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"Medical Journeys" is a set of clinical resources reviewed by doctors, meant for physicians and other healthcare professionals as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.

This month: A noteworthy case study.

An 84-year-old woman with Alzheimer's disease also showed signs of losing her fine motor skills. As described by Ambreen Fatima, MPT, of Galgotias University in Uttar Pradesh, India, and colleagues in their case report in , prior to the diagnosis about 18 months earlier, the patient had been working as a schoolteacher. She was in seemingly good health, with an unremarkable medical history. Since developing Alzheimer's disease, however, she experienced falls, gait abnormalities, cognitive decline, fluctuating moods, and behavioral issues including depression and aggression. These changes interfered with her sleep patterns, social interactions, and general day-to-day activities.

Physical examination identified shoulder shrugging, and "slight disorientation and significant muscle tightness in the upper trapezius region," the team wrote. The patient also had reduced active range of motion, affecting flexion of both shoulders and cervical extension; sensation in her upper and lower extremities was not affected.

"Poor performance in reactive postural control tasks, specifically in compensatory walking when correcting for external disturbances, signals the need for physical therapy intervention," Fatima and co-authors explained. Additionally, assessments of fine motor skills through finger opposition and finger-to-nose testing indicated mild dysmetria.

Interdisciplinary collaboration was key to reducing the patient's symptoms, the case authors emphasized, adding that beyond ensuring appropriate prescription of anti-Alzheimer medication and sedatives, there could be additional benefits from a prescribed physiotherapy exercise program.

Family support was essential in persuading the patient to try the intervention. She had twice-weekly visits for the first month, then once every 3 weeks for the following 4 months, and then a comprehensive follow-up evaluation.

Treatments included passive elbow and knee movements (to compensate for the patient's limited recall of the exercises), and transcutaneous electrical nerve stimulation for pain relief, ranging from 2 to 10 Hz for 10-15 minutes.

"Our treatment plan also included postural drainage, nebulization percussion, and vibration, as well as active breathing exercises utilizing a spirometer, along with chest physical therapy," the authors wrote. The exercise regimen adhered to the guidelines outlined by the American College of Sports Medicine (ACSM).

Patient education included "cognitive strategies, relaxation techniques, the importance of physical activity and strategies to mitigate associated risks, and knowing when to seek medical advice," the team added.

Each day for 4 months, the patient performed two 20-minute sets of breathing exercises consisting of diaphragmatic and pursed lip breathing and incentive spirometer exercises. She also underwent chest physical therapy and nebulization to clear mucus from her lungs and improve breathing, and postural drainage techniques to clear mucus from the upper lobe. This improved the patient's oxygen saturation and overall well-being, the authors reported.

At 4 months, vital signs remained unchanged, but there were several positive findings:

• Slight increase in muscular strength and active range of motion

• Improved motor control of scapulothoracic stabilizing muscles

• Improved postural awareness

• Reduced back and knee pain

More problematic, however, at the time of the case report, the patient continued to have ongoing issues with constipation, "necessitating frequent administration of enemas to alleviate gastrointestinal discomfort," the team noted.

Changes in several self-reported outcome measures were as follows:

• Functional Activities Questionnaire: Score of 13/30 pre-intervention vs 18/30 post-intervention

• Generalized Anxiety Disorder 7-Item Questionnaire: 9/20 vs 12/20

• Mini-Mental State Examination: 12/30 vs 18/30

• Time Up and Go Test: 5 seconds vs 9 seconds

Discussion

Fatima and co-authors noted that physical activity consistently enhances the ability of dementia patients to perform daily activities. However, the specific frequency, intensity, and duration of exercises remain undefined, both by studies and by the ACSM exercise testing and programming , which are tailored to individuals with various chronic diseases and disabilities.

"The key is to establish shared and realistic goals with the patient, while considering not only their physical challenges, but also the social, emotional, psychological, and economic hurdles they may face," the team wrote. "It is essential that, at every stage of rehabilitation, the patient remains the focal point of the interdisciplinary team."

"Rehabilitation is a dynamic process, necessitating continually revised training programs, with effective communication and education being key components," the authors continued, adding that emotional and physical support from the family are central to this process.

Home exercise programs (i.e. strength and aerobic training) can enhance functional capabilities and reduce physical and emotional burdens on caregivers, Fatima and co-authors noted. "Furthermore, participating in exercise routines at home and within the , which involve daily activities and a gradual walking program, has been proven to boost independence in performing daily tasks and overall quality of life."

Early recognition of the signs and symptoms by caregivers, family members, and medical professionals is crucial to help allow timely intervention to increase the possibility of delaying progression of these conditions, the team concluded. "Healthcare providers should utilize the most appropriate methods when evaluating the presence of cognitive disorders."

Read previous installments in this series:

Part 1: Defining Alzheimer's Disease

Part 2: The Complex Pathogenesis and Genetics of Alzheimer's Disease

Part 3: Making the Alzheimer's Disease Diagnosis