Subcortical Vascular Dementia: Case Study

Original Editor - Jonathan Tam, Summmer Bomi Jang, Emily Mulligan, Kiley Praught, Sofia Lamarche, Harrison Mah, Gary Lai as part of the Queen's University Neuromotor Function Project
Top Contributors - Bomi Jang, Jonathan Tam, Kiley Praught, Emily Mulligan, Sofia Lamarche, Uchechukwu Chukwuemeka, Lucinda hampton, Harrison Mah and Koon Kei Gary Lai

Introduction

Dementia is a relatively broad term characterizing a spectrum of symptoms that impact one’s brain function. The condition presents through a progressive and incurable  neurodegenerative disease that can impact an individual’s physical, mental and emotional health. Worldwide, an estimated 55 million people are living with dementia with this population more heavily favouring low and middle income countries. The projected increase in this number demands acknowledgement and accessibility of treatment across interdisciplinary health care professions. A challenging aspect of health care intervention on dementia is the relative inability to cure the disease therefore ceasing progression and restore pre-onset function. Due to this limitation, intervention should be focused on slowing progressive losses and optimizing function in each stage of the disease to best maintain quality of life.

The role of physiotherapy related to Dementia treatment can encompass several interventions targeting things such as; pain relief, physical deconditioning, and balance impairments Across current literature it is suggested some of the most effective physiotherapy interventions for individuals in early stage dementia include exercises to encourage mobility, develop fall prevention programs, and learn adaptations to maximize independence of the patient in their daily activities. Furthermore, related literature suggests that incorporating physical activity into treatment interventions for dementia patients can help combat cognitive deficits.

Vascular Dementia is a common type of dementia described by a blockage of blood supply to the brain resulting in the brain cells to be deprived of oxygen and nutrients, leading to death. Vascular dementia is further divided into two subtypes; subcortical dementia and cerebral amyloid angiopathy. Subcortical, as seen in the following case study, is caused by a disease of the small vessels in the brain reducing blood flow.

The current case study illustrates a patient recently diagnosed with stage three subcortical vascular dementia, who presents at outpatient neurological rehabilitation following a fall. The patient suffers several cognitive deficits related to concentration, communication, and organization. The patient also demonstrates physical deficits manifested in poor balance, weakness and overall slow motor function impacted their ability to complete daily activities. The following case study serves as a documentation of the effect of neurological physical therapy treatment interventions in rehabilitation on the patient’s experience with their diagnosis of stage three Vascular Dementia.

Examination Finding

Clinical Impression

B.B. is a previously independently functioning 60 year old female presenting to outpatient neurological rehabilitation following a minor fall 2 weeks prior. B.B. presents with several marked cognitive and physical impairments that hinder her usual activity level. At time of referral to outpatient rehabilitation, B.B. presents with various physical deficits such as diffuse bilateral lower extremity weakness, impaired coordination and imbalance. Noted cognitive deficits include; attention impairment, inability to maintain concentration and communication difficulties. However, psychomotor slowness appears to be the most pronounced impairment relating to both physical and cognitive functioning. The interaction of these deficits are reflected in B.B.’s slow and unsteady motor functions, and seemingly unorganized and limited communication abilities. Previous transient ischemic attack, subjective and objective assessment findings and hallmark characteristic of psychomotor slowness correlate with the diagnoses of stage three Vascular Dementia otherwise known as Binswanger Disease. The diagnosis of this condition has impacted B.B.’s independence. B.B. has difficulty completing her BADLs and IALDs due to imbalance and perceived fear of falling and is frustrated due to inability to easily organize and communicate thoughts. B.B. is hoping to gain strategies to combat these deficits in order to be able to feel comfortable babysitting her grandchildren again, as she has felt isolated from them in the process of her diagnosis. Previous independent function, limited medical history, age, available support from her husband and stage of diagnosis are factors indicating that B.B. is a suitable candidate for neurological rehabilitation in an outpatient setting. Interventions focused on improving balance, fall prevention, and strengthening could support achieving optimal function for the current stage of diagnosis of this progressive neurodegenerative disease.

Problem list:

1. Progressive balance deficits causing increased falls risk reflected objectively through BERG Balance score of 36/56, and subjective reports of feeling unsteady.
2. Right and left lower extremity weakness shown through decreased MMT scores.
3. Marked slowness in motor function presented through TUG time of 17.5 seconds, 6 minute walk test distance of 136m with 2 breaks and observed through gait spatial parameters.
4. At risk of developing further complications, accelerating progression, and intensifying disease impact through comorbidities and unfavourable lifestyle habits such as high BMI, hypertension, and sedentary lifestyle.
5. Memory impairments reported through subjective history as forgetfulness and objective assessment as a positive result in a mini-cog test.
6. Slow and uncoordinated movements reflected in observation of finger-to-nose test and inability to complete task under more complex conditions such as a moving target. Dysmetria noted in heel-knee-shin test bilaterally.
7. Frustration related to impaired cognitive functioning causing difficulties related to thought organization, communication and concentration.
8. Feelings of concern related to lack of independence in daily activities and being a burden due to reliance on social support system.
9. lack of education on diagnosis and typical disease progression.

Intervention

Our goals for B.B.:

• Improve Berg Balance score to 48/56 in 4 weeks to reduce falls risk.
• Increase lower extremity manual muscle tests to 4/5 bilaterally in 4 weeks.
• Increase community participation by signing up for weekly tai chi class in 4 weeks.
• Increase ambulatory endurance to be able to complete grocery shopping independently in 8 weeks.

B.B's. treatment plan

Physical therapy (PT) is indicated in this case. PT has shown to improve or slow loss in mobility, strength, balance and endurance (HELP, (Rolland, 2012)Forbes, et.al, 2014). These improvements correlated to improved functional independence in mobility and ADLs in individuals with dementia (HELP, (Rolland, 2012)(Forbes, et.al, 2014) ). There are no guidelines to best practice and many studies do not state the therapeutic interventions used, however, consistent with general best practice guidelines we will focus on making therapy engaging, functional and task oriented.

In the initial stages, we will do community based physical therapy two times per week focusing on improving functional abilities and balance. The goal of this initial stage is to improve B.B's. functional abilities so they can safely participate in exercise/physical activity outside of the clinic.Intervention plan in this stage will include primarily balance and lower extremity strength training:

• Balance training: 30 seconds twice per day, 3 days per week.
  • Progression from normal stance width → narrow base of support → tandem stance → single leg stance → standing with trunk rotation
  • Balance training will be done on hard surfaces (tile or wood flooring) and transition to soft surfaces (carpet or even standing on a pillow).
  • In clinic we will do perturbation based training. Including tossing/catching a ball and therapist delivered external perturbations.
    • This will only be done in clinic for safety reasons.

• Lower extremity strength training: 10 reps, 2 sets, 2 minutes rest between sets, 2-3 days per week.
  • ¼ squat (be done at a counter or table for balance support if needed)
  • Sit to stand
  • Knee to counters
  • Step ups (beginning with the support of a railing and progressing to without)

¼_squat

Once balance deficits are improved upon, we will drop down to one physical therapy session biweekly to focus on maintaining function and slowing disease progression. At this transition point the patient can transition to exercise in the community. We will provide B.B. with extensive education about the benefits of regular physical activity on delaying disease progression and optimizing function. We would prescribe B.B. to engage in physical activity consistent with Canada’s Exercise Guidelines for Older Adults (>65). While the Canadian Alzheimer's Society simply recommends the guidelines for adults, we would use the ones for older adults since they include the addition of weekly balance training (HELP3). These guidelines include:

• 150min moderate to vigorous physical activity, 2 days muscle/bone strengthening exercise per week plus weekly balance training (HELP2).

For aerobic and strengthening exercises, we will implement the use of serious games. Serious games refer to any game thats primary purpose is something other than entertainment. There are many different serious games which have shown to improve physical fitness, functional mobility, strength and balance in older adults (Soares et. al, 2016)(Rossito et. al, 2014). Additionally, they have also been shown to increase exercise compliance in older adults (Rossito et. al, 2014). There are various options available but finding one (or more) that B.B. enjoys is key.

In terms of balance training, we will advise B.B. to sign up for a tai chi class each week. Tai chi has been shown to improve balance, reduce falls and improve quality of life as well as short term cognitive function in dementia patients (Lim et. al, 2019)(Nyman et. al, 2019).

We have chosen to transition B.B. to community based exercise to promote independence and make B.B. a more active member of their community. We have also chosen to keep regular appointments to monitor B.B. as their disease progresses and adjust our treatment plan as needed.

Outcomes

After 4 weeks, objective measures were performed again to determine the improvements that were made after the various exercises and treatments were performed. The Berg Balance Scale was re-administered giving a score of 48/56. Her gait speed decreased to 0.69 m/s (MCID=0.13 m/s) as well as the TUG decreasing to 13.1 secs while the dual task TUG decreased to 27 secs. Her ABC scale score increased to 60 which indicates she is in the moderate level of confidence for patients. For the other cognitive tests, her mini-cog test score remained at a 1 while the MoCA score re-administered by the OT decreased to a 23/30. Her dysmetria has decreased as her coordination increased during the heel-shin test.

The changes in her MMTs after 4 weeks are listed in the chart below

Muscle group	Right	Left
Shoulder Flexion	4	4
Shoulder Extension	4	4
Elbow Flexion	4	4+
Elbow Extension	4	4+
Hip Flexion	4	4
Hip Extension	4	3+
Knee Flexion	3+	3+
Knee Extension	4	3+

Overall, these 4 weeks has helped her with her overall confidence and independence. She may still require some assistance in her BADLs and IADLs after discharge that her husband or son can help with. If they are unable to, then a personal support worker (PSW) may be referred to help her at home when needed. She will also still need referral/continued treatments to a speech-language pathologist to address her primary progressive aphasia. She also will need to be referred to a neuropsychologist to continually assess her cognition as the dementia progresses.

Interprofessional Interventions

Neurologist

A neurologist would play a crucial role in the long-term care of B.B as she copes with diagnosis and progresses through the stages of the of stages of Vascular Dementia. This field of medicine the relationship between the brain and the behavioural or cognitive presentation of an individual, with an emphasis on neurological disorders. Since the cognitive losses caused by dementia are such a hallmark feature of the disease, proper assessment and treatment interventions are critical to optimizing function.A neuropsychologist could conduct assessments to determine level of cognitive functioning while tracking the impact of disease progression on this level over time. In additional to assessment, a neurologist may offer medical treatments to reduce symptoms as interventions that lie beyond the scope of physiotherapy. Finally, a neurologist may also assess the efficacy of rehabilitation and medical strategies on function. As reflected in this case study, the inclusion of neurology into B.B's health care offered critical importance to her correct diagnosis of Vascular Dementia through use of Frontal Assessment Battery (FAB) Test, and the ordering and interpretation of imaging. A neuropsychologist could offer these assessments as well as continuous treatment interventions that target B.B's cognitive deficits relating to memory, concentration, planning and communication.

Occupational Therapist

Including an Occupational therapist in B.B's treatment is important for therapeutic treatments to maintain skill or develop new strategies to complete activities of daily living. An Occupational Therapist would work in collaboration with B.B to determine areas in which her disease presentation is affecting her daily life and develop learning strategies to overcome or adapt to these effects while promoting independence. Therapeutic interventions over the course of dementia progression can include; adapting home environment, graded assistance training in ADL/BADL performance and recommendation for equipment usage such as mobility aids.

Speech Language Pathologist

Referral to a speech language pathologist would be beneficial as the profession focuses on the identification and treatment of speech/language disorders and cognitive communication.

Discussion

B.B. is a 60-year female who was initially diagnosed by a physician with Stage 3 Vascular Dementia Subcortical Subtype (also known as Binswanger’s Disease) and referred to an outpatient neurological rehabilitation centre. She was first admitted to a hospital due to a minor fall 2-weeks ago. Furthermore, it is believed by the PCP that B.B. had suffered a TIA within the past few months but went undiagnosed and untreated. Before present, B.B. was completely independent in all BADLs and IADLs despite living with a sedentary lifestyle and controlled hypertension.

As of late, B.B. has noticed a decrease in her abilities to perform ADLs independently, decreased confidence in balance and strength, and several symptoms of cognitive decline including (but not limited to) memory loss, psychomotor slowness and weakness, and difficulty organizing her thoughts. Although Vascular Dementia is incurable, it would be beneficial for the interprofessional team to manage and prevent complications.

Regarding problems amenable to physical therapy care, it is remarkably important to address B.B.’s lack of confidence in balance by improving balance, strengthening weak muscles that may contribute to impaired balance, and maintaining functional range of motion. Some problems that physiotherapists may not be able to treat but ought to keep in mind include B.B.’s memory impairments, unpredictable changes in mood, behaviour, and personality, and Primary Progressive Aphasia which may cause difficulty communicating with the patient.

Specific to B.B’s treatment plan, the physical therapists will provide her with community-based PT treatment two times per week, primarily focused on improving balance and functional abilities. Following Canada’s Exercise Guidelines for Older Adults (>65), there will be 150 minutes of moderate to vigorous aerobic exercise and two days of strengthening exercises each week in addition to balance training. Strategies employed to improve compliance include the use of serious games and activities that B.B. enjoys such as Tai-Chi.

*talk about pre- and post- outcome measures for this case!*

In conclusion, this case study demonstrates the challenges, impairments, and management interventions that can be used for patients with early stage Subcortical Vascular Dementia. The study also provides evidence of interventions and associated outcome measures that may be beneficial for this population. It is always important to understand problems within the scope of PT practice and when to refer out to other healthcare providers. Lastly, while this case study provides one way of providing treatment to this population, interprofessional teams ought to consider the context of each individual patient and their related goals.

Self-study Questions

1. Which of the following a common symptom in patients with Subcortical Vascular Dementia?

A) Psychomotor slowness 

B) Memory impairments

C) Mood changes 

D) Balance deficits

E) All of the above

2. Based on B.B.’s case, she received a score of 36/56 on the Berg Balance Scale, putting her at risk for falls. In order to improve her balance, what is the best evidence-based intervention that may benefit B.B.’s return to the community?

A) Mental imagery of balancing on one-leg

B) Tai-Chi

C) Tying her lower extremities together to challenge balance with narrower BOS

D) Sitting on a bed with no upper extremity support while the therapist adds external perturbations (e.g. shoves, lean and release, etc.)

3. Which of the following may NOT be an appropriate outcome measure for B.B.’s case in the initial assessment?

A) Community Balance and Mobility Scale (CBMS)

B) Timed Up and Go (TUG) Test

C) Activities-specific Balance Confidence Scale (ABC)

D) 10-metre walk test 

Answers: 1) E 2) B 3) A

References

not sure which style yettttt :)