Abstract
Dementia is a leading cause of disability and dependency worldwide, with major physical, psychological, social, and economic impacts on individuals, families, carers, and society [[1]]. Population ageing will see the number of people living globally with dementia rise substantially, from approximately 57 million cases in 2019, to a projected 153 million cases in 2050 [[2]]. The physical, cognitive, and functional disability associated with dementia equates to enormous costs of care globally, with informal care provision accounting for approximately 50% of the estimated US$1.3 trillion dementia cost in 2019 [1, 3].
Individuals with dementia have higher rates of physical health issues, and are significantly more sedentary and less physically active, than people without dementia [4, 5]. Dementia is associated with reduced mobility, increased risk of falls and hip fracture, and deficits in physiological domains including reaction time, muscle strength, coordination, and balance [6, 7]. A recent large-scale international survey reported over 90% of health professional respondents agreed on the importance of health and social care professionals assessing the physical health of people with dementia [[8]]. Providing services to develop, maintain, and restore movement and functional ability, the physiotherapy profession is ideally placed (and the most commonly accessed) to support the physical health needs of people with dementia [9, 10, 11, 12, 13]. Physiotherapy is a vital component of holistic post-diagnostic dementia support and is one of the most frequently offered services to people with dementia in both high- and low-income countries [11, 14]. In Australian residential aged care, where over half of residents have a diagnosis of dementia, physiotherapy is the most prominent allied health profession, accounting for 21% of all allied health workers [12, 15, 16]. Similarly, people admitted to hospital who have dementia are significantly more likely to be assessed and require on-going physiotherapy input compared to people without dementia, with physiotherapy being the most utilised allied health service by people with dementia [10, 13].
The physiotherapy scope of practice remains dynamic and continues to respond to new evidence to support client and societal health needs [[9]]. Of particular relevance to dementia care, physiotherapy scope includes provision of therapeutic exercise and rehabilitation, carer training to facilitate physical activity and mobility, prescription of mobility aids, and pain management [[14]]. The benefits of exercise for improving strength, balance, mobility, endurance, and ability to complete activities of daily living for people living with dementia is well supported by research evidence [17, 18, 19, 20]. However, the effectiveness of the broader scope of physiotherapy interventions for people with dementia remains uncertain, with systematic and scoping reviews unable to draw consistent and definitive conclusions because of low quality and low quantity research evidence [21, 22, 23, 24].The complexity of dementia care, as a primary diagnosis or as a co-morbidity, challenges physiotherapists, who report poor knowledge, low confidence, and uncertainty about their role [25, 26]. Despite being the most utilised allied health service in dementia care, physiotherapy education and training needs continue to be under-represented in dementia research evidence [[27]]. The World Health Organisation [[28]] has emphasised the importance of dementia-specific clinical practice guidelines for future workforce training, and physiotherapists and physiotherapy students have expressed a desire to have access to clear evidence-based guidelines [[29]].
Clinical practice guidelines are "statements that include recommendations, intended to optimise patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options" [[30]]. Low quality and quantity of evidence to support the benefits of physiotherapy in dementia care does not mean that clinical practice guidelines should not be developed. In the absence of quality evidence, conditional recommendations can be developed using rigorous and transparent methodologies to guide patient improvements and minimise the risk of unintended harm. Ancillary benefits of developing consensus guidelines are the likelihood that they will explicitly encourage (and provide a focus for) further relevant research and assist in curriculum development and training needs [[31]].
Currently, no guidelines specific to the physiotherapy management of dementia exist, and the representation of physiotherapy interventions within current dementia care guidelines remains unknown. Surprisingly, this is unique to physiotherapy, with other allied health disciplines including occupational therapy, speech pathology, psychology, and radiography having discipline-specific dementia care guidelines that provide clarity to their respective professions [32, 33, 34, 35]. Development of guidelines specific to the physiotherapy management of dementia will be fundamental in supporting the knowledge, confidence, and certainty of physiotherapists about their role. It will enhance physiotherapy clinical decision making, healthcare quality, and dementia care outcomes [[30]].
Call to action
There is an urgent need for high-quality, evidenced-based, physiotherapy clinical practice guidelines to assist in the delivery of best practice, high quality care, for people living with dementia. Our team have begun the process toward guideline development with a foundational systematic review aiming to identify recommendations within existing dementia guidelines that are specifically relevant to the scope of physiotherapy practice [[36]]. This timely action is imperative if we are to support clinicians working in this critical and growing area of health and social care, who are seeking clarity for their daily practice. The development of dementia clinical practice guidelines tailored to the physiotherapy profession may support teaching in physiotherapy curricula, clinical practice activities, organisational and community standards, public policy development, and future research. As the critical needs of people with dementia and their carers continue to accelerate, our profession must address this fundamental obligation.
Conflicts of interest
The authors have no conflicts of interest to declare.