Postural stability in the cognitively impaired elderly: A systematic review of the literature

Balance and gait performance in older adults with early-stage cognitive impairment

BACKGROUND

People with cognitive impairment are susceptible to fall. Previous studies regarding balance and gait enrolled patients with various severity of dementia. Quantification of the balance and gait performance of people with cognitive impairment may help identify their postural instability and fall risks.

AIM

We investigated the differences in balance and gait among older adults with preserved cognition, amnestic mild cognitive impairment, and mild dementia due to Alzheimer's disease.

DESIGN

Prospective observational study.

SETTING

Outpatient department of neurology or psychology.

POPULATION

Older adults (aged ≥65 years) with independent gait were evaluated using the Mini-Mental State Examination and Clinical Dementia Rating scale. People with other neurological or musculoskeletal disorders were excluded.

METHODS

Participants were classified into three groups: 30 healthy controls, 30 mild cognitive impairment and 30 mild dementia. Balance were evaluated through functional test (Berg Balance Scale [BBS]) and laboratory test (posturography). Gait was assessed by wearable device. Muscle strength and mass were measured through grip force, calf circumstance, and body composition.

RESULTS

The BBS (P=0.04), posturography of fall risk index (FR, P=0.01) and sensory integration indices in eyes open and firm surface (EOFIS, P=0.009), eyes open and foam surface (EOFOS, P=0.003) were substantially different among three groups. EOFIS and EOFOS indices of balance in mild dementia were significantly worse than in MCI. The gait speed (P=0.04) and stride length (P=0.04) were significantly different among three groups. The post-hoc analyses revealed that all above balance and gait indices in subjects with cognitive impairments were significantly worse than in healthy controls. The grip force, calf circumstance and body composition-muscle mass did not significantly differ among three groups.

CONCLUSIONS

It is a piece of evidence that cognitive dysfunction, even in early stage of memory decline, may have some bad impact on balance and gait regardless of the effect of musculoskeletal problems.

CLINICAL REHABILITATION IMPACT

Understanding the difference of specific indices of balance and gait among different severity of cognitive impairments and healthy controls could help to develop better balance-oriented rehabilitation programs in older adults at early-stage cognitive impairment.

Postural instability in cognitively impaired elderly during forward and backward body leans

[Purpose] The aim of this study was to determine whether there are differences in postural stability control while leaning forward and backward between healthy elderly participants and elderly participants with cognitive impairment. [Participants and Methods] Postural stability was analyzed in 36 participants. According to the Mini-Mental State Examination results, participants were divided into the cognitive impairment group and the control group. A force plate was used to register the center of pressure in the sagittal and frontal plane, during two trials of maximum forward and backward body leaning. [Results] Significant differences were shown in both forward and backward leaning between the control and cognitive impairment groups. [Conclusion] The control of stability in the sagittal plane during maximum forward and backward lean of the body in cognitively impaired patients is similar to the results obtained by their healthy peers. However, individuals with cognitive impairment demonstrated larger lateral oscillations, which may be the reason for postural instability in this group, leading to an increased occurrence of falls.

Managing Paratonia in Persons With Dementia: Short-term Effects of Supporting Cushions and Harmonic Techniques

OBJECTIVES

Paratonia, a form of hypertonia typically seen in dementia, is often associated with difficulties in positioning and daily care. No evidence-based therapy or clinical guideline for management is available. In this study, the short-term effect of harmonic techniques (HT) and supporting cushions (SC) on paratonia was explored.

DESIGN

This was a multicenter interventional clinical trial with AB/BA crossover design. Each intervention (SC or HT) was subsequently implemented over 1 week in each of the participants.

SETTING AND PARTICIPANTS

The study included 22 participants with moderate to severe paratonia from 9 different nursing homes in Flanders, Belgium.

METHODS

Measurements of biceps brachii and rectus femoris muscle tone (MyotonPRO), maximal elbow and knee extension (goniometer), and pain (Pain Assessment Checklist for Seniors With Limited Ability to Communicate) were performed on 3 different days within 1 week. The effect of HT on nursing care was evaluated with the Pain Assessment Checklist for Seniors With Limited Ability to Communicate and visual analog scale ratings of discomfort items.

RESULTS

After 30 minutes of positioning with SC, participants had lower biceps brachii muscle tone (P = .041) and higher maximal elbow extension (P = .006) than without SC. After a 30-minute session of HT, a significant increase in biceps brachii muscle tone (P = .032) and maximal extension of elbow (P < .001) and knee (P = .028) was found. Pain (P = .003) and discomfort (P = .001 to P = .019) during morning care were significantly lower when care was preceded by 30 minutes of HT.

CONCLUSIONS/IMPLICATIONS

This explorative study revealed beneficial short-term effects on range of motion for both SC and HT and a positive effect of SC on upper limb muscle tone. Beneficial effects of HT were found on resident's pain and caregiver's discomfort during care. The results of the present study are encouraging and can contribute to the development of evidence-based interventions for paratonia.

Are physiotherapists employing person-centred care for people with dementia? An exploratory qualitative study examining the experiences of people with dementia and their carers

Background

People with dementia may receive physiotherapy for a variety of reasons. This may be for musculoskeletal conditions or as a result of falls, fractures or mobility difficulties. While previous studies have sought to determine the effectiveness of physiotherapy interventions for people with dementia, little research has focused on the experiences of people receiving such treatment. The aim of this study was to gain an in-depth understanding of people’s experiences of receiving physiotherapy and to explore these experiences in the context of principles of person-centred care.

Methods

Semi-structured interviews were undertaken with people with dementia or their carers between September 2016 and January 2017. A purposive sampling strategy recruited participants with dementia from the South West of England who had recently received physiotherapy. We also recruited carers to explore their involvement in the intervention. Thematic analysis was used to analyse the data.

Results

A total of eleven participants were recruited to the study. Six people with dementia were interviewed and five interviews undertaken separately with carers of people with dementia. Three themes were identified. The first explores the factors that enable exercises to be undertaken successfully, the second deals with perceived resource pressures, and the final theme “the physiotherapy just vanished” explores the feeling of abandonment felt when goals and expectations of physiotherapy were not discussed. When mapped against the principles of person-centred care, our participants did not describe physiotherapy adopting such an approach.

Conclusion

Lack of a person-centred care approach was evident by ineffective communication, thus failing to develop a shared understanding of the role and aims of physiotherapy. The incorporation of person-centred care may help reduce the frustration and feelings of dissatisfaction that some of our participants reported.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0756-9) contains supplementary material, which is available to authorized users.

Quantitative Balance and Gait Measurement in Patients with Frontotemporal Dementia and Alzheimer Diseases: A Pilot Study

INTRODUCTION

Alzhiemers disease and Frontotemporal dementia are common neurodegenerative dementias with a wide prevalence. Falls are a common cause of morbidity in these patients. Identifying subclinical involvement of these parameters might serve as a tool in differential analysis of these distinct parameters involved in these conditions and also help in planning preventive strategies to prevent falls.

PATIENTS AND METHODS

Eight patients in age and gender matched patients in each group were compared with normal controls. Standardizes methods of gait and balance aseesment were done in all persons.

RESULTS

Results revealed subclinical involvement of gait and balancesin all groups specially during divided attention. The parameters were significantly more affected in patients. Patients with AD and FTD had involement of over all ambulation index balance more affected in AD patients FTD patients showed step cycle, stride length abnormalities.

DISCUSSION

There is balance and gait involvement in normal ageing as well as patients with AD and FTD. The pattern of involvement in AD correlates with WHERE pathway involvement and FTD with frontal subcortical circuits involvement.

CONCLUSION

Identification the differential patterns of involvement in subclinical stage might help to differentiate normal ageing and the different types of cortical dementias. This could serve as an additional biomarker and also assist in initiating appropriate training methods to prevent future falls.