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Dementia
 is a common condition that affects about 800,000 people in the UK. Your
risk of developing dementia increases as you get older, and the condition
usually occurs in people over the age of 65.
 Dementia is a syndrome (a group of related symptoms) associated with
an ongoing decline of the brain and its abilities. This includes problems
with:

memory loss

thinking speed

mental agility

language

understanding

judgement
 People with dementia can become apathetic or uninterested in their usual
activities, and have problems controlling their emotions. They may also
find social situations challenging, lose interest in socialising, and aspects
of their personality may change.
 A person with dementia may lose empathy (understanding and
compassion), they may see or hear things that other people do not
(hallucinations), or they may make false claims or statements.
 As dementia affects a person's mental abilities, they may find planning
and organising difficult. Maintaining their independence may also
become a problem. A person with dementia will therefore usually need
help from friends or relatives, including help with decision making.
Type of Dementia
Alzheimer's disease
Characteristics
Most common type of dementia;
accounts for an estimated 60 to 80
percent of cases.
Symptoms: Difficulty remembering
recent conversations, names or events is
often an early clinical symptom; apathy
and depression are also often early
symptoms. Later symptoms include
impaired communication, poor judgment,
disorientation, confusion, behavior
changes and difficulty speaking,
swallowing and walking.
Revised criteria and guidelines for
diagnosing Alzheimer’s were published in
2011 recommending that Alzheimer’s be
considered a slowly progressive brain
disease that begins well before
symptoms emerge.
Brain changes: Hallmark abnormalities
are deposits of the protein fragment
beta-amyloid (plaques) and twisted
strands of the protein tau (tangles) as
well as evidence of nerve cell damage
and death in the brain.
Vascular
dementia
Previously known as multi-infarct or
post-stroke dementia, vascular dementia
is less common as a sole cause of
dementia than Alzheimer’s, accounting
for about 10 percent of dementia cases.
Symptoms:Impaired judgment or ability
to make decisions, plan or organize is
more likely to be the initial symptom, as
opposed to the memory loss often
associated with the initial symptoms of
Alzheimer's. Occurs because of brain
injuries such as microscopic bleeding and
blood vessel blockage. The location,
number and size of the brain injury
determines how the individual's thinking
and physical functioning are affected.
Brain changes: Brain imaging can often
detect blood vessel problems implicated
in vascular dementia. In the past,
evidence for vascular dementia was used
to exclude a diagnosis of Alzheimer's
disease (and vice versa). That practice is
no longer considered consistent with
pathologic evidence, which shows that
the brain changes of several types of
dementia can be present simultaneously.
When any two or more types of
dementia are present at the same time,
the individual is considered to have
"mixed dementia" (see entry below).
Dementia with
Lewy bodies
(DLB)
Symptoms: People with dementia with
Lewy bodies often have memory loss and
thinking problems common in
Alzheimer's, but are more likely than
people with Alzheimer's to have initial or
early symptoms such as sleep
disturbances, well-formed visual
hallucinations, and muscle rigidity or
other parkinsonian movement features.
Brain changes: Lewy bodies are
abnormal aggregations (or clumps) of
the protein alpha-synuclein. When they
develop in a part of the brain called the
cortex, dementia can result. Alphasynuclein also aggregates in the brains
of people with Parkinson's disease, but
the aggregates may appear in a pattern
that is different from dementia with Lewy
bodies.
The brain changes of dementia with
Lewy bodies alone can cause dementia,
or they can be present at the same time
as the brain changes of Alzheimer's
disease and/or vascular dementia, with
each abnormality contributing to the
development of dementia. When this
happens, the individual is said to have
"mixed dementia."
Mixed dementia
In mixed dementia abnormalities linked
to more than one type of dementia occur
simultaneously in the brain. Recent
studies suggest that mixed dementia is
more common than previously thought.
Brain changes: Characterized by the
hallmark abnormalities of more than one
type of dementia —most commonly,
Alzheimer's and vascular dementia, but
also other types, such as dementia with
Lewy bodies.
Parkinson's
disease
As Parkinson's disease progresses, it
often results in a progressive dementia
similar to dementia with Lewy bodies or
Alzheimer's.
Symptoms: Problems with movement
are common symptoms of the disease. If
dementia develops, symptoms are often
similar to dementia with Lewy bodies.
Brain changes: Alpha-synuclein clumps
are likely to begin in an area deep in the
brain called the substantia nigra. These
clumps are thought to cause
degeneration of the nerve cells that
produce dopamine.
Frontotemporal
dementia
Includes dementias such as behavioral
variant FTD (bvFTD), primary
progressive aphasia, Pick's disease and
progressive supranuclear palsy.
Symptoms: Typical symptoms include
changes in personality and behavior and
difficulty with language. Nerve cells in
the front and side regions of the brain
are especially affected.
Brain changes: No distinguishing
microscopic abnormality is linked to all
cases. People with FTD generally develop
symptoms at a younger age (at about
age 60) and survive for fewer years than
those with Alzheimer's.
Creutzfeldt-Jakob
disease
CJD is the most common human form of
a group of rare, fatal brain disorders
affecting people and certain other
mammals. Variant CJD (“mad cow
disease”) occurs in cattle, and has been
transmitted to people under certain
circumstances.
Symptoms: Rapidly fatal disorder that
impairs memory and coordination and
causes behavior changes.
Brain changes: Results from misfolded
prion protein that causes a "domino
effect" in which prion protein throughout
the brain misfolds and thus malfunctions.
Normal pressure
hydrocephalus
Symptoms: Symptoms include difficulty
walking, memory loss and inability to
control urination.
Brain changes: Caused by the buildup
of fluid in the brain. Can sometimes be
corrected with surgical installation of a
shunt in the brain to drain excess fluid.
Huntington's
Disease
Huntington’s disease is a progressive
brain disorder caused by a single
defective gene on chromosome 4.
Symptoms: Include abnormal
involuntary movements, a severe decline
in thinking and reasoning skills, and
irritability, depression and other mood
changes.
Brain changes: The gene defect causes
abnormalities in a brain protein that,
over time, lead to worsening symptoms.
WernickeKorsakoff
Syndrome
Korsakoff syndrome is a chronic memory
disorder caused by severe deficiency of
thiamine (vitamin B-1). The most
common cause is alcohol misuse.
Symptoms: Memory problems may be
strikingly severe while other thinking and
social skills seem relatively unaffected.
Brain changes: Thiamine helps brain
cells produce energy from sugar. When
thiamine levels fall too low, brain cells
cannot generate enough energy to
function properly.
Physiotherapy Interventions
Aims of Physiotherapy
1. To improve physical function (mobility, balance, coordination and strength).
2. To reduce risk of falls - changes in judgement and spatial control contribute
to tendency to fall. Exercises improve balance and reduce the fear of falling.
3. To lift mood, ease stress and add calm – Exercises help to reduce the
incidence of depression, agitation and aggression symptoms that are common
with dementia patient
4. To improve general cardiovascular health.
5. To pass time in enjoyable way-provide a sense of accomplishment from the
person with dementia.
6. To improve sleep - sleep disorders are common in dementia patients.
Exercise can help them get into normal sleep routine
7. To slow mental decline – exercise seems to slow brain atrophy especially in
the hippocampus, which influence memory and spatial navigation
An exercise routine should be composed of:
1. Flexibility exercises for Musculoskeletal System:
Exercises increases joint range of movement and muscle strength making daily
tasks easier(4 type of exercise It includes:)
I. Both active and passive ROM (Range of Movement) exercises
• Exercises should focus on strengthening the patient weak elongated extensor
muscles while ranging the shortened tight flexors muscles.
• ROM exercise should be also emphasize restoring range in the neck and trunk
and can be performed in combination with rotational exercises to promote
relaxation
II. PNF (Proprioceptive Neuromuscular Facilitation) Pattern: Muscle
inhibition techniques Hold Relax or Contract Relax.
 Contract Relax is the preferred technique because it combines autogenic
inhibition from isometric contraction of the tight agonist muscles with active
rotation of the limb.
III. Traditional Stretching Techniques:
• Gentle stretching of elbow flexors, hip, knee flexors and ankle plantar flexors.
• Stretching can be combined with joint mobilisation techniques to reduce
tightness of the joint’s capsule or of ligaments around a joint.
• Autostretching or Self-stretching
• Maintain the stretch force atleast 15 – 30 seconds. Ideally the stretches are
repeated atleast 3-5 times.
• Ballistic stretches (high intensity bounding stretches) and aggressive stretch
should be avoided.
2. Balance Training:
It is important in patients with dementia to improve confidence and reduce the
risk of falling. As balance is position specific so both standing and sitting
balance exercises are encouraged. Right movement and frequency of exercises
are suggested by trained physical therapist. They help the patient in improving
general body coordination and provide better sense of surrounding space and
environment.
• The balance training always begin from lower COG (Centre of Gravity) to
higher COG.
• Training should begin with weight shifts in both sitting and standing in order
to help the patient develop an appreciation of his limits of stability.
• By giving the slight push to patient and patient tries to maintain the balance.
• Reaching activities.
• Activities on Swiss ball.
• Kitchen sink exercises: The patient can be instructed heel-toe standing, partial
wall squats and chair rises, single limb stance with side kicks or back kicks and
marching in place, all while maintaining light touch down support of the hands
3. Strength Training:
It helps in building lean muscle mass, increasing metabolism, controlling blood
sugar levels. Ideally 10-15 repetitions of 8-10 exercises should be performed
thrice a week. Resistance may be applied with therabands, light weight
dumbells etc.
4. Gait Training:
Gait re-education helps in improving mobility and functional ability without
support. The major goals are to lengthen stride, broaden BOS (Base of Support),
improve stepping, improve heel–toe gait pattern, increase contralateral
movement and arm swing and provide a programme of regular walking.
• Weight transfer; standing on single limb
• High stepping to strengthen the flexors.
• Side stepping or crossed stepping with or without support.
• PNF activity of braiding, which combines side to side stepping with alternate
crossed stepping to improve the lower trunk rotation with stepping movement.
• Normal heel-toe progression.
• To overcome shuffling pattern, draw foot marks or parallel lines with red or
yellow colours; then ask the patient to walk on it.
• The patient should practice stopping, starting, changing direction.
• Auditory cues can be effective in improving gait. Turning of 180 degree
should be practiced first then 360 degree.
5. Aerobic Exercises:
Aerobic training helps in improving cardiovascular health, strength the
hormones immune system. As physical activity decreased beta-amyloid proteins
leading to decreased amyloid plaque. Neural disruption, hence improving brain
health.
Aerobic exercise includes jogging, cycling, swimming or any physical activity
that rejuvenate the patients pulmonary and cardiac capacity. For maximum
benefits 30 minutes session thrice a week is advised.
Patients can start with 10 -20 minutes sessions depending on fitness levels and
can progress accordingly. Alternative exercise form such as dancing could be
included in aerobic exercises.
It is good for people who find standard exercises and weight training boring. It
can help dementia patient in reducing some of the mobility problems that arise
due to other ailments.
6. Improve urinary incontinence:
Eitiology of incontinence in dementia is multi-factorial. Comprehensive
assessment of factors within and outside the urinary tract is essential.
Management techniques include toileting, medication, physiotherapy, surgery,
and other devices. Physiotherapy includes pelvic floor muscle exercises, bio
feedback, and electrical stimulation.