FACILITATING OPTIMAL INTERACTIONS
Establishing and maintaining a therapeutic relationship with individuals who have AD can be challenging, especially as dementia progresses, but there are many strategies to facilitate success in this endeavor and there is evidence that even late in the disease, a therapeutic connection is possible (Williams
& Tappen, 1999). Prioritizing a “relationship focus” over a “task focus” will better engage clients, facilitating improved participation and outcomes. This requires attention to the immediate practice environment, the manner of communication, and the skill of optimally cueing clients. Communication with individuals who have AD should be simple and direct without being condescending; therapists are sometimes guilty of infantilizing individuals with AD and should be mindful to avoid this. The complexity of conversations and commands can easily be modified to meet the needs of each client, but it is good practice to initially simplify verbal instructions. Facial expressions and body language that are consistent with oral expressions can facilitate optimal communication. Table 6 offers tips for creating a successful therapeutic environment and relationship (Dawson, Gerhart, & Judge, 2017; Fazio, Pace, Flinner, & Kallmyer, 2018; Haak, 2002; Hauer et al., 2012; Heliker, 2009; Hernandez, Coelho, Gobbi, & Stella, 2010; Kovach & Henschel, 1996; Ries, 2018; Sadowsky & Galvin, 2012; Small, Gutman, Makela, & Hillhouse, 2003; E. R. Smith et al., 2011; Stinson, 2000) Music may be a useful adjuvant component to the therapeutic environment, although this may need to be evaluated on a case-by-case basis. Moving or exercising to music may facilitate more participant engagement and movement if the music is well chosen. Frank Sinatra and big band music may not be the optimal choice for the aging baby boomer generation; the increasing numbers of individuals with AD may better relate to the Beatles and the Rolling Stones! There is limited study of the use of music in conjunction with exercise or dance for this population (Low et al., 2016; Satoh et al., 2014; Spildooren, Speetjens, Abrahams, Feys, & Timmermans, 2018), but anecdotally and intuitively, the integration of music into therapeutic interventions may be a useful strategy.
Optimizing environment, communication, and the therapeutic relationship Therapeutic or exercise interventions may take place in a variety of environments, and the comfort of the participant in the given environment is pivotal to the success of the program. Interventions may be in the form of individual physical therapy treatments (e.g., inpatient, outpatient, or home care), caregiver- guided home exercise programs, community-based small group exercise programs, or group exercise programs in long-term care settings. Each setting has benefits and limitations; for instance, the home environment is familiar and comfortable, but it may
have limits related to space or equipment, and it sacrifices the social benefit of community-based group activities. Adult daycare centers are excellent locations for group exercise classes because the community-dwelling participants are a captive audience and are already familiar with the environment. Establishing excellent therapeutic relationships with individuals who have AD requires assuring that individuals’ immediate needs are met (e.g., toileting, thirst, hunger) prior to a therapy session and an investment in learning about a client’s personal and family history. By encouraging a client to talk through a reminiscence (e.g., “Tell me about when you flew planes in the Navy,” “What did you love about teaching?”), therapists can establish a connection that grounds the therapeutic relationship. By knowing family members’ names and bits of information, therapists can help clients to see that there is one team of people working together (e.g., “Your daughter Susan will be thrilled to hear how well you’re doing in exercise class!”).
Table 6: Creating a Successful Therapeutic Environment and Relationship Optimal Characteristics and Tips for Success
References
The environment should be low stress. Avoid agitation, frustration, and fear, which are often caused by confusion/not knowing what to expect.
• Familiar and consistent setting. • Familiar and consistent people.
Kovach & Henschel, 1996; Ries, 2018; Sadowsky & Galvin, 2012; Small, Gutman, Makela, & Hillhouse, 2003; Smith et al., 2011; Stinson, 2000.
• Safe, calm, and predictable. • Little or no distracting stimuli. • Use redirection and refocusing as necessary. • Consistent timing so the program is part of the routine. • Capitalize on social interaction.
The therapeutic relationship should be prioritized over the task.
• Establish an excellent rapport. • Understand client’s personal and family history (which requires investment in information gathering). • Use names of family members, pets, and friends in conversation. • Talk through a reminiscence. • Attend to emotional needs of client with reassurance, respect, and empathy. • Build on interests and cognitive strengths of the individual. • Reward successes. • Smile. • Consciously simplify interactions as needed (e.g., yes-or-no questions, choice of two activities). • Use pleasant but firm voice commands when trying to elicit a response (avoid elevating intonation at the end of an instruction – this implies that a question is being asked and can be confusing). • Instruct toward meaningful (functional) goals versus abstract (nonfunctional) actions. • Provide clear, objective, repetitive instructions. • Gestures, demonstrations, tactile cues, and reassuring touch can be useful communication strategies. • One-step commands (unless capable of more) • Direct, friendly eye contact and facial expression • Avoid asking, “Do you remember . . . ?” • Position self at eye level to communicate.
Fazio et al., 2018; Haak, 2002; Hauer et al., 2012; Heliker, 2009; Hernandez, Coelho, Gobbi, & Stella, 2010; Kovach & Henschel, 1996; Ries, 2018; Sadowsky & Galvin, 2012. Dawson, Gerhart, & Judge, 2017; Haak, 2002; Heliker, 2009; Kovach & Henschel, 1996; Ries, 2018; Small et al., 2003; Smith et al., 2011; Stinson, 2000.
The communication strategies should be simple and direct.
Note . From Western Schools, 2020.
EliteLearning.com/Physical-Therapy
Book Code: PTNY3622B
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