The degradation of gait performance in dual-task, as compared to single-task, conditions has been repeatedly demonstrated in normal and cognitively impaired older adults (Allali & Verghese, 2017; Mesbah, Perry, Hill, Kaur, & Hale, 2017). Generally, a superimposed cognitive task (e.g., naming animals, counting backwards) will have a more substantial impact on gait than a physical task (e.g., carrying a glass of water). Vidoni, Thomas, Honea, Loskutova, & Burns (2012) demonstrated altered Postural control, balance, and falls Research has consistently shown postural control impairment in persons with MCI and dementia, and this is well represented in review studies (Cieślik, Jaworska, & Szczepańska-Gierach, 2016; Mesbah et al., 2017). Degree of postural instability increases as level of cognitive impairment increases, although supportive data for this is primarily in the form of cross-sectional studies as opposed to longitudinal studies. Early in MCI, force plate analysis or computerized posturography may be necessary to identify subtle postural control deficits; as cognitive decline progresses, postural dysfunction is evident on clinical tests (e.g., Berg Balance Scale). The importance of visual input to support upright posture in older adults with cognitive deficits is apparent; that is, eyes closed conditions lead to exaggerated instability as related to age-matched cognitively intact peers. Additionally, and not surprisingly, dual task/divided attention conditions have the same effect, resulting in amplified postural instability. A recent publication by Szczepańska-Gieracha, Cieślik, Chamela- Bilińska, and Kuczyński (2016) confirmed these review study findings and also studied the impact of providing visual feedback in static stance (i.e., standing on a force plate and looking at an eye-level monitor, participants were instructed to keep the Apraxia Apraxia presents as difficulty planning and executing desired motor tasks in the absence of blatant motor or sensory system dysfunction and can substantially impact daily functional tasks. This is usually assessed through observing the pantomimed use of tools or objects and the performance of meaningful and nonmeaningful gestures. A comprehensive literature review on apraxia in AD reveals that, despite the fact that apraxia had long been a diagnostic component for AD, it is not well understood or sufficiently studied (Lesourd et al., 2013). Dementia severity is considered a primary risk factor for apraxia; studies have consistently demonstrated increasing prevalence of apraxia with progressive levels of dementia (Smits et al., 2014; Stamenova, Roy, & Black, 2013). Clinicians need to recognize that one in Tone issues Paratonia is a unique presentation of hypertonia characterized by involuntary variable resistance to passive movement that increases with the progression of dementia (Hobbelen, Koopmans, Verhey, Van Peppen, & de Bie, 2006; Vahia, Cohen, Prehogan, & Memon, 2007). The diagnosis of paratonia is based on the presence of all of the following: ● Involuntary variable resistance during passive movement. ● Absence of clasp-knife phenomenon (an upper motor neuron sign of initial resistance followed by freedom of movement in an extremity, reminiscent of the closing of a pocket knife). ● Resistance to passive movement in any direction. ● Resistance felt in one limb in two movement directions or in two different limbs. ● Degree of resistance that correlates with speed of movement (e.g., less resistance to slow movement, greater resistance to fast movement). These criteria make up the Paratonia Assessment Instrument, which has been deemed valid and reliable in individuals with dementia (Hobbelen, Koopmans, Verhey, Habraken, & de Bie, 2008). One objective of this tool is to differentiate paratonia from rigidity and spasticity. Paratonia, sometimes referred to as Gegenhalten tone or “motor negativism,” may be present in any of the dementias, and risk factors may include vascular
corticomotor function with simple motor task performance early in the course of AD. It is not clear if this altered, more widespread pattern of motor recruitment is related to inefficiency or compensation, but the authors suggest that this may explain degradation in performance related to dual tasking in individuals with AD, in that the altered motor recruitment for single tasks may leave limited resources for more complex dual tasks. screen image of their center of pressure within a central square). While this use of visual feedback improved postural stability for the cognitively intact control group, it had the paradoxical effect of decreasing stability in the cognitively impaired group. It is unclear if this was due to the added cognitive burden of the task or an underlying disturbance in the balance control system. Community-dwelling older adults with dementia fall two to three times more frequently than their cognitively intact age- matched peers and are more likely to be hospitalized and experience greater morbidity and mortality associated with falls (Finkelstein, Prabhu, & Chen, 2007; Frytak et al., 2008; Shaw, 2002; Tinetti, Speechley, & Ginter, 1988). The etiology of falls in individuals with dementia is complex and multifactorial. Decreased gait performance (specifically decreased speed and increased variability) and balance impairment are significant risk factors for falls in older adults with AD and other dementias (Allali & Verghese, 2017; Dolatabadi, Van Ooteghem, Taati, & Iaboni, 2018). Other risk factors include history of falls, use of an assistive device, increasing age, and psychotropic drugs (Fernando, Fraser, Hendriksen, Kim, & Muir-Hunter, 2017). three individuals with AD may present with apraxia (Ozkan, Adapinar, Elmaci, & Arslantas, 2013; Smits et al., 2014). The ability of patients to imitate an activity demonstrated by the therapist and to mimic or perform functional ADL and self- care activities in the context of therapy may be influenced by apraxia. If apraxia appears to be a factor in the management of a particular client after allowing a reasonable time for the client to carry out a movement or skill in response to instruction, gesture, or demonstration, an alternate method of instruction may be indicated. Tactile guidance is a constructive therapeutic strategy to manage apraxia, with the goal of tapering the guidance with repetitive task efforts. etiology of dementia and diabetes mellitus (Hobbelen, Tan, Verhey, Koopmans, & de Bie, 2011). As it progresses, paratonia can complicate the ability to assist functional movements and can ultimately lead to immobility and contractures. Passive ROM is ineffectual in impacting paratonia (Hobbelen, Tan, Verhey, Koopmans, & de Bie, 2012). Mobilizing individuals with advanced AD and paratonia can be extremely difficult; however, movement and function may be facilitated more easily by exploiting the presence of this unique tone. For example, in assisting a client to move forward in a chair in preparation for standing, the therapist may intuitively assist by “pulling” the individual forward with hands placed on the posterior aspect of the shoulders. A client with paratonia will respond by “pushing” backward into the cue of the hands so he or she is pushing back into the chair rather than moving the upper body forward; in effect, the therapist and client are fighting each other. If the therapist modifies his or her hand placement to be on the anterior aspect of the client’s shoulder, the client with paratonia will respond by “pushing” into the pressure of the hands, facilitating movement in the proper direction to achieve forward weight shift in preparation for mobility (Figure 4).
EliteLearning.com/Physical-Therapy
Book Code: PTNY3622B
Page 13
Powered by FlippingBook