Rehabilitation and physiotherapy for people with dementia
Dementia can affect your ability to move around and participate in activities. Each person experiences the dementia differently, but you might experience physical changes like:
- slower reaction time
- weaker muscles
- poor co-ordination
- trouble doing more than one thing at a time, like carrying a cup of tea while walking
- balance problems, including falls.
You might also experience trouble with finding your way around, identifying objects and communicating.
There are many ways to get help with these issues. In this video, Professor Lee-Fay Low, discusses rehabilitation for people with dementia, including:
- cognitive therapies
- occupational therapy
- exercise therapy
- psychological therapies.
Lee-Fay Low is joined by Dementia Advocate Bobby Redman, talking about her own experience, including practical tips.
Transcript
[Beginning of recorded material]
[Title card: Dementia Australia]
[Title card: Moving forward with dementia using rehabilitation]
[Title card: This presentation was recorded on unceded Gadigal land. I acknowledge the traditional owners, Elders past, present, and emerging]
Professor Low: Hello, I'm Lee-Fay Low. I work as a professor in ageing and health at the University of Sydney. In this webinar, I'm going to share some of the scientific evidence of the benefits of rehabilitation for people with dementia, and talk about how you or the person you look after can get services to support their rehabilitation. I'm not going to start, as many dementia talk starts, with pictures of brains. If I show you a picture of a brain, it's just going to reinforce the idea that we need to just treat the brains of people with dementia. I want us to think about treating people with dementia holistically. So, people with dementia are people. And while changes to their brains may be the source of the disease, their day-to-day problems relate to symptoms of dementia.
We know, from our research, that it's the impact of dementia on daily life that makes dementia challenging for people with dementia. People with dementia find it harder to complete their day-to-day tasks of living, like paying bills, or emailing friends, driving safely, or socialising. Some people with dementia tell us they feel confused because the world is harder to understand, and that navigating the world with a cognitive disability can be exhausting. For some people with dementia, being given the label of having dementia is upsetting. So, let's think about dementia as a disease that causes cognitive disabilities that make it harder to do daily activities.
Rehabilitation can help maintain or compensate for these daily difficulties. I'd like to introduce Bobby Redman, a friend and colleague who actually lives alone with dementia. Bobby has developed her own rehabilitative program, which helps her maintain her function, and supports her through her daily difficulties.
Bobby: I looked at all the research and the things that, first of all, that are designed as risk reduction, but I also think slow down the process. So, I've modified my diet, although, I didn't eat badly, but I have no simple sugars and things like that now. I live alone, and I say my technology is my primary carer.
I started off with my phone, we all now live with smartphones and are getting much more comfortable with them, I've found that my planning went out of the window, so I would have the normal regular alarm goes that it's time to go for an appointment, but I would recognise that it was time to go for my appointment, but I hadn't thought about anything that led up to that, so I might still be in the middle of my breakfast and not had a shower because I hadn't planned how it was going to work. So, I now have my phone set up with step-by-step. My kitchen, I've taken photographs of the insides of all my cupboards, and I have those stuck on the outside. So that helps me to put things in the right place and to find things again.
Lee-Fay: So what is rehabilitation? Some of you are probably wondering why we have Bobby talking about diet, technology, or how she's got her kitchen arranged. You're wondering what relevance this has to rehabilitation. Well, these are all examples of rehabilitation for someone with dementia. Many people think of rehabilitation as physical rehabilitation – so the physical work that happens after an injury or stroke. This is one form of rehabilitation, but rehabilitation is much more, much broader than that.
The World Health Organisation definition of rehabilitation says that rehab helps us manage symptoms and changes associated with illness and disability. This includes prevention of the loss of function, slowing the rate of loss of function, compensation for loss of function, or maintenance of current function. So, we want to do all these for people with dementia – these strategies might include something like exercise which helps maintain brain health, either slowing the rate of loss of function, or maintaining current function, it might include use of taxis or public transport to compensate for not being able to drive anymore, a lost function. It might include technology such as glasses, which is my way of compensating for loss function, my eyesight. Other simple technologies might include calendars, phone reminders. Bobby talked about these as using these technological strategies to help her maintain her current function.
Kate Laver and I compiled a book which brings together the evidence for rehabilitation for people with dementia. Today, I'm going to share some of the key learnings from that book. I'm particularly going to talk about less commonly offered rehabilitative therapies for people with dementia in Australia. These particularly relate to physical activity, cognitive interventions, occupational therapy, and psychological therapies. My first takeaway is be physically active. Exercise might help people with dementia by improving the circulation of blood and oxygen to the brain, it can also help by improving heart and physical health, and by improving mood.
Bobby: I’m trying to exercise more. I've never been much of an exerciser, but I get out there and I try to exercise on a regular basis. My mobility is failing, I fall quite a lot. So, I now see a physiotherapist on a fortnightly basis who gives me a range of exercises that I practise in the fortnight. She's very good, and she prints the exercises out for me so that I've got a worksheet to work from. And then, she adds things to it each time I go, or takes things off and changes it around. And that, I believe, is helping to keep me moving.
Lee-Fay: The research tells us that physical exercise works for people with dementia. Physical exercise has been shown to reduce decline in global cognition and working memory, though there's less evidence for other types of cognitive function. Exercise also reduces behavioural changes in dementia, though these reductions are small. The evidence suggests that aerobic exercise at moderate intensity or more, or total training of over 24 hours in total, has greater effect on global cognition. In practise, people with dementia should try and keep physically active. Ideally, this means regular moderate intensity exercise. This means exercise that gets your heart beating faster, such as swimming, or brisk walking, walking upstairs or walking up a slope, or cycling. There's also growing evidence for the benefits of resistance or strength training for people with dementia – so this might mean using weights, or your own body weight, in order to build muscles. Unfortunately, in Australia, there are few dementia-specific exercise services. Look to local seniors’ exercise groups, walking clubs, or even gyms who are supportive of older people.
If you need help to start exercising safely, if you're worried about falling or your heart as you start to exercise, then see a physiotherapist or exercise physiologist after talking to your GP. You can get subsidised visits to physio or exercise physiology through a GP chronic disease management plan, so talk to your GP about this. If you have a community care package, this can also fund access to allied health, such as the physio, exercise physiology, or even help you get to and pay for an exercise group – so ask your community care case manager about this. You might also be able to access a falls prevention program such as Stepping On. These are commonly offered across the states, and are offered to people at high-risk of falls, or who have already fallen. The next lesson from our research is that people with dementia should be mentally and socially active.
Bobby: I do a whole range of mental stimulation with the computer, word games, and Sudoku, and Wordle, and Word Finder, all the different things. Try to work out for myself where the gaps are, where I'm struggling with things, and find something to do. So, my processing speed is very slow now, so I do things, games that I have to do against the clock to try and make myself think better, and I honestly believe that makes a big difference for me.
Lee-Fay: Bobby talked about her own brain training program. Brain training are tasks designed to target one or more cognitive processes. These might include short-term memory, memory for faces, attention, or speed. Brain training usually involves repeated practise of these tasks, these exercises, and more and more often, these tasks are computerised rather than done using pencil and paper. The research tells us that brain training has small to moderate effects on global cognition after the training, and this is maintained three to 12 months later. It also has a moderate effect on speech and language. What we know about brain training is that if you train one area of the brain, so if you are practising your working memory, this doesn't generalise to other aspects of the brain. So, your working memory will improve but your speed and processing won't improve, unless you specifically train speed and processing as well.
Brain training programs are best done under the supervision of a psychologist or neuropsychologist, who can tailor the program to your specific cognitive disabilities or cognitive needs. In Australia, at the moment, it's hard to find a brain training program offered by a psychologist. Here are some brain training programs that you can pay for and do at home with some evidence. These are CogniFit, Happy Neuron, and Brain HQ. Cognitive stimulation therapy is a group social program of enjoyable activities. These activities have been created to stimulate and target different aspects of memory and thinking, including concentration, attention, orientation. Typically, these programs go for about seven weeks, twice a week.
In cognitive stimulation therapy, you might discuss daily affairs, play games, talk about your life, even do some simple maths. There is consistent evidence in the research that cognitive stimulation therapy has moderate effects on global cognition, memory, day-to-day functions or daily tasks of living, and depression. Again, there are few organisations offering cognitive stimulation therapy here in Australia. You might be able to go to a group social program which might have some benefits, and you can access these via the Commonwealth Home Support program.
Cognitive rehabilitation is an individual program where the person is given training and support to achieve their own daily function goals. So, goals might be being able to read their email and use their email again, strategies to feel confident to go out alone, be able to cook a meal without getting distracted, maintaining the ability to keep dressing yourself, or managing difficulties with swallowing. The few studies that have been done so far on cognitive rehabilitation suggests that, after the training, there are large positive effects for the person being able to reach their goals, and this is corroborated by what the carer says.
So, here are my takeaways for staying cognitively and socially active – exercise different parts of your brain, and try to do this every day. This might include playing different types of thinking games such as a crossword or bingo. It also probably includes socialising and talking to different people, which again, stimulates different parts of your brains. Travel, getting out to new places is another great way of stimulating different bits of your brain as well. And lastly, people say, "I do lots of crosswords. Is this good for me?" And I always say, "Well, if you do crosswords, it just stimulates one bit of your brain. So that bit of your brain's going to get really good at doing crosswords, but you need to exercise your whole brain if you want to strengthen all of it." Now, I want to encourage you to think about getting occupational therapy.
Occupational therapists are allied health professionals – so trained health professionals – who help people maintain, or even improve, in activities of daily life. This means doing things around the house, but also out and about in the community. And occupational therapy is all about making sure that you have an engaged and meaningful life. The research is strong for occupational therapy. It shows that occupational therapy for people with dementia improves overall daily function, so ability to do daily tasks. Also reduces behavioural changes in dementia, and improves quality of life. Carers involved in occupational therapy studies with people with dementia say that they've spent less hours helping the person with dementia, they're less distressed or upset by behavioural changes in dementia, and they have improved quality of life.
Bobby: I had an OT come to do an assessment, but unfortunately, she was really much more knowledgeable in the areas of mobility and physical stuff, rather than cognitive stuff, so she really wasn't able to offer me anything.
Lee-Fay: As Bobby told us, sometimes, in Australia, it's hard to find an OT, or occupational therapist, who has experience in supporting people of dementia. Try and get one with experience in dementia. There are a few ways you can get funding for occupational therapy for dementia in Australia. You can ask your GP and get it partially funded through a GP chronic management plan. If you go to hospital, you might be able to get occupational therapy as part of your transitional care plan. Occupational therapy can also be funded through your home care package, might be subsidised by your private health insurance, and you can sometimes find OTs through community rehab services. Go to the Occupational Therapy Australia website to find OTs with a specialisation in ageing, and you might also be interested in checking out the COPE Australia website – COPE is an OT program specifically for people with dementia.
The last type of rehabilitative service I'm going to talk about are psychological therapies. I like to think about them as talking therapies, the way you talk about your feelings, the issues you're having, and try to come to some solutions, or resolutions as to those feelings and difficulties. There are many types of psychological therapies. This includes CBT, or cognitive behavioural therapy, which you've probably heard of in relation to mental health, but also applies to people with dementia. Might include problem-focused therapies where we specifically try to solve problems during therapy, and more generic counselling.
The research tells us that cognitive behavioural therapy reduces depression and anxiety symptoms in people with dementia who started off with these symptoms. The research also tells us that the more broad family of psychological therapies improves depression symptoms for people with dementia. If you're interested in getting psychological therapies for dementia, your first port of call is probably Dementia Australia. They offer counselling, including post-diagnostic support counselling for people with dementia and carers. If you have dementia and also mental health issues, ask your GP about a mental health plan. Under the mental health plan, you get subsidised visits to see a psychologist about your mental health issues. If you are a person with dementia who's interested in learning from other people with dementia, then you should get in touch with Dementia Alliance International. This is an organisation run by people with dementia, for people with dementia, and they run peer support groups online.
In this webinar, I gave you an overview of some of the rehabilitative strategies which are helpful for people with dementia. If you want to know more information, please go to our website, Forward With Dementia. This is a guide to living with dementia. Our website has three sections, one specifically for people with dementia, one for carers, and one for healthcare professionals. Our website has a specific section on supporting wellbeing of people with dementia, and a focus on rehabilitative strategies. You can go there for more of the scientific information about the evidence for rehab strategies, as well as more tips on how to advocate for yourself to get these rehab strategies. Unfortunately, they're not routinely offered in practise yet.
Bobby: None of this information has come from professionals. It's really been my own research and my own work that has identified what I need to do. My background as a psychologist, my professional knowledge has helped me put together strategies to get me through. My biggest worry really is for all these people that don't know these things, because it's now coming six years since my diagnosis, and I believe I'm doing okay, thanks to a lot of stuff that I've got in place.
Lee-Fay: As My final message is that I've met many wonderful people with dementia and their carers, and those people with dementia, like Bobby, have put in their own rehab programs and are living well with dementia. So, I hope this webinar helps you, a little bit, to figure out what your rehab strategy could be. And for more information, of course, please go to our Forward With Dementia website.
[Title card: www.forwardwithdementia.org.au]
[Title card: Together we can reshape the impact of dementia]
[Title card: Dementia Australia. 1800 100 500. Dementia.org.au]
[END of recorded material]
Physiotherapy
Physiotherapy can be a very useful part of managing your life with dementia. A physiotherapist can help you with things like:
- early post-diagnostic clinical care, to help optimise brain health, strength and balance through rehabilitation, exercise and physical activity
- training families and carers to help with enablement or reablement activities
- providing advice about aids like walking sticks or frames
- providing advice about complicated movement issues including use of machines such as wheelchairs and mechanical hoists
- working with families or carers to address changed behaviours that may relate to unmet needs
- assessing non-verbal signs of pain and collaborating with other health professionals and carers to effectively manage pain and enhance quality of life
- providing clinical care and rehabilitation for other physical conditions, like stroke or arthritis.
Physiotherapists are experts in prescribing tailored, purposeful and meaningful activities and exercises for you. They can work with you individually or as part of a team to support your physical and cognitive needs.
Physiotherapy can help improve your quality of life and independence by:
- improving your motor skills, like gait and balance
- reducing your frailty
- reducing your number of falls and fractures
- slowing your cognitive decline
- improving your cognition, agitation and mood.
Early intervention with physiotherapy is the key to assessing, treating and achieving positive outcomes but studies have shown that access to physiotherapy is not offered in a timely manner for people with dementia.
To find out how you can start working with a physiotherapist, talk to your doctor.
Transcript
[Beginning of recorded material]
[Title card: Dementia Australia]
[Title card: Physiotherapy and Dementia]
Dr Tan: Physiotherapy and dementia. This is a webinar for people living with dementia, and their family, carers, and support persons in Australia. Before we start, I would like to have an acknowledgement of country, and I wish to acknowledge the traditional owners of the land on which this webinar has been created. I would like to pay my respects to the Elders past, present, and emerging, and any Elders who may be here with us today.
My name is Joanna-lee Tan. You can call me Jo. And I'm a titled Gerontology Physio, which means I have a specialisation in working conditions related to ageing. And my role with the Australian Physiotherapy Association is the National Chairperson of the Gerontology Group. Our group has put together this webinar to help people who are living with dementia, and to help people understand what physiotherapy can help people with. This webinar will talk about the physical impacts of dementia on the body, the role of physiotherapy in helping people overcome some of these difficulties, and how to access physiotherapy.
The physical impacts of dementia are not always the most obvious part of the condition. A lot of people focus on memory changes, or difficulty speaking, or other issues like that, but sometimes, the physical aspects are also a part of the condition, and that's where physiotherapy comes in. So, some of the physical aspects are related to changes in the person's brain, and they can impact your physical function because the brain is responsible for controlling the body and how it moves.
One of the things you might notice is that the body is a bit slower to react to changes in surfaces, or if you need to move quickly. The brain is also responsible for controlling our muscles, so the way the brain connects to the body is through the nerves that come from the brain to the muscles, and the brain needs to tell those muscles what to do. So, if there's a difficulty in connecting to the muscles, they're not going to be getting as many information messages, which can make them feel a bit weaker. And this can also be a similar feeling in terms of how muscles and joints coordinate each other to move the body.
There's also some difficulty when you need to move your body but you're also having to do other things. We call that multitasking. A common thing might be if you are walking while carrying something, for example, a cup of tea, or if you are having to reach for something while stepping at the same time, stepping over objects, looking around to see what's coming your way. Those kind of combination movements can be a bit of a problem. And because of all of this, an aspect of both reaction times, strength and coordination, sometimes people living with dementia can have problems with their balance, and they may experience falls like everybody else.
I'll give you an example of how this can impact your physical function in terms of just a simple act of going for a walk. So, how do you think these dementia symptoms might affect your ability just to go for a walk? We all like to go for a walk. It's a very common form of exercise, but when we're out walking, there's things that can challenge us. As you can see here on the slide, there's some people riding their scooters coming along. They might be coming along while you are having a nice walk, and you don't notice them because you're concentrating on the pathway, and that could be a little bit unsettling. Also, when you're going for a walk, the surfaces are not always nice and smooth, so the picture on the right you can see is pretty challenging. There are some long steps going up a hill, so walking's not always a simple activity. However, physios like to work with people to help them overcome some of these challenges. We know that our brain health can be optimised. What that means is that certain activities can help promote our brain working more efficiently. One of them might be improving your cardiovascular fitness. That's exercises where you are getting more oxygen to your brain, like going for a faster bike ride, like an exercise bike, you get your heart rate up, and that actually improves your blood flow to your brain.
These muscles that might be a little bit harder to control can actually be strengthened by doing specific strength exercises. So, when a muscle is contracted, it forms new connections with the brain as the brain tells it what to do. And the more of these contractions, the muscle grows, making it stronger. Balance is also something that we can be improving all the time, because balance is always that combination of messages to the body and the body reacting. And certain balance exercises practised regularly can improve your balance. So having a good, fast working brain is optimised, getting lots of blood muscles that are strong, and balance mechanisms within your body optimised, all of those things can actually contribute to a person maintaining their strength, fitness, and independence.
Physios do quite a bit of research, particularly around falls and balance, but in many other fields. And what physios have been really interested in is doing a lot of research on the aspects of the physical changes related to dementia. And what we have been finding is that people who do regular strength exercises, which include resistance training and balance, will improve their balance, and that can actually reduce falls. We do know that if you have a fall, obviously, there's a chance that you might injure yourself. So, making sure that you do everything you can to reduce these falls is actually going to be a very good option.
Physios also work together on other aspects of keeping people away from being injured when they have fall. So, if you are concentrating on your environment, and you are learning about moving in your environment, that will actually help reduce your chance of falling as well. What we've found is by doing the regular exercise, you can also slow the decline in cognitive function. So, by keeping all these connections going and making the brain work harder, it actually keeps the brain working, and reduces some of the changes that might occur over time. All of these interventions can actually help people generally feel better, and maybe they're thinking about other aspects in their life like being able to remember things can improve as well.
Physiotherapy like to be involved in the full healthcare assessment of someone who has a diagnosis of dementia, so it doesn't always happen, but we're promoting that as part of this collaboration with Dementia Australia. We are part of your health team, so your health team you might think is your GP, maybe your specialist, a trusted nurse that you see, but we'd like you to think about including physiotherapy in your health team. We do work with other allied health professionals, so traditionally, you might think about a speech pathologist is an allied health, or an occupational therapist, podiatrist, we're all part of those additional health professionals that can really help to optimise someone's health and wellbeing.
We do an assessment as part of our normal process whenever we see anyone for any condition, and we'd like to think of our assessments as being holistic, taking the time to address physical issues, discuss any emotional or thinking issues, and when we are working about a program, we are going to work together with you. We are very famous for helping people with their pain. So, everyone has aches and pains, but obviously, physiotherapy is a profession specialised in pain management. Apart from thinking about issues related to strength and balance, we are there to help people who have pain. And also, sometimes, some pains we are not sure what they're all about, and that helps us to talk to you about different types of issues that you might be having, and that might help you organise your day so that we can actually work out what times a day you're getting pains or other issues, and try and build a program around that.
As I've said, physio can help. We've got exercise and mobility programs, specialised balance classes. You might find these in the community, in your local council, physios might be running classes there, they might be running them in your local community health program. Sometimes, in residential aged care, we run exercise and balance classes. So we're not just seeing people one-to-one, we also see people in groups. We like to help people be out and about safely, so we are pretty good people to talk to about using walking sticks or specialised walking frames just to help people who might have difficulty with their balance and they need a little bit of extra help.
When people have various conditions or if you've been in hospital, if you've had joint surgery, or you've had another problem that's led to needing some rehabilitation, physios are also part of that team, and you may encounter some physios if that happens. If you happen to feel like you need some rehabilitation because you've had some time off from being sick, for example, like a lot of people had Covid, and that actually resulted in them feeling a bit weaker, or breathing problems, physiotherapists have been really active in helping people recover from Covid, and the associated ailments related to that.
We talked about pain, but one of the main issues that people have that can cause pain is arthritis, and we like to help people manage arthritis by giving them special exercises and advice. We also sometimes provide massage or other therapeutic techniques to relieve pain related to arthritis. Also, making sure you're addressing any physical issues relating to your body can help improve your mood and you feel happier if you're not worried about aches and pains, or worried about falling over. And also, it might help you sleep better. So, we know that if you exercise regularly, you do actually usually sleep better.
I talked about walking aids. In this picture here, you can see this is one of my clients, he's using a larger style walking frame, and these kind of walking frames are really good for outside if you are in the yard, or if you are going out walking in the community. But there's other kinds of aids that are smaller, more compact. We have some smaller ones that are good for carrying things if you feel like you're a bit struggling with your balance while you're carrying something in the house, there's some types of frames to help with that. Some frames have chairs on them so if you get tired you can have a rest, and the most important thing with walking frames is to get them properly fitted, because if the handles are at the wrong height, it can really interfere with the way you use it, but it might give you some shoulder pain.
Now, the other thing, physios, you can see them in a clinic, you can see them in a hospital, but they can also come to you. So, if you are feeling like it's difficult to get out of the house, or you haven't got transport, physiotherapists can do home visits. And when we come to someone's home, it's really nice because we get to feel what's important to a person in their home. We can look at their environment, we can make suggestions about navigating around your house safely. We can work with occupational therapists to talk about if any specialised equipment or rails might need to be put in, just to improve the safety in your home.
Balance and falls, we talked about that. And this lady here is doing some specialised balance exercises, and it's never too early to start practising your balance. Some people might have previously done something like yoga or Tai chi, and those activities do improve your balance because part of the exercises usually include balance activities, and working on your balance can help reduce falls.
One of the things when we talk about exercise and fitness is to think about what things you like to do. A lot of times, people have particular sports or activities they've played throughout their life, and it's really those activities that we like people to think about continuing to do, because that's important for your quality of life. So, if you find that some of the symptoms relating to dementia are affecting your ability to interact with regular sports or activities, it could be that you might want to adapt some of those activities to make them still a part of your life. An example might be if you've liked playing golf, and you find walking around the golf course a little bit tiring because you're concentrating while you're playing, having someone or yourself use a buggy might be a way of making that round of golf a little bit easier, and you'll still get the enjoyment of the activity, but it might not be taking as much out of you.
Another example might be if you've played karate, done karate in your lifetime, but it's a little bit fast-paced for you, so stepping to something like Tai Chi, which might be a similar activity but a little bit slower pace, helps to keep your balance and strength, but it's probably a little bit slower, and a little bit easier to participate in. So, what we're talking about is modifying the way you do things, still doing them, but modifying them. And that can be a way of maintaining your connections with the activities you enjoy, especially if you are able to negotiate with those people that you're doing these activities with to help them understand how they can help you as well.
The other thing is getting involved with family and friends, so participating together when we do activities can actually help you feel a bit more confident when you're doing them, and you can enjoy them because you're having fun with your friends and family. I love this picture. Here's a couple that, it looks like they were washing up, and the music might have come on, and they said, “Let's have a dance.” And that's one way of just still being physically active, but you're not actually doing a specific activity. It's just popped into your day spontaneously. But certainly, music and dance are something most of us enjoy, and it can be an easy way to get your body moving. And when you're moving, you are releasing a lot of positive chemicals in your brain, and that can make you feel happier, and also has some aspects of an exercise, it gets your blood flowing, it gets your joints moving, you can feel more free, might even be working on your balance. So, just a simple thing like having a dance in your house is a way of getting moving and exercising.
Getting access to physiotherapy can be a little bit challenging, sometimes. So, we've put some website information on the Dementia Australia homepage there, but I'd like to explain a few ways you can get access to physio. In terms of people who see a specialist and they might be having some tests related to being diagnosed with dementia, some of these clinics exist where there's a multidisciplinary team, and a physio might be part of that team, and they might do some assessment of physical function, balance, coordination, strength, and then work with that team to come up with, perhaps, what we call a rehabilitation plan.
There are private physiotherapists. There's probably one on most street corners these days but private physiotherapists can be accessed without a GP referral. Now, if you have private health insurance, that can cover some of the costs towards going to see the private physio, and that can actually be a way of getting to see someone for a number of visits or ongoing care. Medicare is something that has an aspect for physiotherapy, but you need to speak to your doctor, and they do a plan so you can see a physio that way. Hospitals also have some option to see a physiotherapy through their outpatient, or there's some community systems through My Aged Care that allow access to physiotherapy. NDIS for younger people is another option, if you have a package that can include physiotherapy care, and also in a residential facility there's usually a physio there.
So, it's important to ask for physio for yourself and your carer. Everyone can have different reasons to see a physio, but sometimes, they don't get referred. If you're not sure, you can speak to your doctor, or if you're in hospital for something, you can ask the people in the hospital, you're in the residential care or you have an aged care package. The people who look after you can help you access physio. I love this photo, I reckon it's somewhere very mountainous, but they've put in lots of different roads to get through this pass in the valley. And I think that's a good reflection on what this process of navigating our way through life is like. There are many different paths you can take, but what we'd like to say as physios is we're here to help you navigate some of these paths, so I'd like to thank you for listening today, and I hope I've given you some ideas about what physiotherapy can do for people who are diagnosed with dementia. And if you'd like to access a physiotherapist, our Australian Physiotherapy Association has a website with some resources there at choosephysiotherapy.com. And if you want any more information, you can have a look on the Dementia Australia information page relating to this webinar. Thank you very much.
[Title card: Together we can reshape the impact of dementia]
[Title card: Dementia Australia. 1800 100 500. Dementia.org.au]
[END of recorded material]
Occupational therapy
Occupational therapists (OTs) can help you stay independent by helping you with techniques, equipment and support for your day-to-day activities and home life.
Dementia Australia has a support service where occupational therapists will help you make your home more dementia-friendly.
Transcript
[Beginning of recorded material]
[Title card: Dementia Australia]
[Title card: How occupational therapy can assist you]
Christina: Hello, and thank you for joining this webinar on occupational therapy and dementia. Before we begin today, and in keeping with Occupational Therapy Australia's commitment to reconciliation and respect, I would like to acknowledge the traditional custodians of country throughout Australia and their connections to the land, sea, and community. We pay our respects to their Elders past, present, and emerging, and extend that respect to all Aboriginal and Torres Strait Islander people with us today.
Firstly, let me introduce myself. My name is Christina Wyatt, and I'm an occupational therapist and a professional practise advisor for Occupational Therapy Australia. Occupational Therapy Australia are the national peak professional association for occupational therapists and students in Australia. We are a member based not-for-profit organisation, and we provide support and services to our members, enabling them to work across a diverse range of practise areas, and with a diverse range of people.
Today's webinar is all about how occupational therapy can support someone living with dementia. During this session, I plan to take you through some points about what we know of dementia, introduce the role of occupational therapy to you, discuss the many ways in which occupational therapists work with people living with dementia, and provide some advice about services and resources that can support someone with a dementia diagnosis to receive the right services, including occupational therapy.
So what is dementia? Dementia itself is not a single specific condition. Rather, it's an umbrella term for a large number of conditions that gradually impair brain function. Impairments or changes caused by dementia can include cognition, language, memory, perception, personality, behaviour, and mobility, and other physical impairments. Dementia is now the third leading cause of disease burden in Australia. Up to 472,000 Australians are living with dementia, and more than half of the people in residential aged care have a dementia diagnosis.
There are several risk factors for dementia. Age, for example, is a well-known risk factor for dementia, with the risk doubling every five to six years for people over 65. Having said that, ageing is not a determinant of developing dementia, and in some circumstances, dementia can develop in people under 65, known as younger onset dementia. Age is classified as a non-modifiable risk factor, but there are many other risk factors for dementia that can be minimised known as modifiable risk factors. A recent report presented by The Lancet Commissions identified 12 modifiable risk factors for dementia, with these risk factors accounting for around 40% of worldwide preventable dementia. Key modifiable risk factors include hypertension or high blood pressure, hearing impairment, smoking, obesity, depression, physical inactivity, diabetes, social isolation, excessive alcohol consumption, traumatic brain injury, and air pollution.
The main types of dementia include: Alzheimer's disease, a degenerative brain disease caused by nerve cell death resulting in shrinkage of the brain; vascular dementia, a disease that is mainly caused by issues with blood flow to the brain through events such as stroke or bleeding into or around the brain tissue; dementia with Lewy bodies, a disease caused by degeneration and death of nerve cells in the brain due to the presence of abnormal spherical structures that develop inside the nerve cells called Lewy bodies; and frontotemporal dementia, a disease that is caused by progressive damage to the frontal and/or temporal lobes of the brain.
Dementia can also be associated with other conditions such as Parkinson's disease, Huntington's disease, and Down Syndrome. As mentioned earlier, prolonged substance abuse and severe brain injuries are risk factors for dementia and can lead to specific types of dementia. Having multiple types of dementia at once is also common, and is referred to as mixed dementia. Dementia can present differently from person to person, and for some individuals, from day-to-day. Dementia progression and symptoms can vary due to personal characteristics like age and health conditions, type and severity of dementia, with some dementias presenting with particular symptoms, age at diagnosis, and personal circumstances like care and living arrangements or access to health services.
Despite the variations in symptom, presentation, and progression, all cases of dementia will eventually result in cognitive and physical decline. Dementia-related symptoms are often grouped into three stages: mild, moderate, and advanced dementia. Occupational therapists work with people across all stages of dementia to help mitigate the impact symptoms have on daily life. Early intervention is key to maintaining function and independence for as long as possible.
The first stage of dementia is mild dementia. It is defined by subtle changes to cognition or behaviour, but because many people still retain independence in basic activities of daily living, these changes may not be recognised as dementia and are instead attributed to old age. As mentioned earlier, the onset of symptoms may differ or be gradual. These symptoms can include forgetfulness and confusion, irritability and appearing more apathetic, poor judgement and decision making, disinterest in activities, vision or speech problems, behavioural changes, and a decline in higher order or more complex activities of living like finances, planning, and organising self and others.
The next stage is moderate dementia. Symptoms in this stage are more distinct, an impact on key activities of daily living such as driving and preparing meals. In addition to these symptoms and the ones outlined earlier, moderate dementia symptoms may include increased fear and paranoia, increased forgetfulness and confusion, inappropriate or uncharacteristic behaviours, and loss of function.
Advanced dementia is the final stage of dementia in which health and functional ability decline such that the person becomes more dependent on others for their activities of daily living like dressing, bathing, and toileting. The person may experience severe memory loss, problems with communication, difficulty swallowing, incontinence, decreased mobility, or complete immobility in the final months or weeks of life. Most people in advanced stages of dementia require extensive care, often from permanent residential care settings.
So, who are occupational therapists and how can they help someone live with dementia? Occupational therapists work to maximise a person's active enjoyment in life by identifying barriers to participation, and by building strategies to minimise any risks or impediments to participation. To achieve this, we apply a person-centred and holistic approach to our practise. What does those words mean? Well, it means we consider all the aspects that make up a person, and all the life roles they find meaningful. We then work on strategies to achieve optimal health and well-being through participation in these meaningful occupations of life.
When occupational therapists use the term occupation, we aren't talking about paid work. The term occupation is used to describe all the everyday things we do in our life, all the things we do to be who we are, all the things we do to create a meaningful life, and all the things we do so we can engage with the wider society and culture. These meaningful activities might include the routine daily tasks we do to take care of oneself and others, work or volunteering activities, activities where we engage with others socially, or activities that allow us to participate in hobbies or leisure pursuits.
For people living with dementia, an occupational therapist can support you in maintaining your independence and quality of life for as long as possible. Occupational therapists apply a strength-based approach when working with people with a focus on fostering personal goals, abilities, and motivations. We break down all the meaningful tasks or occupations to fully appreciate what the task involves, and what it requires of someone. We also consider the environment, and how it may support or hinder a person's ability to perform their meaningful occupations. These environments may range from a person's home, through their work, social, or community settings.
How do we do this? Well, as mentioned earlier, occupational therapists take a holistic approach. We do this by fully exploring the person, their environment, and their support systems, and the activities or occupations that are important or meaningful to them. Through these key parameters, we can truly appreciate all the facets that make up an individual. There are many ways occupational therapists can support a person with dementia, and these will often interact and overlap.
I'll now take you through the key areas of a person's life that an occupational therapist might address when working with someone living with dementia. People with dementia might start to struggle to do their daily activities like personal care, meal preparation, or housework. In these circumstances, occupational therapists might adopt a variety of strategies to ensure ongoing safe participation in daily activities.
We might look to retrain a person on how to perform a certain activity to highlight their abilities and to mitigate any risks. We may train carers on how they can assist someone to safely undertake certain tasks. Small aids or equipment may be prescribed to facilitate participation like long handled showering aids, or dressing aids, or toileting aids. We may also modify the environment to make it easier or safer for someone with dementia to participate in these activities of daily living.
As function deteriorates, a person with dementia might need their environment altered to allow. them to safely navigate and use the space, or to support them to participate as safely and independently as possible in their meaningful activities. These changes, as mentioned earlier, are usually done in consideration of the way a person is performing the task, anticipated changes to function that may come with the dementia diagnosis, and carer support requirements. Changes can be small like increased lighting along passageways to facilitate night access to toilets, through to more complex changes like major modifications to spaces like bathrooms.
Changes to a person's memory, ability to make decisions, or coordinate themselves to perform regular daily activities is a common presentation for someone with dementia. People with dementia may also experience behaviour changes as a result of cognitive changes. Occupational therapists can work with the person, and their family or carers, to identify solutions to compensate for the cognitive changes being experienced, and provide strategies to utilise their strengths so they can continue to engage in their meaningful activities.
Strategies, such as calendars, diaries, and building daily routines, can often be very helpful for someone living in the early stages of dementia. More structured supports may be considered in the moderate stages, such as alarms or digitised diaries to remind people of their important daily activities. Signage or colour coding of the environment can also be used to help guide people with moderate dementia through their environment.
People living with dementia may experience physical decline and loss of functional mobility. Functional mobility relates to someone's ability to perform routine movements, such as transfers on or off furniture, or navigation of steps or stairs, and deficits in these areas can negatively impact someone's ability to participate in various meaningful activities.
These changes might be related to the type of dementia someone has been diagnosed with or related to other health conditions they have that are exacerbated by dementia. Much like the strategies covered in daily activities or environment, occupational therapists can assist with prescription of small aids or equipment, environment modifications, falls and balance prevention strategies, or exercise and activity redesign or retraining. Enabling a person to live with dementia to maintain relationships with family, friends, and colleagues, or connections to their community of interest is really important, so is creating opportunities to make new connections if former ones drop away. Occupational therapists often work in the context of meaningful activities to facilitate or enhance connection with others.
Occupational therapists will assist a person's ability to access their community whether that be by driving or by using public transport options, consider their cognitive or language impairments, and how this might impact on their ability to connect with others, and may consider new ways of staying connected like digital or virtual methods, particularly during times like these of pandemic and quarantine.
Recreational and leisure activities are an important part of many people's lives, and the ability to perform these activities impact on our quality of life and well-being. Occupational therapists will often work with people experiencing dementia, and their carers or families to ensure they can maintain their recreational and leisure pursuits. This might include strategies to support access to these activities with and without carer support, ways to continue to participate, including activity modification or aids and equipment, or ways to open up new opportunities for recreational leisure when dementia-related deficits may prevent someone from participating in long-held pursuits.
Occupational therapists can provide support to those caring for someone experiencing dementia. We have a role in supporting carer well-being and safety. Occupational therapists might provide stress management techniques, or mindfulness training to those carers who need the support, in addition to linking carers with professional services, such as specialist carer support agencies or counselling support. Occupational therapists can also ensure carer safety and well-being by ensuring the environment is set up to facilitate safe delivery of care, and through the training of safe manual handling techniques.
Occupational therapists often work as part of a multidisciplinary approach to dementia. Multidisciplinary teams that support people with dementia often involve other medical and allied health professionals, such as physiotherapists, speech and language therapists, dietitians, podiatrists, nurses, and psychologists. Strategies and interventions recommended by occupational therapists may be designed and delivered following collaboration and consultation with other allied health and medical professionals. Occupational therapists can help connect people with dementia to other health professionals if they haven't yet been, to ensure the holistic needs of the person are being best addressed.
There are a number of different ways people experiencing dementia can access occupational therapy services. The My Aged Care website provides a referral point for older people to access assessment and funding for the allied health services they need, including occupational therapy. The process involves firstly registering, then undertaking an assessment from which referrals for necessary services will be generated. This can include referrals to health professionals like occupational therapists, or to other services like home-based support or respite care.
Allied health services provided in the community are funded in a variety of ways: through federal aged care funding, eligible to those registered with My Aged Care and assessed as needing those services; through a GP chronic disease management plan or mental health plan, and they offer Medicare-subsidised allied health services for physical or mental health needs; and through state government funded programs by community health services. A discussion with your GP will help you determine which services you're eligible for, and we’ll assist you with the necessary steps and referrals to access these services.
Department of Veteran Affairs cardholders may be eligible for occupational therapy services. A referral from your GP, a medical specialist, or your hospital treating doctor is required. A call to the Department of Veteran Affairs is encouraged to confirm that your card entitles you to occupational therapy services. Those with private health insurance may have coverage that funds occupational therapy or facilitates access to health and wellbeing programs that include occupational therapy. Other people may opt to arrange private occupational therapy services with local providers. Occupational therapists are also involved in providing specialist services in programs like movement disorder clinics, behaviour support services, or pain management programs. A GP or medical specialist would be best placed to identify and refer to these specialist services.
It is worth noting that there are a number of services available outside of those described earlier that are specifically for people living with dementia. These services often work alongside, collaborate with, and compliment services provided by an occupational therapist. These include the National Dementia Support Program, a government initiative predominantly delivered by Dementia Australia that offers information, education programs, services and resources aimed at improving awareness and understanding about dementia, so that people living with dementia and their families can make informed decisions about the support services they access.
Dementia Australia is the national peak body for people of all ages living with all forms of dementia and their family and carers, and they offer a number of programs and services. Some worth noting include the National Dementia Australia Helpline, a free service for anyone affected by dementia to seek support and advice, and the Dementia-Friendly Communities program, providing resources, services, and strategies for individuals, communities, and groups to better support people living with dementia in the community.
Dementia Support Australia is a national service held by HammondCare, and they offer expertise in dementia care across three key programs. The Dementia Behaviour Management Advisory Service provides client-focused information, assessment, and advice to both staff and carers supporting people with dementia across community, acute, and residential care settings. The Severe Behaviour Response Team is a 24/7 mobile workforce aimed at providing assessment and tailored recommendations to support people experiencing severe behaviours or psychological symptoms of dementia living in eligible residential care settings. The Needs Based Assessment program identifies those who are eligible to receive the specialist dementia care program. This program offers individualised care to those experiencing severe behavioural psychological symptoms of dementia, who cannot be cared for in a mainstream residential care facility. The program aims to reduce or stabilise the behavioural or psychological symptoms, so that people can move back to less intensive care environments.
Some other services that aren't dementia specific but are worth noting include the "Find an OT" service offered by Occupational Therapy Australia. This service helps people locate a private occupational therapist with specific skills or clinical expertise in their area. As explained earlier, the Department of Veteran Affairs can be a source of funding for occupational therapy input to those who are eligible. The Australian Government Care Gateway is a service designed to support those acting in a carer role. They offer resources and links to services to provide support to carers Australia-wide. As mentioned earlier, the My Aged Care is the key gateway for older Australians to access aged care services and funding nationwide.
Occupational therapists work across and within many of the programs described, so it is important for people living with dementia to understand what they may be eligible for, and who can best support their needs. We welcome any questions that you might have of us as occupational therapists, and you may contact us at our Occupational Therapy Australia service. We look forward to hearing from you and wanting to best support you and your needs. We thank you for your time today, and we hope that you found this webinar useful in understanding how occupational therapy can support people living with dementia.
[Title card: Together we can reshape the impact of dementia]
[Title card: Dementia Australia. 1800 100 500. Dementia.org.au]
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