task. We found that neural repetition effects manifested in patients with amnestic mild cognitive impairment, the earliest form of clinical Alzheimer's disease, during emotional working memory tasks, but they did not manifest during the task that lacked the embedded working memory manipulation. Specifically, the working memory task evoked neural repetition effects in the P600 time-window, but the same neural mechanism was only minimally implicated in the task without a working memory component. We also found that group differences in behavioral repetition effects were smaller in the experiment with a working memory task. We suggest that cross-domain cognitive challenge can expose "defunct" neural capabilities of individuals with amnestic mild cognitive impairment.

Low Arousal Positive Emotional Stimuli Attenuate Aberrant Working Memory Processing in Persons with Mild Cognitive Impairment

Emotional enhancement effects on memory have been reported to mitigate the pathophysiology of Alzheimer's disease (AD). However, relative to their manifestation in persons without pathologic aging, these effects may be reduced in magnitude or even deleterious, especially in tasks that more closely model ecologic memory performance. Based upon a synthesis of such reports, we hypothesized that in persons with AD low arousal positive stimuli would evoke relatively intact emotional enhancement effects, but that high arousal negative stimuli would evoke disordered emotional enhancement effects. To assess this, participants with and without mild cognitive impairment (MCI) presumed to be due to AD performed an emotionally-valenced short-term memory task while encephalography was recorded. Results indicated that for persons with MCI, high arousal negative stimuli led to working memory processing patterns previously associated with MCI presumed due to AD and dementia of the Alzheimer-type. In contrast, low arousal positive stimuli evoked a processing pattern similar to MCI participants' unaffected spouses. Our current findings suggest that low arousal positive stimuli attenuate working memory deficits of MCI due to AD.

Application of motor learning in neurorehabilitation: a framework for health-care professionals

Learning motor skills is an essential part of most rehabilitation processes. Facilitating and supporting motor learning is particularly challenging in neurological rehabilitation: patients who suffer from neurological diseases experience both physical limitations and difficulties of cognition and communication that affect and/or complicate the motor learning process. Therapists (e.g. physiotherapists and occupational therapists) who work in neurorehabilitation are therefore continuously searching for the best way to facilitate patients during these intensive learning processes. To support therapists in the application of motor learning, a framework was developed, integrating knowledge from the literature and the opinions and experiences of international experts. This article presents the framework, illustrated by cases from daily practice. The framework may assist therapists working in neurorehabilitation in making choices, implementing motor learning in routine practice, and supporting communication of knowledge and experiences about motor learning with colleagues and students. The article discusses the framework and offers suggestions and conditions given for its use in daily practice.

Visuospatial function predicts one-week motor skill retention in cognitively intact older adults

Motor learning declines with aging, such that older adults retain less motor skill after practice compared to younger adults. However, it remains unclear if these motor learning declines are related to normal cognitive changes associated with aging. The purpose of this study was to examine which cognitive domains would best predict the amount of retention on a motor task one week after training in cognitively intact older adults. Twenty-one adults ages 65-84 years old were assessed with Repeatable Battery for the Assessment of Neuropsychological Status, which assesses five cognitive domains (immediate and delayed memory, visuospatial/constructional, language, and attention). Participants also completed one training session of a functional upper extremity task, and were re-tested one week later. Stepwise regression indicated that the visuospatial domain was the only significant predictor of how much skill participants retained over one week, with a visual perception subtest explaining the most variance. Results from this study support previous work reporting that older adults' capacity for motor learning can be probed with visuospatial tests. These tests may capture the structural or functional health of neural networks critical for skill learning within the aging brain, and provide valuable clinical insight about an individual's unique rehabilitation potential.

Motor priming in neurorehabilitation

Priming is a type of implicit learning wherein a stimulus prompts a change in behavior. Priming has been long studied in the field of psychology. More recently, rehabilitation researchers have studied motor priming as a possible way to facilitate motor learning. For example, priming of the motor cortex is associated with changes in neuroplasticity that are associated with improvements in motor performance. Of the numerous motor priming paradigms under investigation, only a few are practical for the current clinical environment, and the optimal priming modalities for specific clinical presentations are not known. Accordingly, developing an understanding of the various types of motor priming paradigms and their underlying neural mechanisms is an important step for therapists in neurorehabilitation. Most importantly, an understanding of the methods and their underlying mechanisms is essential for optimizing rehabilitation outcomes. The future of neurorehabilitation is likely to include these priming methods, which are delivered prior to or in conjunction with primary neurorehabilitation therapies. In this Special Interest article, we discuss those priming paradigms that are supported by the greatest amount of evidence, including (i) stimulation-based priming, (ii) motor imagery and action observation, (iii) sensory priming, (iv) movement-based priming, and (v) pharmacological priming.Video Abstract available. (see Supplemental Digital Content 1, http://links.lww.com/JNPT/A86) for more insights from the authors.

The relevance of short-range fibers to cognitive efficiency and brain activation in aging and dementia

The integrity of structural connectivity in a functional brain network supports the efficiency of neural processing within relevant brain regions. This study aimed to quantitatively investigate the short- and long-range fibers, and their differential roles in the lower cognitive efficiency in aging and dementia. Three groups of healthy young, healthy older adults and patients with Alzheimer's disease (AD) participated in this combined functional magnetic resonance imaging (fMRI) and diffusion tensor imaging (DTI) study on prospective memory (PM). Short- and long-range fiber tracts within the PM task engaged brain networks were generated. The correlation between the fMRI signal change, PM performance and the DTI characters were calculated. FMRI results showed that the PM-specific frontal activations in three groups were distributed hierarchically along the rostrocaudal axis in the frontal lobe. In an overall PM condition generally activated brain network among the three groups, tractography was used to generate the short-range fibers, and they were found impaired in both healthy older adults and AD patients. However, the long-range fiber tracts were only impaired in AD. Additionally, the mean diffusivity (MD) of short-range but not long-range fibers was positively correlated with fMRI signal change and negatively correlated with the efficiency of PM performance. This study suggests that the disintegrity of short-range fibers may contribute more to the lower cognitive efficiency and higher compensatory brain activation in healthy older adults and more in AD patients.