It’s a too-common scenario: You cannot perform therapy with an elderly person because of the patient’s “confusion.” This symptom is common to dementia, delirium and sometimes depression, but experts say “the three D’s” don’t necessarily have to prevent an older patient from receiving the benefits of physical therapy.

“I’m often asked, ‘How far should a therapist go to mobilize a patient?’ I help the patient to be as functional as possible,” says Bill Healey, PT, EdD, assistant professor in the physical therapy department at Northwestern University’s School of Medicine, Chicago.

Delirium occurs in up to 50% of older patients postoperatively and even more often in elderly patients in intensive care units, according to a July 28 article in the Journal of the American Medical Association.

Dementia affects nearly 10% of individuals older than 65 in the general population, the Geriatric Mental Health Foundation in Bethesda, Md., reports. In that age group, about 25% of hospitalized patients have dementia, according to a January 2008 article in American Journal of Nursing. Depression occurs in 15% of people older than 65 and in up to 50% of nursing home residents, the GMHF estimates.

Differentiate the “D’s”
Healthcare providers often mistake depression and delirium in elderly adults for dementia, Healey says. Not only do the disorders require different rehabilitation approaches, he explains, but delirium necessitates immediate medical attention because its cause is almost always another medical condition.

“If it’s a new presentation of delirium, it is important to make sure the patient gets medically screened, to find out the root cause,” says Alice Bell, PT, corporate director of clinical services for Genesis HealthCare in Massachusetts.

Besides increasing age, pre-existing cognitive impairment is a common risk factor for delirium. Other delirium triggers include admission to intensive care, drug reaction or withdrawal, general anesthesia, infection, drug or alcohol abuse, dehydration and malnutrition.

One way to differentiate delirium from dementia and depression is its abrupt, acute onset. It can occur within minutes, whereas the onset of depression can be days to weeks and symptoms in dementia usually occur over years, Bell explains.

Because the three disorders have some similar symptoms, Healey says patient assessment may require a screening tool. Tools include the Mini-Cog to detect dementia, the Confusion Assessment Method to identify delirium and the Geriatric Depression Scale.

Creative Activity Design
If a patient has a problem that could worsen, such as contractures, a wound, or a risk for skin breakdown, it may be appropriate to start an intervention before delirium clears. The PT should minimize distraction, Healey says. A crowded hall or therapy gym may escalate the patient’s confusion, so instead stay in the patient’s room for treatment.

Target therapy for a time when the patient feels best. That may be in the morning for patients with delirium or dementia, in which symptoms usually worsen in the evening (“sundowning effect”), but may be in the afternoon for depressed patients, Healey says.

When working with patients with dementia, the therapist should focus on residual abilities, Bell recommends. “Find out what skills are still available, so we can leverage the remaining cognitive abilities,” she says.

For instance, patients with dementia often retain long-term memory, so Bell suggests modeling an exercise on an activity they remember from work or a hobby. For a patient who used to work at a desk, it might make sense to work with the patient on transfers in front of a desk or other familiar object, she says. Or the therapist may want to add a basket to the patient’s walker to make it look like a grocery cart.

“It’s very much about understanding what their past roles were and translating that to the therapy setting,” Bell says.

That translation requires creativity from the therapist as well as a through history taking and, if the patient is not a reliable reporter, talking to family members.

Teaching approach will depend on the individual’s learning style and cognitive abilities. In moderate dementia, visual learning may no longer be present, and as dementia progresses, the patient needs repetition and consistency. “We have to make sure we teach every caregiver to do an activity exactly the same way,” Bell says.

It is common for patients with early-stage dementia to become depressed. The therapist should ask what the patient likes to do and tailor exercise around those activities, Bell says.

The PT also can focus on smaller goals when patients are depressed. “If a goal is to walk independently with a cane, today the goal could be to walk independently with a walker to the bathroom,” Healey says.

Whether a patient has depression, dementia or both, Bell says the goal should be to “make therapy a patient-focused experience that is relevant and will engage them as well as have the functional results we’re hoping to see.” •

Kathleen Louden is a freelance writer.