Difficulty communicating

Effective communication is an exchange of thoughts, information, and other messages from one person to another. Since Alzheimer's patients have a brain impairment, it can be very difficult for them to understand and communicate. Word finding and other communication problems can leave patients feeling anxious, agitated, and upset. To help minimize these problems, remember to:

• allow enough time for communication-give the patient plenty of time to listen and respond
• demonstrate visually-show the patient what you mean
• maintain good non-verbal behavior-use eye contact, touch, smiles, and move slowly
• keep at the patient's eye level-if they're sitting or standing, position yourself at their level
• provide multiple clues and suggestions-"fill in the blanks" for the patient by making suggestions, one at a time
• change the subject-if you can't understand the patient after trying everything, take a break and try again later
• stay calm-the patient needs you to remain calm, even under pressure
• do one task at a time

Poor vision

Poor vision can add to already existing communication difficulties in patients with Alzheimer's. Vision is an important part of communication. Watching facial expressions, establishing eye contact, seeing gestures and nods can all help good communication. Poor vision can also increase the risk of falls and injury.

Poor vision may include apparent signs of clumsiness, falls, and bumping into things. To cope with such problems:

• eliminate visual distraction (such as too much furniture)
• experiment with lighting-not too dark and not too much glare
• when speaking to the patient, make sure you're in front of them and they can see you; avoid sitting or standing at their side
• decrease use of gestures and non verbal communication
• check the patient's medications-side effects can include blurred vision

Hearing problems

Hearing problems can aggravate the symptoms of Alzheimer's disease. They can add to a patient's isolation and confusion and, in some cases, are related to auditory hallucinations and paranoia. To cope with hearing problems:

• make sure the patient can see you well (don't sit at their side)
• use eye contact and touch
• decrease distracting background noises (such as the radio or TV)
• speak slowly and clearly without shouting; also try lowering the tone or pitch of your voice (low tones are easier to hear)
• use gestures or demonstrations
• double-check to make sure you are understood

Pain

Alzheimer's patients may be unable to tell you when they are experiencing pain. It's important that you look for secondary signs such as:

• Increase in agitation or irritability
• sensitivity to touch
• facial cues such as grimacing

If you notice these symptoms, or suspect the patient is in pain, consult your physician.

Loss of motor skills or driving ability

Deciding when a patient should or shouldn't drive is a difficult decision. Driving is often associated with one's feelings of independence, adulthood and freedom. Unfortunately, a motor vehicle is also a lethal weapon. Patients with Alzheimer's often experience problems that make driving dangerous. If the patient is unwilling to stop driving you may want to:

• request that the Department of Motor Vehicles retest the patient's driving skills
• explain the risks to your doctor and have him or her write a prescription saying the patient shouldn't drive
• disable the car
• take away the keys

Whatever you do, be sure to arrange for alternate transportation so that the patient does not become isolated when they stop driving.

Wandering

Wandering is a stressful and potentially dangerous symptom of Alzheimer's disease. It is important to consider the possible causes of wandering, including:

• stress created by too much noise or activity
• unmet basic needs such as food, toilet, or companionship
• physical problems such as pain
• inactivity
• changes in weather
• confusion about the time of day
• searching for a familiar living environment or person
• searching for a lost object
• past routines
• a reaction to hallucinations or delusions

How to prevent wandering

Even though wandering can seem like an unsurmountable problem, there are steps you can take to prevent or minimize wandering. These steps include:

• remove things that suggest leaving, such as coats or hats
• increase daily exercise
• decrease or increase the patient's stimulation
• check the patient's vision and hearing
• determine if there is a pattern to the patient's wandering (certain time of day or certain path)
• determine if there is a cause (needing something or searching for something)
• change medications

Whether you can prevent the patient's wandering or not, it is important that you make the changes necessary to insure their safety:

• provide night lights
• install door locks or alarms
• keep a current picture of the patient for reference
• have the patient wear an ID bracelet or tag with contact information
• provide a safe place to wander (such as a locked, fenced yard)

Catastrophic reactions

Catastrophic reactions are extreme outbursts of emotion, most often anger or agitation. Catastrophic reactions are difficult to work with so the best strategy is to work on preventing them. Common triggers for catastrophic reactions include:

• too many demands or too many questions at once
• too much noise and activity
• difficult tasks
• particular people
• criticism
• fatigue

You can decrease the likelihood a catastrophic reaction will occur by:

• speaking slowly and softly
• making one demand at a time
• completing each demand before moving on to the next
• avoiding fatigue
• making eye contact
• taking a break and trying again later

Once a catastrophic reaction has started there are some things you can do. Try to:

• soothe and empathize with the patient (be sure to avoid criticism)
• if possible, remove the patient from the scene of conflict
• distract or redirect the patient-offer an alternate activity the patient enjoys (such as taking a coffee break)
• get help if you need it

Keep your responses kind and supportive during a crisis and also remember to give praise and pay attention to the patient at non-crisis times (such as when they are cooperative and pleasant). That way you will reinforce the patient's behavior when they are behaving well and make it more likely that they will behave this way more often.

Bathing

As Alzheimer's disease progresses, patients need assistance in caring for themselves. Alzheimer's patients may forget the need to bathe, feel frightened of bathing, or feel uncomfortable having someone help them with such a private task. To make bathing as easy as possible try to:

• ensure privacy
• have the bath water ready beforehand
• let the patient touch the water
• gradually undress the patient
• go slowly
• give specific verbal instructions, one at a time
• avoid showering the face
• save shampooing until last
• avoid bath oils that make the tub slippery
• install non-skid stickers and grab bars; remember that most falls and injuries occur in the bathroom
• use gentle touch
• cover up mirrors if they disturb the patient

If a patient won't cooperate,

• give choices such as "do you want to take a bath or shower?"
• avoid confrontation
• try again later
• try another bather
• don't persist too long, it can cause a catastrophic reaction in a patient who is flatly refusing
• schedule baths around upcoming events; when the patient has a reason to be clean, such as going to church or having visitors, they are often more willing to bathe
• consider providing sponge baths

Dressing

Being comfortably and nicely dressed is often important to the patient's sense of well being. With clear suggestions and directions, patients are often able to do a fair amount for themselves. Encourage the patient to do as much as possible and be aware of eliminating frustrations, such as too many choices of clothing, or items that are difficult to fasten. When assisting a patient with dressing:

• lay articles of clothing out in sequence
• pick clothes that fit easily
• use specific verbal and visual cues such as "here are your socks" while handing them the socks
• give one simple instruction at a time and wait until the patient is finished before moving on
• undress only one part at a time; have the next article of clothing ready to put on
• speak gently
• keep the dressing routine as consistent as possible
• if the patient wants to wear the same thing over and over, obtain duplicates

Eating

Many Alzheimer's patients have difficulty with eating. Here are some ways to prevent such problems:

• offer one food at a time; when the person finishes with one food offer another
• make sure the place setting and foods are varied in color (otherwise it may be difficult to see where the foods are)
• try lighter weight utensils; also try serving more finger foods such as bananas, fish fillets, whole wheat bread, or breakfast bars
• check for dental problems, poor fitting dentures, mouth dryness, or swallowing difficulties
• provide a relaxing eating area (for example, an uncluttered area with soothing music)
• provide adequate fluids (dehydration is a common problem with dementia patients); avoid caffeine (it's a diuretic) and serve jello, popsicles, juices, and ice cream to increase fluids
• consider the side effects of medications (some medications may induce nausea or affect appetite)
• ask the patient's doctor if a dietary supplement such as Ensure is needed to provide additional nutrition

Medication safety

As a caregiver, it is important that you understand the effects of medications and how to use them. Be alert to possible side effects and be careful to have your physician evaluate all medications regularly.

Some other medication reminders are:

• don't ever change dosages without consulting your physician
• try to give medication at a specific time and in a specific way each time
• check to make sure the medication has been swallowed; crush pills and mix with applesauce if the patient has trouble swallowing
• keep medications in a locked place
• keep a record of medications and dosages in case of an overdose
• watch for uncharacteristic changes in the patient's mood (such as excessive tiredness or agitation); consult your physician promptly to check for overmedication

Toileting

Good toileting habits can prevent an array of health and behavioral problems. Some things to consider:

• make sure the bathroom is clearly marked with a sign (use a picture if the patient doesn't understand signs anymore)
• if the patient begins having trouble with incontinence, take him or her to the bathroom every two to four hours; do this on a routine basis (such as before meals)
• continually evaluate the level of assistance needed
• provide adequate lighting along the pathway to the bathroom
• make sure the patient's room is near a bathroom
• remember that urinary tract infections are common in elderly people; if a fever persists for more than 24 hours, contact your doctor

Depression

About 20 to 30 percent of patients with Alzheimer's disease will also develop depression. Depression is treatable. Make sure you are aware of the symptoms and seek help for the patient when they occur. Here are some common signs of depression:

• talking about or appearing "sad" or "down"
• decreased interest in previous activities
• crying more than usual
• significant weight loss or weight gain
• eating more or less than usual
• insomnia-not being able to sleep
• hypersomnia-sleeping too much
• agitation (or restlessness)
• talking less than usual
• feelings of guilt
• lack of concentration
• fatigue
• feelings of worthlessness
• recurrent thoughts of death or suicide

If a patient can no longer speak, watch their body language. See if you can notice changes in the patient's mood:

• at certain times of day
• around certain people
• during certain events

If depression is suspected, a physical exam is necessary to be sure the dementia patient doesn't have a medical condition that is affecting their mood. It is unknown what really causes depression. Some depression may be brought about by:

• an upsetting experience
• repeated changes
• sad incidents
• changes in the nervous system that are beyond the patient's control

What can you do to reduce depression in a patient?

Emotions, behavior, and thought all work together to maintain depression and contribute to a downward spiral of mood. In a depressed patient it is important to try to:

• break the cycle of inactivity
• increase pleasant events

Use your knowledge of the patient to find activities they will enjoy. Make a list of these activities and schedule them regularly (such as daily or weekly). Give the patient lots of reassurance and support for participating. Some ideas for pleasant activities include:

• listening to or singing to music
• looking at old photos
• talking about favorite topics
• going for walks or rides
• being with animals or children
• doing simple projects

For pleasant events to be successful they must:

• be fun
• be done in small steps
• be introduced slowly
• be used with encouragement
• fit the patient's abilities

Paranoia or suspicious behavior

About one-third of patients with Alzheimer's disease develop paranoid or suspicious behaviors. These behaviors can be very disturbing to caregivers. It is important not to take these behaviors personally. Be aware of factors that can aggravate paranoia:

• sensory deficits (hearing, vision) can cause the patient to withdraw or to misconstrue events
• boredom
• environmental problems (lighting/noise)
• sensory overload (too much noise/activity)
• changes in daily routine or the environment
• medications
• daylight changes in the late afternoon and early evening

When the behavior occurs, don't try to orient, correct, or argue with the patient (this can just make them feel frustrated). Instead try to:

• redirect or distract their attention
• use physical touch when appropriate
• reassure the patient that they are safe and you will take care of them

Some ways to avoid paranoid or suspicious reactions are to:

• increase lighting
• give regular reassurance
• regulate people contact
• maintain a daily routine and minimize changes
• keep the patient active
• avoid stressful activities in the late afternoon or early evening; make sure the patient is well rested and has adequate attention from you during this period

Hallucinations and delusions

Hallucinations are seeing, hearing, smelling, tasting, or feeling, things that aren't there. Hallucinations occur in about 20 percent of patients with Alzheimer's disease. The most common hallucinations are visual and auditory.

Delusions are beliefs that are contrary to the truth (such as when a patient thinks they are at a stranger's house when in fact they are at home).

Both hallucinations and delusions are secondary symptoms of the disease and do not mean that the patient is "going crazy." It is important to remain calm, consistent, and supportive of the patient when hallucinations or delusions occur. The following are some suggestions for managing these symptoms:

• don't tell the patient that they are "imagining things"-this often just upsets the patient
• respond to the fears and the feelings being expressed by saying, "that must be scary" or "it must be difficult for you"
• let the patient know that you are available to them when they feel frightened
• maintain a soothing voice
• make sure you offer as much or more attention to the patient during the times they are not having hallucinations or delusions
• change the subject or distract the patient
• check the environment for glare, shadows, or objects which might be misconstrued (sometimes events or people on television are perceived as being real; mirrors may also be confusing to severely demented patients)
• eliminate noises that might confuse the patient