Table 3: Six Care Domains for Persons with Alzheimer’s Disease • Domain 1: Patient function Patient is functioning at maximum level of independence consistent with physical potential and patient and caregiver wishes. • Domain 2: Caregiver support Caregiver (or caregivers) identified and given information and support to best balance his or her caregiver role and personal life in accordance with personal needs and wishes of caregiver. • Domain 3: Medical care Patient receives optimal medical care consistent with accepted standards of care and patient and caregiver preference. • Domain 4: Psychosocial Patient and caregiver understand monitoring parameters to assess mood and behavioral concerns and are satisfied with employed management strategies. • Domain 5: Patient nutrition Patient is in targeted body weight range, and patient and caregiver are satisfied with diet and nutritional status. • Domain 6: Advance directives planning Patient and caregiver understand purposes of advance directives, living will, and durable power of attorney for health care; the patient enacts them according to his or her personal values and needs and, ultimately, the caregiver sees that his or her wishes are followed. Note . Adapted from Chronic Care Networks for Alzheimer’s Disease. (2003). Tools for early identification, assessment, and treatment for people with Alzheimer’s disease and dementia . Retrieved from http://www.alz.org/national/documents/brochure_toolsforidassesstreat.pdf. Reprinted with permission. MOVEMENT DISORDERS ASSOCIATED WITH ALZHEIMER’S DISEASE
Once believed to occur late in the course of the disease, movement disorders, particularly gait changes, are now recognized to occur with MCI and early in the course of dementia (Bridenbaugh & Kressig, 2014). In fact, there is convincing evidence that subtle subclinical gait changes Gait Normal aging brings about predictable gait changes. Older adult gait is not simply a slower version of young adult gait. The following temporal, spatial, and postural changes have been repeatedly evidenced in systematic reviews of gait changes with aging: ● Decreased self-selected gait speed. ● Decreased step and stride length. ● Increased stance time and double-limb support time. ● Increased step width (not a universal finding across studies). ● Increased variability of gait (operationally defined as variability in step or stride time, length, or width). ● Decreased excursion of movement at lower extremity joints. ● Decreased reliance on ankle kinetics and power. ● Less upright posture. (Beauchet et al., 2017; Boyer, Johnson, Banks, Jewell, & Hafer, 2017; Herssens et al., 2018) In comparison to cognitively intact older adults, individuals with dementia often demonstrate exaggerated gait findings, including gait that is slower and more variable than their age- matched peers (Bridenbaugh & Kressig, 2014; Mc Ardle et al., 2017).
(temporal-spatial parameter changes that are evident on a computerized walkway but not to the naked eye) are predictive of cognitive decline in older adults (Beauchet et al., 2016; Kikkert, Vuillerme, van Campen, Hortobágyi, & Lamoth, 2016; Valkanova & Ebmeier, 2017). A safe and skillful gait requires some level of executive functioning. In neurological physical therapy, there was much excitement in the 2000s related to the new use of partial body weight supported treadmill training and the ability to exploit spinal cord central pattern generators (CPGs) to facilitate walking on a treadmill without higher cortical control (i.e., in the presence of spinal cord injury). Functional ambulation in a busy or complex environment cannot be driven by CPGs alone and requires higher cortical activity in the form of executive functions, including planning, divided attention, judgment, problem solving, and cognitive flexibility. Montero- Odasso, Verghese, Beauchet, & Hausdorff (2012) developed a schematic demonstrating the integration of gait and cognition degradation with age (Figure 3). Their model acknowledges that cognitive impairment and gait impairment have historically been viewed across separate and distinct continua, but they suggest that the two are interconnected. This concept is well substantiated in current literature, which demonstrates a strong association between executive functioning and falls (Kearney, Harwood, Gladman, Lincoln, & Masud, 2013; Montero-Odasso & Speechley, 2018).
Figure 3: Relationship Between Gait and Cognition
(A) shows a traditional conceptual model of parallel decline of gait and cognition. (B) shows the current interrelated model of decline of gait and cognition.
Note . From Montero-Odasso, M., Verghese, J., Beauchet, O., & Hausdorff, J. M. (2012). Gait and cognition: A complementary approach to understanding brain function and the risk of falling. Journal of the American Geriatrics Society, 6 0(11), 2127-2136. Copyright 2012 by John Wiley & Sons. Used with permission.
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