Physical and Vestibular Physical Therapy Referrals in People with Alzheimer Disease

Abstract

People with Alzheimer disease (AD) are at increased risk of falls and disproportionately burdened with vestibular impairment compared to healthy older adults. Although physical therapy (PT) and vestibular physical therapy (VPT) are effective rehabilitation interventions in improving balance and fall risk, referral patterns for these services in the AD population are understudied. A retrospective chart review was conducted of patients seen for primary AD care at a tertiary AD referral center to investigate the frequency of rehabilitation referrals. Of the 801 people with AD seen for AD care in one year, 48 individuals (6.0%) were referred to PT and 5 individuals (0.6%) to VPT. People with AD appear to receive very infrequent PT and VPT referrals, despite the potentially large number of people with AD who could benefit from PT and VPT services to improve their balance and vestibular function.

INTRODUCTION

People with Alzheimer disease (AD) have increased balance impairment compared to people without AD¹, including a 60–80% annual incidence of falls, which is twice the incidence of falls in cognitively intact older adults². Recent evidence has demonstrated that people with AD have an increased prevalence of vestibular hypofunction, which is two-fold more common (approximately 50%) in people with AD relative to age-matched cognitively intact adults (approximately 25%)³. Vestibular hypofunction is also known to contribute to balance impairment and fall risk⁴.

Vestibular physical therapy (VPT) is a specialized form of physical therapy (PT) that targets maintaining stability of gaze and balance during head movement. A substantial body of evidence supports the effectiveness of VPT in improving balance and reducing symptoms in individuals with intact cognition with vestibular impairment, including older adults⁵. People with AD have shown that they can benefit from other exercise programs and physical therapy rehabilitation interventions targeting balance and function⁶. However, the rate at which persons with AD are being referred to VPT and even PT more broadly is unknown.

In this study, we investigated referral rates for people with AD to PT and/or specifically to VPT by performing a retrospective chart review of a single institution that provides a high volume of AD care. We hypothesize that the number of people with AD being referred to PT or VPT is disproportionately lower than the 50–60% of people with AD who have vestibular and balance impairment and experience falls.

METHODS

A retrospective review of medical documentation from the Epic electronic medical record of people with AD seen at Johns Hopkins Hospital or Johns Hopkins Bayview Medical Center for AD care from July 1, 2017 to June 30, 2018 was conducted. Eligible patients were seen in the Johns Hopkins Memory and Alzheimer Treatment Center (JHMATC), a multidisciplinary clinic dedicated to AD care, or by Johns Hopkins providers who see and manage patients with AD outside the JHMATC (e.g. these providers practiced at different clinical sites than the JHMATC, or saw other types of patients in addition to patients with AD). People with AD who may have received at least one referral to physical or vestibular therapy were initially screened by CPT procedure codes: “Ambulatory Referral to Physical Therapy”, “PT Eval and Treat”, “PT Evaluate and Treat”, “PT Evaluation”, and “PT Vestibular Rehab”; or who received an International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code: “Weakness” (ICD R53.1), “History of Falling” (ICD Z91.81), “Unspecified Abnormalities of Gait and Mobility” (ICD R26.9), “Other Abnormalities of Gait and Mobility” (ICD R26.89), or “Dizziness and Giddiness” (ICD R42). Medical records with these procedure or diagnosis codes were then manually reviewed to positively identify people with AD who had a PT or VPT referral documented as an order or in their clinical notes by their provider of AD care in the specified time period. Cases with a documented rehabilitation referral were further reviewed to identify the clinical specialty of the referring physician and whether the person received therapy and for how many weeks. These data were gathered from available physician and therapist notes. This review was approved by the Johns Hopkins University Institutional Review Board.

RESULTS

As seen in Figure 1, 801 people with AD were seen at Johns Hopkins for AD care between July 1, 2017 to June 30, 2018. 48 people (6.0%) were referred to PT at least once, for a total of 51 PT referrals (Table 1). 5 people (0.6%) were referred to VPT.

Figure 1.

Identifying the rate of referral to physical therapy (PT) or vestibular physical therapy (VPT) for people with Alzheimer disease (AD).

Table 1.

Characteristics of physical therapy referrals in people with Alzheimer disease.

Physical therapy referral (n = 51)	n (%)
Clinical specialty of referring physician
Geriatrics	19(37.3)
Internal Medicine	8(15.7)
Neurology	24(47.1)
Received physical therapy
Yes	26(51.0)
No	5(9.8)
No data to confirm	20(39.2)

Four hundred and fifty-five people with AD were seen by a multidisciplinary team of geriatricians, neurologists, and geriatric psychologists at JHMATC. Of the other 346 people with AD, 171 people (49.4%) were seen by geriatricians, 22 (6.4%) people were seen by internists, and 160 (46.2%) people were seen by neurologists. Seven people had encounters with multiple AD care specialists in one year. PT referrals were from Internal Medicine (n = 8; 15.7%), Geriatrics (n = 19; 37.3%), and Neurology (n = 24; 47.1%), but VPT referrals were only at the recommendation of neurologists (n = 2) or specifically vestibular neurologists (n = 3).

The available data was next used to examine adherence to the prescribed therapy. We determined that a person had not received therapy if a provider specifically mentioned in their note that the patient did not receive therapy, or if the person died within a few days of referral. People who did receive therapy had documentation of a therapy visit. Of the people referred to PT, 51.0% received therapy, 9.8% did not receive any therapy, and 39.2% had no data to confirm whether they received therapy. Of the people referred to VPT, 1 person received VPT, 1 person did not receive VPT, and 3 people had no data to confirm whether they received therapy. From available information on 19 people who received PT, the average course of therapy was 3.3(±2.0) weeks. There were no corresponding data available for people with VPT referrals.

DISCUSSION

People with AD are known to have increased gait and balance impairment compared to peers with intact cognition¹. The annual incidence of falls in this population is 60–80%², with vestibular loss as a known contributor to fall risk⁴. Approximately 50% of people with AD are likely to have vestibular hypofunction³. Despite this high prevalence of fall risk, gait and balance impairment, and vestibular loss in people with AD, only 6.0% of people in this study were referred to PT and 0.6% to VPT. Possible reasons for people not receiving PT or specifically VPT referrals could be multifold, including 1) uncertainty about the utility of PT or VPT in people with AD; 2) inaccessibility to appropriate care; and 3) unrecognized etiologies of gait and balance issues. It is possible that the provider, therapist, person’s family, or the individual do not recognize the person’s rehabilitation potential. The individual also may not complete therapy due to lack of transportation, lack of insurance, limited access to vestibular specialists, or other factors that could make attendance at therapy sessions difficult⁷. Additionally, the low number of specifically VPT referrals suggests either that AD care providers are referring patients to general PT to address balance problems, or that awareness of the high prevalence of vestibular impairment in people with AD (~50%) is low.

These results suggest that there are opportunities to refer more people with AD to PT or VPT. PT is effectively applied in other realms of rehabilitation for people with AD, and specific strategies that use motor learning principles have been recommended for use in individuals with dementia⁸. A new framework emphasizing the motor learning abilities of people with cognitive and vestibular impairment was established and may provide useful strategies to guide balance and VPT for people with AD⁹. Given the established effectiveness of VPT in reducing falls¹⁰, these underutilized rehabilitation interventions have the potential to lower fall risk in people with AD.

Limitations of this study included its use of specific procedure and diagnosis codes in the Epic electronic medical record to identify people with PT or VPT referrals; certain referrals may have been missed. Individuals who simultaneously received care at other facilities, through hospitalizations, or specialty care at Johns Hopkins may also have received PT or VPT referrals by other providers. Additionally, we had limited data on whether people with referrals actually received therapy. Future studies can also inform which people with AD may benefit most from balance, gait, and vestibular assessment and from referral to PT or VPT to address these impairments.

In conclusion, this study conducted in a high-volume AD clinical care center suggests that the AD population at large is in large part not receiving PT and VPT services. Providing these rehabilitation services can expand the options available to people with AD and their caregivers to address balance problems and fall risk.