PHysical Therapy Success in the Presence of Dementia - PowerPoint Presentation

1. PHysical Therapy Success in the Presence of DementiaDr. Stacy Millar PT, DPT, GCS

2. What is dementia?"Properly defined, dementia is characterized by persistent observed cognitive changes resulting from an illness." (1)Click to add text

3. Review of Brain Sections and Function http://ib.bioninja.com.au/options/option-a-neurobiology-and/a2-the-human-brain/brain-sections.htmlto add text

4. Blood SupplyClihttp://www.medicalrf.com/The-circle-of-willis-image_RF000027326.htmlck to add textClichttps://www.alz.org/alzheimers-dementia/what-is-alzheimers/brain_tourk to add text

5. Nerve Cell https://www.alz.org/alzheimers-dementia/what-is-alzheimers/brain_tourk to add text"An adult brain contains about 100 billion nerve cells" (2)Branches form the pathways for communication between neuronsSignals travel along branches to synapse with communicating neurons

6. Synapse thttps://simple.wikipedia.org/wiki/Neuron#/media/File:Neuron.svghttps://en.wikipedia.org/wiki/Chemical_synapse#/media/File:Chemical_synapse_schema_cropped.jpg

7. plaqueshttps://www.flickr.com/photos/nihgov/38686503251Amyloid: protein fragments abnormally formed by bone marrowBeta Amyloid: protein fragment from amyloid precursor protein (APP)Healthy brain will break down and excreteAlzheimer's brain cannot break down and therefore accumulates and forms plaques

8. TanglesConsist of a protein called Tau of which is a component of a microtubuleAltered chemical messages cause Tau proteins to detach from microtubules Creates insoluble twisted fibers inside brain cells causing neurofibrillary tangles

9. http://essays.biochemistry.org/content/56/99.figures-onlyhttps://health-innovations.org/2015/03/25/harmonized-neuroimaging-protocol-for-measuring-early-sign-of-alzheimers-has-been-developed/https://www.neuroscienceassociates.com/reference/diseases/approach-ad/

10. Types of dementia

11. Vascular dementiaMulti-Infarct Dementia"...additive effects of small and large infarcts that produce a loss of brain tissue." (1)Signs specific to dementia related to multi-infarctsAbrupt onsetStep-by-step deteriorationFluctuating courseEmotional labilityCommon Disturbances:Problems with memoryAbstract thinking, judgement, impulse control, and personality

12. Reversible dementia/deliriumCognitive dysfunction that can be corrected"Estimates show that 10% to 30% of those presenting with dementia symptoms can be treated to correct a metabolic or structural condition, also resulting in restoration of intellectual function." (1)Conditions that can mimic dementia:Drug complicationsInfectionNutritional, psychiatric, and metabolic disordersTrauma

13. pseudodementia"...term used when dementia-like behavior is actually the result of a major depressive episode." (1)Defining characteristics:Psychomotor retardationFlattened affectDisinterest in events around them

14. Lewey Body Dementia"Lewy body dementia (LBD) is a disease associated with abnormal deposits of a protein called alpha-synuclein in the brain." (4)2nd most common form of progressive dementia (5)Effects more than 1 million individuals just within the US (4)Typically begins around age 50 (4)Lasts an average of 5-8 years from time of diagnosis until death (4)https://www.nia.nih.gov/health/what-lewy-body-dementia

15. Signs & symptomsVisual hallucinations (differing factor from other dementias)Movement disorders that mimic Parkinsonian mobilityPoor regulation of bodily functions (autonomic nervous system)Cognitive problems Sleep difficultiesFluctuating attentionDepression and Apathy*True diagnosis can only be made via autopsySevere dementiaAggressive behaviorIncreased risk of fallsWorsening Parkinsonian symptomsDeathcomplicationsLewy body dementia(4)

16. Dementia of Alzheimer's Type (14)"Early Onset Familial Alzheimer's"Caused by genetic defects on chromosomes 21,14, and 1Autosomal dominantOccurs in 50% of first degree blood relativesOccurs before age 60Accounts for only 5% of AD casesClick to add texthttps://www.alz.org/alzheimers-dementia/research_progress/earlier-diagnosis

17. Dementia of Alzheimer's type (14)"Late Onset Alzheimer's"Most common form of ADOccurs in people 65 or olderParticular gene involved called APOE (apolipoprotein E)Has 3 normally occurring alleles APOE-4 = risk factor for the diseaseAPOE-2 = protective factor 

18. Typical Pattern of Plaque Formation "The hierarchical pattern of neurofibrillary degeneration among brain regions is so consistent that a staging scheme based on early lesions in the entorhinal/perirhinal cortex, then hippocampal Ammon subfields, then association cortex, and finally primary neocortex is well accepted as part of the 1997 NIA-Reagan diagnostic criteria (NIA-RI Consensus 1997)."(27)https://www.alz.org/alzheimers-dementia/what-is-alzheimers

19. Healthy brain vs. Alzheimer's brainhttp://www.noticias.com.ve/contaminacion-aumenta-riesgo-de-padecer-alzheimer/https://www.dementiacarecentral.com/video/video-brain-changes/

20. Stages of alzheimer'sMild/Early StageModerate/Middle StageSevere/Late Stage

21. Mild/early stage (6)

22. Moderate/middle stage (6)

23. Severe/late stage (6)

24. 7 A's of dementia (11)Anosognosia:  no knowledge of  illnessAmnesia:  loss of memoryAphasia:  loss of languageAgnosia:  loss of recognitionApraxia:  loss of purposeful movementAltered Perception:  loss of visual perceptionApathy:  loss of initiation

25. AnosognosiaParticularly likely to occur if pathology is in tempero-parietal lobePoor judgement and problem-solvingResistance to care STM is most important as it allows for information to be maintained long enough to get into long-term storageWithout STM, patient with dementia can no longer consciously learnDeclarative – experienced over timeProcedural – all tasks learned Amnesia7 A's of dementia (11)

26. AphasiaOften still recognizes non-verbal communicationExpressive aphasia – associated with frontal lobePerson able to comprehend speech but unable to produce languageReceptive aphasia – associated with temporal lobePerson has deficit in comprehending languageLoss of recognition toVisual – objects and facesAuditory – soundsSomatosensory – touchesAgnosia7 A's of dementia (11)

27. ApraxiaLoses ability to plan, sequence, and execute each step within a taskVisuo-spatial discrepanciesDepth perceptionAltered Perception7 A's of dementia (11)

28. ApathyTypically occurs with damage to medial frontal lobe Over time, will not initiate conversations or activities without cueing 7 A's of dementia (11)

29. PreventionExposure to bright light (go outside/sit by window)ExerciseDaytime rest (not too late in the day)Being overly tiredUnmet needs such as hunger or thirstDepressionPainBoredomCausesSundowning (13):"...restlessness, agitation, irritability, or confusion can occur or worsen as daylight begins to fade." 

30. Sundowning (13)Coping Strategies:Decrease noise, distractions, too many people, etcDistract person with a favorite activity, snack, video, tv showQuiet and calm time in the evening close to bed time Minimize shadows so not to cause confusion (draw curtains or turn on lights)Listen and respond calmly 

31. MMSEUse the Mini Mental State Examination to determine where patient is in ability to function and learn"... assessment of an older adult’s cognitive status is instrumental in identifying early changes in physiological status, ability to learn, and evaluating responses to treatment." (7)"The Mini Mental State Examination (MMSE) is a tool that can be used to systematically and thoroughly assess mental status.  It is an 11-question measure that tests five areas of cognitive function: orientation, registration, attention and calculation, recall, and language.  The maximum score is 30.  A score of 23 or lower is indicative of cognitive impairment.  The MMSE takes only 5-10 minutes to administer and is therefore practical to use repeatedly and routinely." (7)

32. Scoring24-30: Normal range18-23: Moderate cognitive impairment0-17: Marked cognitive impairment

33. Global Deterioration Scale

34. Level 1No cognitive declineVery mild cognitive declineAge associated memory impairmentNo noticeable deficits in employmentLevel 2Global deterioration scale (12)

35. Level 3Mild Cognitive declineEarliest evidence of deficitsDecreased performance in social settingsLevel of denial highAnxiety highModerate Cognitive DeclineUnable to perform complex tasksFlat affectWithdrawal from challenging situationsLevel 4Global deterioration scale (12)

36. Level 5Moderately Severe Cognitive DeclineMust have assistance with daily tasksDisorientation to timeSevere Cognitive DeclinePersonality and emotional changes occurDelusional behaviorCannot carry out purposeful actionLevel 6Global deterioration scale (12)

37. Level 7Very Severe Cognitive DeclineVerbal abilities lostIncontinentGeneralized rigidityOnly basic pyschomotor skillsGlobal deterioration scale (12)

38. Treatment Options

39. Alzheimer's is primarily a disease with deficiencies in the brain's cholinergic systems                        http://psychiatricdrugs.com/neurology/acetylcholine/Medication research is focused on either increasing available acetylcholine (cholinergic agent), preventing its destruction (cholinesterase inhibitors), or by minimizing damage to the nerve cells due to effects of oxidation and inflammation https://study.com/academy/lesson/cholinergic-drugs-mechanism-of-action.htmlhttps://www.medscape.com/viewarticle/705284_2

40. CholineComponent of various foods but can be found in capsule formAssociated with only modest improvements and that was in those in the earlier stages of illnessMay increase alertness and awarenessWorks best when used in combination with other drugsNaturally found dietary substance in foods such as egg yolks, meat, fish, and soybean productsShows greater ability to slow down disease progression than cholineCan be found in capsule form; however, the amount needed to provide beneficial effects would be impossible to ingest in this formLecithinCholinergic Agents(14)Known to improve availability of acetylcholine in the brain, enhance synthesis, and increase release in the synapses between neurons

41. Cholinesterase Inhibitors(14)Tacrine:Higher potential for liver toxicity thereby increased blood testingMay slow cognitive impairment by 6-12 monthsGalantamine:Extracted from the bulb of a daffodil species Works in a more unique way than the others in that is stimulates a specialized ACh receptor on neurons known as nicotinic receptorsStimulation of nicotinic receptors enhance learning, memory, and inhibits build up of beta amyloidBenefits lasted 12 monthsAricept (Donepezil):Indicated for mild to moderate dementiaMay slow disease progression for 6 months or morePhysostigmine:Can cross blood brain barrierVery narrow dose range between being effective versus being toxicShort half-lifeExelon (Rivastigmine):Works by inhibiting both acetylcholinesterases and butrylcholinesterasesIndicated for moderately severe to advanced dementia

42. Cholinergic Receptor Agonists(14)Stimulate the receptors that receive acetylcholine Benthanechol Chloride:Produced decreased confusion, increased initiative, and enhanced productive activityDelivered via a drug infusing pump implanted into the abdominal wall and is connected to an intracranial catheter allowing the drug to cross the blood brain barrierArecoline and RS-86Produced little or no significant improvement

43. NeuropeptidesShort chains of amino acids that have strong interactions on the nervous systemEnhance communication between body cells, tissues, and organsProduced in studies reversal of memory impairment, enhanced cognitive abilities, improved neurotransmission in memory and learning, decreased depression, increased energy, attention, and concentrationUtilized and studied as a nasal sprayHelped memories appear more quicklyVasopressinOther Medications(14)

44. Glutaminergic AgentsMemantine:Acts on glutaminergic neurotransmission Aids in decreased loss of a specific glutamate receptor known as NMDA receptor NMDA receptor noted to be found in the deterioration found in Alzheimer's diseaseSlowed progression of symptoms in moderately severe to severe Alzheimer'sProvides neuroprotection as well as symptom reliefCurrently awaiting its production within the USHormone that help nerve cells survive by preventing damage from inflammation and oxidationPromotes growth of cholinergic neuronsStimulates neurite growth and synapse formationestrogenOther Medications (14)

45. AntioxidantsOxidative stress results when antioxidant defenses are overwhelmed by free radical formationProtect neurons from this oxidative stressVitamin E:Traps free radicals and interrupts the chain reaction that damages cellsPrevents cell death caused by glutamate and beta-amyloid proteinsSelegiline (Deprenyl):Known as a scavenger of free radicalsSlows progression of diseaseIncreased risk of Alzheimer's disease with high cholesterolHigh cholesterol and fat increase amount of beta-amyloid in the brainBeta-amyloid and cholesterol stimulate an inflammatory response causing vessels to constrict Thereby, statins modulate immune responses by decreasing inflammation StatinsOther medications (14)

46. Tricyclic Anti-DepressantsAmitriptyline & Doxepin:Higher potential for side effects of increased confusion and memory lossDesipramine or Nortriptyline:Decreases potential for cognitive impairment as compared to above listed Prevent nerve cells from eliminating serotonin Zoloft, Prozac, Paxil, Celexa, Luvox, Effexor, & WellbutrinAids in treating verbal agitation, anxiety, fear, panic, restlessness, depressionTrazodone & CitalopramGreatest risk for postural hypotensionRemeron & SerzoneMight aid sleep at night but coud carry over to drowsiness next daySelective Serotonin reuptake inhibitors (SSRIs)Anti-Depressants(14)"Results are mixed, but the use of antidepressants in treating Behavioral symptoms seen with Alzheimer's disease is encouraging."

47. Side EffectsElderly have lower tolerance than youngerBrain impairment increase effects and/or interfere with effectiveness of medicationsHypotensionDry mouth, blurred vision, dilated pupils, constipation, urinary retention, nasal congestion, and increased heart rateExtrapyramidal reactionsSlowed movements, muscle rigidity, resting hand tremor, shuffling gait, drooling, and mask-like face Tardive dyskinesia Involuntary lip and tongue motions, writhing movements of arms and legsHaldolNavane ProlixinLoxitaneExamplesOther medications(14)Major tranquilizers

48. Side effectsCan build up in the body over timeDrowsiness NervousnessDizzinessHeadacheIrritabilityFatigueBlurred visionValiumLorazepamXanaxRestorilLibriumExamplesOther medications(14)Minor Tranquilizers

49. AntipsychoticsMore favorable side effectsUsed to treat behavioral and psychological symptoms of dementia Risperidone (Risperdal)Quetiapine (Seroquel)Olanzapine (Zyprexa)Valproic Acid (Depakote)Carbamazepine (Tegretol)Mood StabilizersOther Medications(14)

50. "Isolation or restraint must not be imposed in any form as a means of coercion, discipline, convenience or retaliation by staff."(15)https://publications.tnsosfiles.com/rules/0940/0940-03/0940-03-06.pdf

51. Why Should Therapy be involved?

52. why should therapy be involved?

53. Circulating Insulin-like growth factor enhanced via exercise for brain insult protection(16)"Our findings also indicate that exercise is neuroprotective because of increased passage of circulating IGF-1 into the brain because when this passage is blocked, exercise is no longer neuroprotective,""An additional mechanism involved in IGF-1 mediated exercise neuroprotection is likely related to enhanced neuronal glucose metabolism.  Improved glucose metabolism is essential for neurons to be able to survive to injury, and increased glucose consumption is a typical response to brain injury.""Brain uptake of blood-borne IGF-1 is essential for exercise-induced increases in the number of newly formed hippocampal neurons and in widespread c-Fos expression in neurons."  https://www.frontiersin.org/articles/10.3389/fneur.2011.00028/full

54. Why Should Therapy Be involved?

55. Therapeutic approachIt is our responsibility as therapists working with those with dementia to meet them where they are at

56. Therapeutic Treatment Options(18)"Similarly, the application of TG [therapeutic gardens] has been shown to reduce behavioral problems (e.g., fear and anxiety) during post-stroke rehabilitation procedures, improve ambulation, promote positive reminiscences, stabilize sleep-wake cycles and reduce stress, suggesting this treatment option as a complementary therapy for dementia patients dwelling in aged-care facilities."https://depts.washington.edu/hhwb/Thm_Healing.html

57. Use of Therapeutic Gardens(18) "...exposure to natural environments improved inappropriate behaviors in patients with dementia.  Research has shown that a wander garden resulted in increased feelings of freedom, improved quality of life, and reduced agitation, including the number of falls and the need for high doses of antipsychotics in dementia patients.""...older adults with AD derive benefits from exposure to gardens in that they foster walking, socialization, and higher self-esteem while reducing depression and aggressive behaviors, including isolation and vulnerability."http://gardendesignseibao.blogspot.com/2017/06/dementia-garden-design.html

58. Canine-Assisted Therapy(19)"This approach includes animal-assisted therapy, defined as an intervention in which an animal is incorporated as an integral part of the treatment process, in order to promote an improvement in physical, psychosocial, and/or cognitive functioning of the person treated.""Our study provides evidence of the significant benefits of canine-assisted therapy for quality of life in people with Alzheimer's disease.""...a higher quality of life is associated with lower levels of depression, a decrease in the presence of neuropsychiatric symptoms, and less dependence on activities of daily life."https://www.samvednacare.com/blog/2017/09/11/6-benefits-of-pet-therapy-for-dementia-patients/

59. Essential Oil use for treatment of agitation in Dementia(20)-Scent detection relies on immediate memory -Scent recognition is more delayed memory processing-Fragrances can evoke strong memories of earlier times -Limbic system's amygdala governs emotional response-Hippocampus is involved in retrieval of memories surrounding scenthttps://www.dreamingearth.com/blog/essential-oils-dementia/

60. Essential Oil use for treatment of agitation in Dementia(20)Lemon balm is a more recent scentMore effective in people without dementia due to being too potentLess familiar scentMay have a more clinical or pharmaceutical basisMore effective in reducing agitation in people without dementiaLavender was a popular herb in earlier 20th century Grown in gadens Used as perfumes & disinfectantsOlder people with dementia would recognize it and be comforted by itMore effective in reducing agitation and physical non-aggressive behavior in people with dementiahttps://www.facebook.com/lemonandlavendeo

61. Frequency of Family visits influences symptoms(21)"Stimulation of cognitive activity is important for reducing cognitive decline, and communication is one of the important stimuli for this.""It was clear that family contact was associated with the maintenance of psychological functions in aged people with moderate dementia.""This result suggests that family visits in a nursing home are useful for prevention of aggravated dementia in subjects with a slight level of dementia, and as a cure for subjects with a moderate level of dementia.""This study demonstrates that the frequency of family visits is associated with suppression of BPSD [behavioral and psychological symptoms of dementias], and is particularly effective for subjects with moderate dementia."https://www.caring.com/senior-living/assisted-living/

62. Impact of Group activities and their content with dementia(22)https://www.flickr.com/photos/135633694@N04/20546884060/

63. - "Active participation levels were highest for the exercise, music, and art groups."- "Wellbeing was observed to be lower during unstructured time compared to the activities."- "Wellbeing was also higher for reminiscence therapy than for general group activities"- "The most successful group activities were games and choral singing, whereas the least successful were story-telling and poetry, with other topics being in between or having a greater impact on a specific outcome, such as exercise impacting active participation."                                                  (22)

64. Musical Memory and TherapyCan be very calming for the dementia patient, particularly when it allows rememberance and famililarityhttps://mageerehab.org/about-us/care-team/music-therapy/

65. Musical Memory preserved in advanced Alzheimer's dementia(23)

66. (23)

67. Appropriate approachesAvoid criticismConsistent but simple commandsGive sensory cuesProvide demonstrationAllow resting periodsTasks should be repetitiveInvolve family and direct caregiversBreak tasks into simple tasksClear and calm cuesOne word commandsMake task as functional as possibleAllow time for their responseSpeak normalDo not slow down sounds or over-exaggerate the words or increase volume

68. Appropriate Approaches(14)Maintain a routine for daily activitiesAlways request the desired behavior in the same setting ( i.e.  eating in the dining room, dressing in bedroom or bathroom)Possibly try checklists Be encouragingDecrease stimuliEat with the patientLeave a light on in the bathroomLabel the important rooms ( i.e. bathroom, bedroom, dining room)Label with picturesPlace stop sign at doors you don't want them to go through

69. Appropriate ApproachesWhen assisting patient's with more fine motor activities, maintain your position from behind the patient to allow appropriate motion, sequencing, and visual input rather than assisting patient from the front that can further confuse the embedded programhttps://www.aota.org/Practice/Productive-Aging/Alzheimers-Dementia.aspx

70. Treatment environmentFree of clutterFree of distractionsWell-lit areasAppropriate temperature per patientLow volumeSafeAvoid patterns on floor if possibleFigure-ground Tread on stairsBright tape on stairs Visual-spatial perceptionhttp://www.psicologosenlallama.com/2013/06/aprobar-atencion-y-percepcion-con-m-j.htmlhttp://www.canelaysal.com/teoria-de-la-gestalt/gestalt/

71. Therapeutic approach

72. "How do physical therapists report (bill) time spent delivering patient education?"No designated code for reporting patient educationTime reported of providing the skilled service of patient education depends upon the therapist's intended outcome Reflect intent, detailed instructions for the patient, comments, and observations of patient's/caregiver's success in learning Must relay the skilled service delivered and how it relates to the plan of care"what should be included in documentation about patient education?"Billing & Documentation Q&A(24)

73. Skilled Maintenance(25)Coverage of a maintenance program is based on assessment by the PT of the patient's condition and the need for skilled care to carry out a safe and effective maintenance programCovered in cases of therapeutic interventions requiring a high level of complexity"Medical necessity" is required for all services covered by MedicareServices covered can be rehabilitative, maintenance, or slowing of declinePhysical therapist must be able to justify services are reasonable and necessary Considered skilled to instruct caregivers and occasionally review outcome

74. Skilled Maintenance(25)

75. Home HealthThe 13th, 19th, and 30th reassessment requirements are still required for a skilled maintenance programAssessment to reflect why services are skilled and why the skill of a physical therapist is required to maintain function or prevent/slow declineFunctional measures should be utilized to track the status within the patient's condition to decipher reasonable expectationsMedicare requires plan of care be physiian re-certified every 90 daysEven a maintenance program must be certified by a phyician within 30 days of the initial treatment date as well as recertified every 90 days or when plan of care duration has expired (whatever comes first)OutpatientSkilled Maintenance(26)

76. Statistics (14)

77. Personal reflection through each stage2005-No symptoms at all 2012-End of Early Stage2013-Mid Stage2014-Late Stage

78. You treat a disease, you win, you lose. You treat a person, I guarantee you, you'll win, no matter what the outcome.                 -Patch Adams

79. Our job is improving the quality of life, not just delaying death.                -Patch Adams

80. Works Cited1.  Guccione, Andrew.  (2000).  Geriatric Physical Therapy, United States of America:  Mosby.2.  Alzheimer's Association.  (2018).  Retrieved from https://www.alz.org3.  Bright Focus Foundation.  (2015, July 1).  Amyloid Plaques and Neurofibrillary Tangles.  Retrieved from                  https://www.brightfocus.org/alzheimers/infographic/amyloid-plaques-and-neurofibrillary-tangles4.  National Institute on Aging.  (2018, June 27).  What is Lewy Body Dementia?.  Retrieved from                   https://www.nia.nih.gov/health/what-lewy-body-dementia.5.  Mayo Clinic.  (2017, August 9).  Lewy Body Dementia.  Retrieved from                 https://www.mayoclinic.org/diseases-conditions/lewy-body-dementia/symptoms-causes/syc-20352025.6.  Johns Hopkins Medicine.  (2018, August 9).  Stages of Alzheimer's Disease.  Retrieved from                  https://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/stages_of_alzheimers_disease_134,64.

81. Works Cited7.  Kurlowicz, Lenore. & Wallace, Meredith.  (1999).  The Mini Mental State Examination (MMSE).  The Hartford      Institute                     for Geriatric Nursing, (3).  Retrieved from https://www.mountsinai.on.ca/care/psych/on-call-resources/on-                         call-resources/mmse.pdf.8.  Teri, Linda, Logsdon, Rebecca, & McCurry, Susan.  (2008).  Exercise Interventions for Dementia and Cognitive                   Impairment:  The Seattle Protocols.  J Nutr Health Aging, 12(6), 391-394.9.  Paillard, Thierry, Rolland, Yves, & de Souto Barreto, Philipe.  (2015).  Protective Effects of Physical Exercise in                   Alzheimer's Disease and Parkinson's Disease: A Narrative Review.  Journal of Clinical Neurology, 11(3),               212-219.10.  van Halteren-van Tilborg, Ilse, Scherder, Erik, & Hulstijn, Wouter.  (2007).  Motor Skill Learning in Alzheimer's                    Disease: A Review with an Eye to the Clinical Practice.  Neuropsychol Rev, 17, 203-212.

82. Works Cited11.  Puxty, John, Abbott-McNeil, Deanna, & Murphy, Susanne.  (2009). Brain and Behaviour: The 7 A's of Dementia                [PowerPoint Slides].  12.  Reisberg, Barry.  (2005, September 14).  Global Deterioration Scale.  Retrieved from                 http://geriatrictoolkit.missouri.edu/cog/Global-Deterioration-Scale.pdf13.  National Institute on Aging.  (2017, May 17).  Tips for Coping with Sundowning.  Retrieved from                 https://www.nia.nih.gov/health/tips-coping-sundowning14.  Gruetzner, H.  (2001).  Alzheimer's A Caregiver's Guide and Sourcebook.  New York, NY:  John Wiley & Sons, Inc.15.  (n.d.). https://publications.tnsosfiles.com/rules/0940/0940-03/0940-03-06.pdf.16.  Carr, Eva, Treo, Jose Luis, Busigina, Svetlana, and Torres-Aleman, Ignacio.  (2001).  Circulating Insulin-Like Growth                       Factor 1 Mediates the Protective Effects of Physical Exercise against Brain Insults of Different Etiology                      And Anatomy.  Journal of Neuroscience, 21(15): 5678-5684.

83. Works cited17.  Fleiner, Tim, Dauth, Hannah, Gersie, Marleen, Zijlstra, Wiebren, and Haussermann, Peter.  (2017).  Structured physical                    Exercise improves neuropsychiatric symptoms in acute dementia care: a hospital-based RCT.  Alzheimer's                    Research & Therapy, 9(68):1-9.18.  Chukwuemeke Uwajeh, Patrick, Onosahwo Iyendo, Timothy, Polay, Mukaddes.  (2019).  Therapeutic Gardens As a Design                   Approach For Optimising The Healing Environment Of Patients With Alzheimer's Disease And Other Dementias:                   A Narrative Review.  Elsevier. 1-14.19.  Sanchez-Valdeon, Leticia, Fernandez-Martinez, Elena, Loma-Ramos, Sara et al.  (2019).  Canine-Assisted Therapy and                    Quality of Life in People With Alzheimer-Type Dementia: Pilot Study.  Frontiers in Psychology, 10(1332):1-6.20.  Watson, Karen, Hatcher, Deborah, Good, Anthony.  (2019).  A randomised controlled trial of Lavender (Lavandula                    Angustifolia) and Lemon Balm (Melissa Officinalis) essential oils for the treatment of agitated behaviour in                     Older people with and without dementia.  Complementary Therapies in Medicine, 42:366-373.

84. Works Cited21.  Minematsu, Akira.  (2006).  The Frequency of Family Visits Influences the Behavioral and Psychological Symptoms of                    Dementia (BPSD) of Aged People with Dementia in a Nursing Home.  J. Phys. Ther. Sci. 18:123-126.22.  Cohen-Mansfield, Jiska.  (2018).  The impact of group activities and their content on persons with dementia attending                   them.  Alzheimer's Research & Therapy.  10(37):1-8.23.  Jacobsen, Jorn-Henrik, Stelzer, Johannes, Fritz, Thomas Hans, et al.  (2015).  Why musical memory can be preserved in                   advanced Alzheimer's disease.  Brain A Journal of Neurology, 138:2438-2450.24.  Elliot, Carmen.  (2019, September).  FAQ: Coding for Patient/Client Education.  Retrieved from www.apta.org.25.  APTA.  (2015, October).  FAQ: Skilled Maintenance: What Constitutes Skilled Maintenance?  Retrieved from www.apta.org.26.  APTA.  (2015, October).  FAQ: Skilled Maintenance: Documentation.  Retrieved from www.apta.org.27.  Serrano-Pozo, Alberto, P. Frosch, Matthew, Masliah, Eliezer and Hyman, Bradley T. (2011)  Neuropathological alterations in Alzheimer's                       Disease.  Cold Spring Harb Perspect Med, 1:a006189