By Beth Cayce, MPT, Gerontology — Founder & CEO, CaraVita Home Care
October is National Physical Therapy Month, and this year the American Physical Therapy Association is building its campaign around a phrase I wish every family I meet could hear: PT For Future Me.
The idea is that the strength and mobility you build today are what carry you through the decades ahead. I trained as a physical therapist before I ever started a home care company. That training is still how I see people.
When I walk into a home, I notice how someone rises from a chair, whether they reach for a wall in the hallway, and which shoulder they favor coming up the front steps. Those small mechanics tell a story about what the next year is going to look like.
So let me tell you the part of the physical therapy story that does not get enough attention. It is not what happens during therapy. It is what happens the week after it ends.
The Discharge Cliff Nobody Warns Families About
Here is how it usually goes.
Your mother has a hip replacement, a bad spell of pneumonia, or a hospitalization that left her weaker than she went in. Physical therapy follows.
For a few weeks, someone comes to the house, or she goes to an outpatient clinic, and there is structure. Someone is watching. Someone is counting repetitions and adjusting the plan.
Then the authorized visits run out.
The therapist writes up a home exercise program, walks through it, hands over a printed sheet with stick-figure diagrams, and says the thing every therapist says:
Keep doing these. And then the house goes quiet.
Research on this is not encouraging. In a study of 556 adults over 65 who had been discharged from physical therapy, 90% said they had been given a home exercise program — and 37% were no longer doing it.
The reasons were not laziness or stubbornness. They were barriers: a change in health status, weather that made it hard to get moving, weakness, shortness of breath, low confidence, and a quiet belief that the exercises would not make much difference anyway.
That last one is the heartbreaker.
Fear of falling was one of the barriers associated with not exercising. So the very thing the exercises are meant to address becomes the reason they stop.
The gains earned over six weeks of skilled therapy can begin slipping away without continued activity. And the loss is rarely dramatic enough for anyone to notice in the moment.
It is a slow give. One less trip down the driveway. A chair moved closer to the kitchen. The upstairs bedroom traded for the den.
What “Just Do Your Exercises” Actually Asks of Someone
Put yourself in your father’s slippers for a minute.
He is 81. His knee aches most mornings. The handout says ten repetitions of four exercises, twice a day.
He is not sure whether the tightness in his calf on exercise three means he is doing it right or doing it wrong. There is nobody to ask. The clinic number goes to voicemail.
His daughter calls on Sundays and asks how he is doing, and he says fine, because what else do you say?
By Thursday, he has done the exercises once. By the following week, he has decided he will start again Monday. None of this is a character flaw.
It is what happens when you take a clinical routine built on supervision, feedback, and accountability and remove all three at once.
When Dementia Is in the Picture, the Cliff Becomes a Wall
Everything I just described gets harder when the person also has Alzheimer’s disease or another dementia.
Not a little harder. Categorically different.
Start with what a home exercise program assumes.
It assumes you can read a handout. It assumes you remember on Tuesday what you were shown on Monday. It assumes that at some point in the day, without anyone prompting you, you decide to begin.
Those are exactly the kinds of abilities dementia can disrupt.
Here is what I have watched happen more times than I can count. A woman with moderate dementia has a terrific therapy session. She follows the cues. She does the sit-to-stands. Her balance visibly improves over four weeks. She is a model patient.
And an hour after the therapist leaves, she may have no memory that anyone was there.
The handout on the counter means nothing to her because reading it requires knowing why it is there.
What is remarkable — and hopeful — is that the movement itself may remain even when the memory of learning it does not.
Memory for familiar movements and practiced skills relies on different brain systems than memory for facts and recent events, and these abilities can remain more durable in many people living with dementia. A person may not remember having therapy yesterday, yet when someone demonstrates or begins a familiar exercise with them, they may be able to continue the movement correctly.
In a very real sense, the body can remember what the calendar does not. That single fact should change how these cases are handled, and too often it does not.
Where It Goes Wrong
When a therapist has not been trained in dementia, a few predictable things can happen. Verbal instruction gets used where demonstration is needed.
“Now I want you to shift your weight to your left leg and raise your right heel.”
That is several pieces of information in one instruction. For someone with dementia, it may simply be too much to process.
Show the movement. Do it alongside them. Give one cue at a time. Use touch if necessary. The same person may perform it beautifully.
Pain gets misread as behavior. People with dementia may lose some of their ability to identify, describe, or communicate pain. Pain may appear as resistance, agitation, pulling away, or simply refusing to stand. Instead of assuming someone is being “uncooperative,” we need to ask: What might this person be telling us? Could something hurt? Sometimes the resistance is the report.
Therapy may end for the wrong reason.
Families may be told their parent is not a good rehabilitation candidate, is not making progress, or cannot carry over instructions.
If you are told therapy is ending because your mother is not improving, it is worth having a conversation rather than simply accepting the conclusion. Ask the provider directly whether maintenance therapy may be appropriate in her case.
What Dementia-Trained Care Actually Looks Like
A therapist who understands dementia may use the same exercises — but deliver them differently.
Use the same time of day whenever possible, because routine can do some of the work that memory cannot. Give one cue at a time. Demonstrate first. Embed movement in something meaningful: walking to the mailbox rather than “gait training,” or reaching for cups in the cabinet rather than “overhead range of motion.” Keep the environment simple because clutter and distractions compete for attention. And learn the person’s best hours.
Capability in dementia is not always a fixed number. It can change across the day. Then the therapist leaves. And much of that has to continue with whoever is in the house.
The Part Families Are Set Up to Miss
Adult children are often the last to know that mobility is slipping — and not because they are inattentive.
They are working from snapshots: a visit, a phone call, a holiday. Their parent, meanwhile, is quietly adapting.
People are extraordinarily good at reorganizing their lives around a limitation until the limitation is nearly invisible to someone looking in from the outside. The signs are often observable, but you have to be there on an ordinary Tuesday to see them:
- Pushing off both armrests to stand when a month ago one hand was enough.
- Touching the wall, counter, or furniture while moving through the house — what therapists call furniture walking
- Taking the stairs one at a time, with both feet landing on each tread
- Turning with several small steps instead of one smooth pivot
- A new reluctance to leave the house that gets explained as simply “not feeling like it”
- Meals becoming simpler because standing at the counter has become harder
- Wearing the same clothes because picking them up from the chair is easier than going to the closet.
These kinds of changes may signal declining mobility or function. But somebody has to notice them.
Where a Caregiver Actually Fits
I want to be precise here because this is where families can become confused about the role of home care.
A caregiver is not a physical therapist, and no caregiver should invent exercises or independently modify a therapist’s plan.
That is not their job. The role is closer to what a training partner does — and it is more valuable than it sounds.
A caregiver is there on the ordinary Tuesday. They can set out the handout and chair at the same time each morning and in the same manner, so the program becomes a routine instead of a decision. They can count repetitions out loud. They can walk alongside someone on the driveway loop. They can provide permitted medication reminders so prescribed medications are taken according to the person’s care plan. And they can notice that Wednesday’s session was cut short because of shoulder pain — and Thursday’s was, too.
That last piece matters enormously.
It is where a caregiver stops being simply an extra pair of hands and becomes an important observer in the larger care picture.
At CaraVita, our caregivers are W-2 employees with a clinical team behind them — nurses and care coordination staff to whom they can report changes.
When a caregiver notices that a client’s gait has changed or exercises are being skipped because of new pain, that observation does not simply sit in a notebook. It moves. It reaches the family and the professionals who can determine whether additional assessment or a return to therapy may be appropriate.
Why Dementia Training Is Not an Optional Extra
For a client living with dementia, the caregiver’s role becomes even more important.
The person may not independently remember to begin the program. Someone may need to initiate the routine, demonstrate the movement, and provide the cues that allow the person to participate.
That work requires skills that are not necessarily intuitive.
Knowing to demonstrate rather than over-explain. Knowing that a refusal at 4 p.m. may reflect fatigue, discomfort, or pain — and that the same invitation may be received very differently at 10 in the morning. Knowing how to begin an activity with someone rather than directing them to do it. Knowing not to quiz or correct: “Don’t you remember? We did this yesterday.” That may accomplish nothing except creating frustration. And knowing that agitation during a transfer may be information about what the person is experiencing physically — not simply a “behavior.”
A caregiver without that training is not a bad caregiver. They are being asked to improvise a specialized skill set that nobody taught them, in someone’s living room, often alone.
This is why I built dementia training into our own program rather than treating it as a specialty add-on.
Our Dementia Life™ program exists because caring well for someone with dementia is a discipline with its own methods — not simply general caregiving performed more patiently.
When a caregiver trained this way notices that a client is bracing during transfers or that the morning walk has quietly gotten shorter, that observation reaches our nurses and care coordination staff — and it reaches the family.
After 28 years of running this company, I have become convinced that many declines we call “sudden” were not sudden at all. They were visible for weeks to someone who happened to be standing there.
Six Questions to Ask Before the Last Therapy Session
If your parent is approaching discharge, do not let the final visit go by without asking:
1. Which exercises matter most if she can only manage two?
Ask the therapist to prioritize. A short program that gets done is more useful than a complete program that does not.
2. What should the exercises feel like — and what should make us stop?
Families need to understand the difference between expected exertion and a warning sign.
3. What specific milestone would tell us she is losing ground?
Ask for something observable: walking distance, chair-rise ability, assistance required, or another measure appropriate for your parent.
4. What would warrant coming back to therapy?
Know what changes should prompt a call to the therapist, physician, or other healthcare professional.
5. What in this house is working against her?
Ask the therapist to look at the environment before therapy ends.
6. If memory is a factor, who is going to start these sessions?
If your parent cannot reliably initiate the program independently, say so plainly.
Ask the therapist to demonstrate the exercises to the person who will actually be helping. Ask for the cueing language that works best.
And if you are being told therapy is ending for lack of progress, ask whether maintenance therapy should be considered.
Write the answers down. Put them where the caregiver can read them.
What I Want You to Take From Physical Therapy Month
The APTA’s theme this year is about the future version of yourself that today’s movement protects.
I would add one thing, after 28 years of watching families in Metro Atlanta navigate what happens after therapy.
Physical therapy can accomplish tremendous things. But the weeks after therapy ends are where gains can begin to come apart — quietly, in homes where the small changes may go unnoticed.
And when dementia is part of the picture, having someone there who understands how to initiate, cue, observe, and communicate becomes especially important.
The exercise that helps keep a person moving only works if it actually happens. For someone who cannot reliably remember or initiate the routine, that may require another person to help begin it in a way that works with how that person’s brain is functioning now.
That is a solvable problem.
It requires somebody to be there, to know what they are doing, to notice when something changes, and to reach out to the person’s support team when it does.
CaraVita Home Care has served families in Roswell, Alpharetta, Sandy Springs, Milton, Johns Creek, and across North Fulton since 1998.
If your parent is coming to the end of a course of physical therapy and you are not sure what comes next, we are glad to talk it through.
Call CaraVita at 770-643-1712 or visit caravitahomecare.com
If you or an aging loved one is considering home care in Alpharetta, GA, please contact the caring staff at CaraVita Home Care today. (770) 643-1712
