Physiotherapists play an important role for people living with dementia both in the community and residential aged care environment. Physiotherapists are experts in the assessment and analysis of human movement and the musculoskeletal structures causing movement impairments and pain.
In Residential Aged Care Facilities (RACF), physiotherapists work with the Resident and their family/caregivers through the progressive stages of dementia with particular focus on the progressive decline of their physical ability to walk, maintain balance and communicate their pain. The physiotherapist will utilise a range of assessment and intervention approaches to best address the individual Resident’s needs as dementia progresses. The physiotherapist’s role is an integral part of a RACF team approach to support the Residents living with dementia, the care they need with dignity and enhance their quality of life.
The team approach ensures that care provided is individually tailored to the Residents needs. The team all play a part in providing a comfortable, enabling and safe environment that supports their individual level of independence and engagement. To support the Resident’s wellbeing and quality of life, the team collaborate to establish supportive interactions and engagement with the Resident through meaningful communication and listening skills, and monitoring their daily behaviours, physical capacity and interests.
The physiotherapy assessment identifies the Resident’s physical, functional and cognitive capacity, possible musculoskeletal pain and other health status limitations to determine the individual’s level of independence and engagement in activities of daily living (ADL). Assessments for newly admitted RACF Residents will often require ongoing periods of brief assessments, as the Resident may have an impaired ability to engage in lengthy assessments. Physiotherapists utilise their experienced human movement observation skills to determine the Residents individual abilities and limitations, level of insight to their personal safety and falls risk, and determine if and how pain impacts their physical capacity and their ability to engage in meaningful activities such as group exercises. If the Resident has an impaired level of personal safety which places them at risk of falls, the physiotherapist works with &/or educates care staff to set up safe physical spaces within their environment to enable the Resident to maintain and safely support their level of independence.
As dementia progresses, the individual often displays an increased difficulty (and frustration) in communicating their needs, pain, feelings and thoughts. For Residents living with dementia, physiotherapists utilise pain assessment tools such as the Abbey Pain Scale and where available in RACFs, the PainChek App to accurately assess pain for Residents who are unable to express/communicate their pain.
PainChek can be used to record pain via the Numerical Rating Scale (NRS) or Abbey Pain Scale, which is the pain assessment tool for those with non-verbal dementia. Some RACFs have introduced the PainChek App which utilises AI driven facial recognition technology (via smart phone &/or tablet) which looks at the Resident’s face and analyses the facial muscle movements indicative of pain. This enables an objective outcome measure which graphically records pain in real-time. Along with RNs, physiotherapist now utilise PainChek for all pain management interactions with Residents where available in RACFs. The following example describes how physiotherapist combine their physical assessment with PainChek for Residents living with dementia.
At each physical assessment, the physiotherapists assess pain via the PainChek App and its inbuilt six pain assessment parameters pre & post movement or intervention. The six pain assessment parameters include: face (e.g. brow lowering, tightening of eyelids), voice (e.g. noisy pain sounds, crying), movement (e.g. guarding/touching body part, abnormal sitting/standing/walking), behaviour (e.g. fear or extreme dislike of touch, people, distress), activity (e.g. resisting care, altered routines), and body (e.g. profuse sweating, rapid breathing) during the pain assessment to determine if pain is a contributing factor to the Residents behaviour challenges.
Often Residents living with Dementia are referred to Dementia Support Australia (DSA) when the Residents displays challenging changes in their behaviour that impact on their care. DSA providers may also liaise with physiotherapists regarding changes in the Residents physical mobility and pain that may be impacting on behaviour changes.
Following the DSA Report, the physiotherapist will conduct a musculoskeletal pain assessment with the Resident. The pain assessment is usually conducted over several days at different times of the day to capture the Residents pain response during ADLs, mobility, activities and during episodes when challenging behaviours are displayed. This involves a collaborative team approach with the RN, care staff and Leisure & Lifestyle team.
Following the physiotherapists musculoskeletal pain assessment with PainChek, the physiotherapist will liaise with the RACF team to recommend how care needs can be provided to address and minimise the musculoskeletal pain experienced by the Resident. Some examples include dressing sequencing, sitting posture support, reviewing fall prevention strategies and providing supported opportunities to mobilise &/or exercise throughout the day.
Along with pain management, more research is required to better understand the relationship between exercises and dementia. Engaging Residents living with Dementia in regular exercise and movement is a key recommendation to reduce cognitive decline (dementia.org.au/risk-reduction), improve &/or maintain physical capacity and overall wellbeing. Physiotherapists prepare and provide group exercise programs for Residents living with dementia. In some RACF, this is in conjunction with the Leisure & Lifestyle Team.
For Residents who have difficulty engaging in the group environment, the physiotherapist will initially provide a 1-on-1 exercise/mobility program for the Resident with the aim of progressing to the exercise group. For example, Mr H displayed resistance to care and chose to remain in his room throughout the day, leading to prolonged periods of isolation. However, he was receptive to a daily walk in the garden with his physiotherapist who developed a trusting rapport with Mr H, enabling him make supported decisions. As trust and rapport continued to develop, the physiotherapist would ask Mr H if he wanted to increase the daily walking distance and walk past Residents participating in Leisure & Lifestyle activities. Mr H gradually agreed, with his daily walk now including a seated rest break whilst watching the group activities. Over a couple of weeks, this progressed to Mr H initiating sitting with group and participating for short periods. Along with supporting Mr H’s physical mobility, the physiotherapist had developed a trusting rapport with Mr H, enabling her to identify the changes in his behaviour that displayed he ‘had enough’ of the group and wanted to return to his room. During this progression, the physiotherapist shared and discussed her approach and observations for Mr H with care staff and the Leisure & Lifestyle team, forging a continuity of care team approach to support Mr H, minimise his resistance to care, reduce long periods of isolation in his room and improve his overall wellbeing and quality of life.
In summary, physiotherapist play a key role in supporting both the Residents living with dementia and the RACF team to provide individualised care, comfort and quality of life through meaningful and structured opportunities to remain physically, mentally and socially engaged.
Madelyn Nicole
Physiotherapist, Clinical Manager (PCare).
References:
Dementia Australia https://www.dementia.org.au/
Dementia Support Australia https://www.dementia.com.au/
PainChek https://www.painchek.com/
Aged Care Research & Industry Innovation Australia (aria) https://www.ariia.org.au/knowledge-implementation-hub/dementia-care/dementia-care-evidence-themes/physiotherapy