CASE: GROUP 1- 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.
Examination Findings
Subjective
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 5 mg / tablet OD,
Aricept 5 mg PO qHS initially, may increase to 10 mg/day after 4-6 weeks if
warranted
Memantine 5 mg PO once daily initially; increased by increments of 5 mg/day
each week; maintenance target dosage (>5 weeks): 20 mg/day PO divided q12hr
Health Habits: Previous smoker (8 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.
Objective
Observation:
 Forward stooped posture
 Thoracic kyphosis
 No use of gait aid
Gait Analysis:
 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
ROM:
 Cervical AROM:L and R rotation ½ range
 Shoulder AROM:WNL b/l
Wrist AROM:
o R wrist flexion full ROM
o R wrist extension ¾ range, limited by muscle weakness
o L wrist flexion full ROM
o L wrist extension full ROM
Manual Muscle Tests:
U/E:
o Shoulder:5/5 strength for all movements b/l
o Elbow:5/5 strength for all movements b/l
o 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
Outcome Measures:
 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
Coordination Tests:
 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
Clinical Hypothesis
Clinical Impression
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 lower extremities (L/E) can be a contributing factor
to the loss of balance, whereas the weakness in her upper extremities (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.

Intervention
Goals
 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[24] (Links to an
external site.). As well, individuals with AD make significant improvements in
performing tasks during early practicing and maintain this learning as the trials go on[24]
(Links to an external site.). 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.
Balance
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[26] (Links to an external site.). 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

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[34] (Links to an external site.). 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.
Outcome
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.