Alzheimer’s Disease in a semi-professional pianist: A case study
Alzheimer’s Disease in a Semi-Professional Pianist: A Case Study
By Sarah Arbour, Larissa Carlucci, Paola Finizio, Jamie Gray, and Alex Jones
Alzheimer's disease (AD) is a common form of dementia, characterized by loss of memory and other cognitive abilities. The role of physiotherapy in patients with AD is to address any body structure and function impairments, as well as assist the patient to overcome their activity and participation restrictions. Further, a physiotherapist's role has been found to help prevent the progression of physical and cognitive decline. The following is a fictional case study about a patient named Mrs. G. The purpose of this article is to explore the clinical presentation and physiotherapy treatment of a semi-professional pianist with AD. Mrs G. is an 87-year-old female who presents with a two-year history of AD. Recently, the nursing staff at Mrs. G’s retirement home recognized impairments in her cognition and consulted a physiotherapist. During Mrs. G’s assessment, noticeable deficits in balance, cognition and fine motor control were discovered. The primary aim of Mrs. G’s treatment plan was focused on improving fine motor skills to regain the ability to play the piano. The treatment plan also included balance, gait, endurance, strength and flexibility training. Following the intervention, Mrs. G showed improvements in wrist extensor strength, and scores on the Timed Up and Go, Berg Balance Scale, and Action Research Arm Test. The physiotherapy intervention ultimately decreased her risk of falls by enhancing her balance, and increased her wrist extensor strength to assist in her piano playing. Mrs. G should continue to attend physiotherapy monthly to monitor her condition and progress her exercises.
- AD = Alzheimer’s Disease
- ADL = activities of daily living
- ARAT = Action Research Arm Test
- AROM = active range of motion
- BBS = Berg Balance Scale
- b/l = bilateral
- CoG = centre of gravity
- CVD = cardiovascular disease
- FAQ = Functional Activities Questionnaire
- IADL = instrumental activities of daily living
- L = left
- L/E = lower extremity
- MMSE = Mini-Mental State Exam
- MMT = manual muscle test
- R = right
- TUG = Timed Up and Go
- U/E = upper extremity
- WHOQOL-BREF = World Health Organization Quality of Life-BREF
- WNL = within normal limits
This article details a fictional case developed by physiotherapy students for educational purposes.
Alzheimer’s Disease, by definition, is a progressive neurodegenerative disease affecting memory and cognition. Common in older adults, Alzheimer’s Disease is the most prevalent pathophysiology causing approximately 60-80% of dementia cases. Some key risk factors include age >65 years, hypertension, obesity, family history and other genetic factors.
The following video provides an overview of dementia and recommended strategies for supporting individuals with dementia.
The deterioration of neurological function is due to brain cell death, primarily caused by plaques that block nerve signals and tangled proteins that prevent nutrient circulation in neurons. Clinical presentation of the disease has substantial variance between patients, depending on the location of brain inflammation and atrophy. Common signs and symptoms of Alzheimer’s Disease include impairments in memory, problem solving, reasoning, comprehension, attention, and orientation.
Several researchers have explored the role of physiotherapy in the management of Alzheimer’s Disease, on a case-by-case basis. One such example is a fictional case study describing the benefits of physiotherapy education and home exercise programs to manage aerobic fitness and strength in a patient with Early-Onset Alzheimer’s. In another case study, researchers collected qualitative data through interviewing two patients and their spouses to investigate the relationship between participation in physical activity and Alzheimer’s Disease. Furthermore, a systematic review was conducted to address the barriers, facilitators and motivators for physical activity participation in individuals with Alzheimer’s Disease. This study identified the importance of caregiver involvement and individualized exercise programs to promote physical activity participation in this population.
In patients with Alzheimer’s Disease, physiotherapy has been shown to preserve independence through mobility exercises and functional task training. Physiotherapy has also been shown to prevent falls through strengthening, stability, postural control and balance training. Moreover, physiotherapy can help to control behaviour and mood through pain management and regular exercise. Additionally, physiotherapy may have a protective effect on cognitive function and could contribute to delaying decline in neurological function.
Despite the benefits of physiotherapy mentioned above, patients with Alzheimer’s Disease are at a higher risk for longer hospital stays, lack of access to healthcare services, premature institutionalization, and inadequate care that does not meet their goals. This highlights the importance of rehabilitation interventions that aim to prolong function and preserve independence in this patient population.
The purpose of this fictional case study is to explore the role of physiotherapy in maintaining functional independence and delaying decline in neurological function for a patient with Alzheimer’s Disease. Specifically, this patient presents with several cognitive deficits, including short-term memory loss and behavioural changes, as well as motor impairments in fine motor control, balance and coordination. The following sections explore various assessment techniques and intervention strategies aimed to enhance participation in physical activity and optimize quality of life for individuals with Alzheimer’s Disease.
Mrs. G is an 87-year-old female who presents with a two-year history of Alzheimer's Disease. She is relatively healthy and active, despite comorbid conditions including hypertension and osteoporosis. Mrs. G is a retired English teacher of 41 years and semi-professional piano player who started playing early in her childhood. Following her diagnosis, Mrs. G’s family decided to move her into a retirement home to ensure that she was well-supported with access to nursing and personal support staff. Over the last month, the nursing staff at her retirement home noticed a significant decline in her cognitive function involving short-term memory deficits, confusion, paranoia, and recurrent irritability. However, her long term memory has not yet become an issue. In response to these findings, they consulted a physiotherapist to address Mrs. G’s concerns. During the physiotherapy assessment, Mrs. G notes that she is experiencing difficulty playing the piano. She reports feeling as though her hands are not able to move like they used to, making it challenging to play intricate songs. She is particularly troubled by the deficits in her upper extremity fine motor skills, as one of her favourite activities is playing the piano every evening. Mrs. G also communicates that she is experiencing a loss of balance when walking around the retirement home, making it more difficult to participate in daily walks and fitness classes.
Patient Profile: 87-year-old female retired English teacher and semi-professional piano player.
History of Present Illness: Mrs. G was diagnosed with Alzheimer’s Disease two years ago. Over the past month, she has presented with fine motor, balance and coordination deficits disrupting her piano playing and daily physical activity. As noted by the nursing staff, she is showing signs of short-term memory loss and paranoia.
Past Medical History: Previous bilateral knee surgery for meniscal repair six years ago. History of hypertension and osteoporosis.
Medications: Bisoprolol, Aricept, and Memantine.
Health Habits: Previous smoker (8 pack years) who currently does not drink any alcohol.
Family History: Mother passed away at age 98 from Alzheimer’s Disease. History of cardiovascular disease on the paternal side.
Social History: Mrs. G is a widow who currently lives alone in a retirement home apartment and has some assistance in ADLs. She has two daughters who live within two hours of the retirement home and visit most weekends. Mrs. G spends her days playing the piano and loves to interact with the other residents. She takes daily walks around the gardens with friends, and attends weekly fitness classes at the residence.
Previous Functional History: Independently ambulatory without a gait aid for 30 meters with minimal fatigue. Able to play piano for 30 minutes every day without coordination difficulties.
Precautions/Contraindications: Short-term memory loss and paranoia may interfere with learning new exercises and adherence to the treatment plan.
- Forward stooped posture
- Thoracic kyphosis
- No use of gait aid
- Slowness of movement showing signs of bradykinesia
- Able to walk 10 meters before losing balance
- Wide base of support and notable instability
- Shortened gait cycle
- Significant loss of concentration and attention
- Forward stooped posture to adjust CoG
- Cervical AROM: L and R rotation ½ range
- Shoulder AROM: WNL b/l
- Wrist AROM:
- R wrist flexion full ROM
- R wrist extension ¾ range, limited by muscle weakness
- L wrist flexion full ROM
- L wrist extension full ROM
Manual Muscle Tests:
- Shoulder: 5/5 strength for all movements b/l
- Elbow: 5/5 strength for all movements b/l
- Wrist: moderate weakness, pain-free, and poor motor control b/l. R wrist extensor strength grade 3/5.
- L/E: 3/5 mild weakness, pain free, and slight motor control deficits b/l
- Mini-Mental State Exam (MME): score of 18/30
- Mini-Cog Test: score of 2/5
- Timed Up and Go Test (TUG): 14 seconds
- Berg Balance Scale (BBS): score of 40/56
Fine Motor Control Tests:
- Action Research Arm Test (ARAT): score of 25/57
- Finger to nose: smooth, coordinated with slight dysmetria R>L
- Finger opposition: moderate impairment R>L with lack of coordination
Self-Reported Outcome Measures:
- WHOQOL-BREF: scores of 66/100 (physical), 84/100 (psychological), 72/100 (social relationship), and 81/100 (environment)
- Functional Activities Questionnaire (FAQ): score of 12/30
During the subjective interview, Mrs. G describes having difficulty with fine motor control, balance, and hand coordination. This is affecting her ability to perform ADLs, such as brushing her teeth and getting dressed. The patient is becoming more fatigued when playing the piano, with noticeable deficits in coordination and muscle strength. She also has significant short-term memory deficits and shows signs of paranoia. The weakness she is experiencing in her L/E can be a contributing factor to the loss of balance, whereas the weakness in her U/E can be attributed to her decreased ability to play the piano and complete fine motor tasks.
The patient’s TUG score of 14 seconds indicates that she is at a high risk of falls and is dependent in the community. Furthermore, her BBS score of 40/56 is consistent with the balance problems she is experiencing and also places her at a medium risk of falls. Mrs. G received a score of 45 on the ARAT, indicating moderate recovery potential with respect to her U/E performance. She scored lowest on the 16 items reflecting fine movement of the hand and fingers. Her performance on the finger to nose test and finger opposition test shows decreased fine motor coordination, revealing mild dysmetria. Her FAQ score of 12/30 suggests that she has functional and possible cognitive impairments, specifically with her IADLs. Mrs. G's score on the WHOQOL-BREF suggests a slightly below average quality of life, primary within the physical domain. Her cognitive ability was assessed using the Mini-Mental State Exam and the Mini-Cog Test, where both revealed a mild and clinically meaningful cognitive impairment. Overall, these findings support the classification Mrs. G's impairments as Mild Alzheimer's Disease.
- Decreased ability to perform IADLs based on FAQ score
- Decreased fine motor control and hand coordination impacting her ability to play piano
- Decreased balance, characterized by instability and loss of balance within 10 meters of ambulation
- Trouble with certain ADLs (hygiene and dressing), due to fine motor impairments
- Cognitive impairments, including components of Mini-Cog Test, short-term memory loss, and behavioural changes
- Improve BBS score to 46/56 within 6 weeks, to decrease falls risk and increase balance during gait.
- Improve score on ARAT from 25 to 20 within 6 weeks, to recover fine motor loss.
- Improve TUG score to 10 seconds within 10 weeks, in order to be classified as independent and low risk of falls.
- Be able to play one song on the piano, 2x/week with minimal finger and hand muscle fatigue within 12 weeks.
- Maintain MMSE score of 18 over 12 weeks of treatment, to prevent decline in cognitive status.
Management Plan:The management plan was developed considering Mrs. G’s condition, goals, values, and setting. A primary concern to address was the identification of her difficulties with fine motor control of the hand and fingers impacting her ability to play piano and perform her ADLs. As well, the identification of her decreased lower extremity strength impacting her balance and gait was considered important. Secondarily, her cognitive and behavioural changes were identified as components to either maintain or improve upon. Multi-component training has been shown to be effective at improving functional performance in elderly patients with AD, with positive effects on upper and lower extremity strength, endurance, agility, and balance. Thus, in order to specifically address these concerns and reach her goals, the following routine was developed:
Fine Motor Skills and Coordination
It was important for Mrs. G to practice her fine motor and coordination skills, as these deficits impacted her ability to play piano and perform some of her ADLs. The peg board drill, finger opposition, and finger-to-nose tasks require hand-finger coordination and accuracy. It has been shown that when individuals with AD repeatedly practice a task, they can retain the motor skills for over a month following training. As well, individuals with AD make significant improvements in performing tasks during early practicing and maintain this learning as the trials go on. Therefore, practicing fine motor skills that mimic meaningful functional tasks can improve Mrs. G’s ability to retain these skills and maintain her independence and quality of life.
Decreased balance and mobility have been observed in individuals with AD. As balance has been shown to be a strong indicator of falls risk, it is important to address this concern. In order to improve Mrs. G’s balance, she needs to practice challenging balance tasks that force her to overcome the challenges. Some exercises that have been shown to improve balance with individuals with AD include weight shifts, side steps, and tandem walking. With Mrs. G’s initial level of balance on examination, the balance exercises used were weight shifting and internal perturbation training. As Mrs. G’s balance and strength improves, it is expected that the abnormal components observed in her gait (shortened gait cycle, wide base of support, slowness in movement) will also improve. These improvements will likely have a positive effect on her postural stability and kyphotic posture, as walking impairments may impact posture in individuals with AD.
Strength, Endurance, and Flexibility
In the objective examination, it was noted that Mrs. G had some weakness in her forearm extensors and lower extremities. These weaknesses may impact her fatigue during piano playing and her difficulty with balance and walking. It has been observed that resistance training improves agility, strength, balance, and flexibility in individuals with AD. Therefore, by implementing exercises that promote lower and upper extremity strength, it is likely that she will see improvements in piano playing, balance, and walking. Exercises that focused on her lower extremity strength included supported ½ squats, supported double leg calf raises, and standing hamstring curls. These exercises target major muscle groups required for walking and balance. Resistance training has also been shown to significantly improve an individual’s TUG score, meaning improved ability to ambulate and decreased risk of falls. In order to strengthen Mrs. G’s forearm and finger flexors and extensors for piano playing endurance, she was given a rice-box strengthening exercise. This exercise allows her to easily practice several important hand movements with resistance. The above strengthening exercises will be performed 3x/week for best results. A stretching routine was also included in Mrs. G’s program, as it has been shown that stretching may reduce soreness post-exercise, and that flexibility exercises have a moderate positive effect on cognitive tasks and behaviour.
Cognition and Behaviour
Walking at the retirement home was included in Mrs. G’s exercise program, as she noted her enjoyment in walking with fellow residents during her subjective interview. Aerobic-style exercise is associated with improved neurocognitive performance. Cardiorespiratory fitness has been shown to slow the functional decline of individuals with AD, thus positively affecting their independence. It has been shown that these benefits can be achieved with 20-30 minutes of aerobic exercises performed daily. Her walking was adapted with the use of a gait aid and/or assistance, so that Mrs. G gets the benefits of improved cardiorespiratory fitness without the risk of falls.
Music as a healing therapy for an individual’s physical, emotional, cognitive, and social needs has been well documented in previous literature. Music-supported therapy, in which patients produce tones, scales, and simple melodies on an electronic piano or an electronic drum set, significantly enhanced cognitive functioning in the domains of verbal memory and focused attention. It was also shown to improve depressive symptoms and mood, which are both common symptoms in patients with AD. Similarly, choir singing has shown significant improvements in mood and energy, as it promoted participation, interaction, enjoyment, improved motivation, and stress release and relaxation. The involvement in a choir group has been shown to increase an individual’s quality of life, as measured by the WHOQOL-BREF Questionnaire. Both music-therapy and choir were meaningful interventions to Mrs. G, as she has a love for music and social interaction.
The literature supports the use of multi-component training, as shown in Mrs. G’s exercise program, to improve functional performance in elderly patients with AD. In order to gain the benefits of the program, walking and stretching will be performed daily, whereas strength training will be performed 3 times per week. However, there is little evidence on the frequency protocols for fine motor skills and balance training aspects of the program; Therefore, these tasks will be performed 1-2 times daily in massed practice, as tolerated by Mrs. G. The intensity of the program was recommended using the revised Borg Rating of Perceived Exertion scale (0-10), as there was no prior knowledge of Mrs. G’s maximal effort in many of these tasks. As shown, when Mrs. G improved in these exercises, she progressed into a more difficult version to continue to make functional gains. The prescribed interventions have been shown to improve the main problem areas identified, and can help Mrs. G reach her goals. Certain interventions overlap to target the same goal. For example, resistance training is shown to increase both strength and balance. As well, music-supported therapy is shown to increase both cognition and fine motor skills. The program takes Mrs. G’s baseline functioning into consideration, aligns with her interests and values, involves setting-specific tasks, and targets her goals for improvement.
Following the assessment of Mrs. G's case, a three-month physiotherapy plan was implemented. Her treatment plan was directed toward improving her fine motor skills, hand coordination, static balance in standing, and dynamic balance in gait. The program consisted of three physiotherapy sessions per week and focused on strength and endurance. Mrs. G also performed fine motor control activities and balance exercises daily. Follow-up physiotherapy sessions were completed weekly for the first month, and biweekly thereafter.
During the three months of treatment, Mrs. G’s U/E MMTs improved slightly. There was notable improvement in Mrs. G’s R wrist extensor strength to a grade ⅘. Similarly, Mrs. G’s R wrist ROM improved to near full ROM. These improvements will assist Mrs. G with her piano playing.
The scores on her outcome measures following the physiotherapy intervention are listed below:
- MMSE = 18/30
- Mini-Cog Test = 2/5
- TUG = 10 seconds
- BBS = 45/56
- ARAT = 35/57
- FAQ = 12
The MMSE and Mini-Cog Test revealed the same scores pre- and post-treatment, suggesting that there was no change in the patient's cognitive status. These tests will continually be used to track Mrs. G's cognitive status over time. The combination of strength, endurance, balance and coordination exercises resulted in a decrease in Mrs. G’s TUG score by 4 seconds, placing her at a lower risk of falls. Mrs. G demonstrated a positive response to the balance intervention, observed through a clinically significant improvement on her BBS score. Mrs. G’s BBS score increased by 5 points, specifically with improvements in standing unsupported, standing with eyes closed, and standing with feet together. The ARAT was used as both an assessment and treatment tool, and revealed an improvement of 10 points. These improvements were highest among the fine motor movement items within the grip and pinch sub-scales.
Mrs. G should continue to attend monthly physiotherapy follow-ups in order to track her improvement, address any new concerns, and progress her exercises. These appointments will assist her with managing her coordination, balance and fine motor control to enhance her piano playing and ambulation. Mrs. G should also be monitored for secondary impairments as her disease progresses. Additionally, Mrs. G will be referred to an occupational therapist for a home safety assessment, assistance with ADLs and dressing aids, and providing other adaptive equipment that she may need. In the near future, Mrs. G's mobility and cognitive status should be reassessed for the potential use of assistive devices to maintain her safety.
This case study outlines the physiotherapy assessment and intervention plan for Mrs. G, a semi-professional pianist with Alzheimer’s Disease. Her chief complaint was reduced ability to play the piano and participate in physical activity at the retirement home where she resides. Clinically, she presented with impairments in wrist extensor strength, hand coordination, fine motor movements, and balance, categorizing her at an increased risk of falls. Following physiotherapy assessment, she participated in a three-month treatment plan targeting her individualized rehabilitation goals. Over the course of the intervention, she completed three physiotherapy sessions per week, focusing on strength and endurance. Her fine motor skill activities and balance exercises were completed daily. Mrs. G attended follow-up sessions weekly during month one, and biweekly for months two to three. The physiotherapy intervention decreased her risk of falls, enhanced her balance during gait, and increased her wrist extensor strength, ultimately allowing her to regain the ability to play the piano and participate in physical activity.
A unique finding in Mrs. G’s case is her difficulty controlling her hands despite her ability to remember all of her piano songs. The fine motor task of piano playing is stored as a motor program in the brain, while the memory component of music would be stored in a separate brain area. Thus, this discordance may be attributed to the area of Mrs. G’s brain affected by the disease pathology, with the cognitive aspect of the skill remaining intact while the motor aspect is impaired. In this case, outcome measures including the Action Research Arm Test, the finger-to-nose test and the finger opposition test were used to assess Mrs. G’s upper extremity fine motor control and coordination. By quantifying Mrs. G’s motor impairments using these objective assessment tools, the physiotherapist can create an individualized intervention plan targeting the areas in need of improvement.
In the literature, there are many case studies investigating the role of physiotherapy in treating older adults with Alzheimer’s Disease. Similar to Mrs. G, many patients with this disease experience cognitive symptoms such as short-term memory loss and confusion, behaviour changes including aggression and paranoia, and motor deficits in balance, coordination, and fine motor skills. There is strong evidence suggesting that physiotherapy is helpful in the management of Alzheimer’s Disease, through its contribution to preserving independence, preventing falls, and delaying cognitive decline.
Despite the known benefits of physiotherapy management, patients with Alzheimer’s disease and related neurological disorders have higher rates of health disparities associated with loss of independent living and autonomy in decisions regarding their healthcare plans. Click the following link to learn more about some of the key health disparities related to the stigma surrounding the various forms of dementia: Alzheimer Society 2017 Awareness Survey.
Several factors may contribute to the health disparities experienced by individuals with Alzheimer’s Disease. Some examples include:
- Lack of autonomy and involvement in care planning
- Lack of participation in exercise interventions
- Lack of social support, leading to poor mental health and problematic behaviours
- Lack of disease-specific education and training for healthcare providers
As integral members of the care team, physiotherapists can be important advocates for patients with Alzheimer’s Disease. Firstly, physiotherapists can implement patient-centered care by discussing patient-centered goals, considering the patient’s values and beliefs, and treating patients with dignity and respect. Secondly, physiotherapists can promote autonomy by informing patients of their rights, supporting patients in their decisions, and ensuring patients have adequate access to healthcare. Thirdly, physiotherapists can show compassion by taking the time to actively listen to the patient, build therapeutic rapport to enhance emotional comfort, and encourage patients to be active participants in their treatment plan.
The main goals of physiotherapy interventions in this population should include preserving independence and optimizing quality of life. The following outlines several ways in which this can be achieved.
- Enhance patient autonomy by providing choices whenever possible
- Emphasize functional task training to enhance independence in ADLs and IADLs and reduce caregiver burden
- Take the time to understand the patient’s individual needs to provide patient-specific resources
- Educate caregivers on services available in the community to prevent burnout
In addition to the suggestions outlined above, the following provides some general guidelines that physiotherapists can use when working with patients with Alzheimer’s Disease.
- Schedule a regular routine for treatments
- Ask simple, specific questions
- Focus on one task at a time
- Minimize distractions in the environment
- Maintain patient dignity at all times
- Introduce yourself and your role with every interaction
- Ask about symptoms frequently
- Talk to the patient rather than the caregiver whenever possible
Due to the nature of Alzheimer’s Disease, communication can be a challenge for physiotherapists. The following video provides suggestions for enhancing communication with individuals with dementia.
To put these strategies into practice, physiotherapists can enhance verbal communication by providing simple stepwise instructions and speaking slowly with frequent pauses to allow sufficient time for information processing. Furthermore, non-verbal communication can be optimized by utilizing actions or images to explain tasks, while being mindful to use non-threatening body language. Additionally, communication can be enhanced by engaging in active listening and demonstrating empathy.
To summarize, physiotherapy is an integral part of managing symptoms of Alzheimer’s Disease and can contribute to enhancing quality of life and preserving independence in this patient population. It is important for physiotherapists to collaborate with an inter-professional care team to provide personalized care that aligns with the patient’s goals. There are numerous strategies that physiotherapists can use to promote open communication and provide effective patient care while considering implications of the disease. By providing patient-centred care, physiotherapists can help patients maintain their physical and cognitive functioning, allowing them to participate in meaningful activities within their community.
The following questions are intended for self-study purposes to test your knowledge obtained from reading this case study.
In your initial assessment, you are evaluating Mrs. G’s walking gait. You notice that after about 10 meters, she begins to lose her balance. Which compensation strategy might Mrs. G use to prevent herself from falling?
- Decrease step length to minimize time in single leg stance
- Increase walking speed to reduce postural sway
- Reduce base of support by keeping her feet closer together
- Increase hip flexion in the swing phase to maintain upright posture
On your fifth visit with Mrs. G, she does not recognize you and seems reluctant to participate in physiotherapy. What would be an appropriate way to respond?
- Encourage Mrs. G to try to remember who you are by explaining what you did in the previous treatment session
- Leave Mrs. G alone because she is exhibiting unusual behaviour
- Ask Mrs. G’s caregiver for consent to proceed with treatment, as Mrs. G is unable to make this decision for herself
- Re-introduce yourself, explain your role as a physiotherapist, and your goals for the treatment session
During a physiotherapy treatment session, you are teaching Mrs. G a new exercise and she seems to be confused by your instructions. What would be an appropriate strategy to facilitate teaching this skill?
- Provide multiple cues to allow her to make connections between the various aspects of the skill
- Demonstrate the exercise before she performs it and provide simple instructions one step at a time
- Explain the exercise in detail and describe the muscles being activated in each stage of the movement
- Describe the biomechanics of the exercise to help her better understand the movement pattern
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