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Basic Suggestions to Improve
Care
While no way is known to restore normal functioning to patients
with Alzheimer's disease, ways exist to modify the patient's physical
and social environment to maximize his/her capabilities and, at
the same time, minimize stress. However, since each patient is different,
not all suggestions can be universally applied.
Three basic techniques generally help the patient function as independently
as possible:
- Adjust the environment so that the patient can interact with
it in an organized and effective way.
- Have family members give assistance whenever necessary.
- Make use of community and medical resources.
Improving Orientation
The patient may experience difficulty determining where he/she
is or knowing the time of day or day of the year. He/she also may
fail to recognize a familiar face, even that of a close relative.
These and similar problems of orientation can create embarrassment,
frustration, and stress for both the patient and family members.
A number of strategies can help reduce difficulties in orientation.
One of the most important things to remember is that it is not helpful
to quiz or "test" the patient. It will only serve to frustrate
both the patient and caregiver and not improve the patient's ability
to remember information on his/her own.
Structure the environment
- Perhaps the most useful factor in preserving orientation is
creating a home environment that is simple, orderly, and predictable,
yet also allows freedom of movement. The more variability in the
patient's surroundings, the more likely it is that he or she will
become confused and disoriented.
- One room, or a portion of a room, can be modified to fit the
needs of the patient as an "orientation area." This
helps create simplicity and order in the home environment. This
orientation area should be centrally located and easily accessible.
- Items essential to the patient for daily living activities,
such as eyeglasses, keys, and writing accessories, might be placed
in this area. Thus, the orientation area can serve as a focal
location in which the patient can find orientation clues, specific
information, and items needed in the course of a day.
- A clock (perhaps digital), a calendar, and a bulletin board
or slate will provide a means for keeping track of the time and
important messages.
- A daily schedule of activities for the patient and family members
should be posted to assist the patient in remembering what appointments
or activities are scheduled and where family members are at all
times.
- Labeled pictures of family members, close friends, or pets will
help the patient associate names with faces (such as, brother
John); our cat (Sigmund).
- Structure can be imposed on the remaining portions of the house
by labeling drawers, closets, or rooms.
- Avoid changing the arrangement of furniture, color schemes,
or anything else that will reduce familiarity of the surroundings.
- Make sure that frequently used areas such as the bathroom and
hallways are well lit at night.
- Keep the bedroom located as close to the bathroom as possible
and have conspicuous cues directing the patient to the bathroom.
Cue the patient
- It is helpful for family members to provide moment-to-moment
cues for the patient. Upon awakening, some comment can be made
that tells the patient what day and what season it is. This type
of cueing is particularly helpful outside the home. (For example,
you might say, "We are at the post office to buy some stamps
and to mail a letter to our son, Fred.")
- Tell the patient in advance what is scheduled for the day, as
well as where he/she is going, with whom, and for how long. Reviewing
these activities upon their completion will also be helpful. "We
are done buying stamps and mailing the letter to our son, Fred."
These strategies can be successfully applied to most activities
of daily living. Such approaches will help maintain desired behaviors
and enable patients to function within the limits of their abilities.
Since these abilities are likely to decline with time, adjustments
in management must be made accordingly.
Some useful techniques for common activities of daily living are
described below. Since each patient is different, you may have to
make some modifications. In general, scheduling activities at the
same time each day will add a degree of predictability to the patient's
environment.
Activities of Daily Living
Washing and Grooming
Reduce activities in the bathroom to an easy and orderly sequence.
Designate a shelf for the patient's use and label and arrange the
accessories used for washing and grooming in the order they are
to be used. To remind the patient where to return each accessory,
the shape of each one can be outlined on the surface of the shelf
with waterproof tape or ink. Labeling sink valves and removing all
unnecessary or potentially dangerous instruments reduces the chance
of injury. If necessary, someone should check on water level and
temperatures for bathing. Also consider installing slip-proof surfaces
in the shower or bath, mounting support handles and rails, or installing
a bath bench. As the illness progresses, bathing may become increasingly
difficult and a source of conflict for patients and caregivers.
Having a home health aide assist with this task reduces the level
of stress on the caregiver.
Eating
You may notice changes in what the patient prefers to eat. The
patient's tastes and ability to eat certain foods will vary with
time. The family should recognize and adjust to food preference
changes, but at the same time try to make sure the patient maintains
a balanced diet.
Medications
Your family member will likely receive a variety of medications.
For some patients, a daily reminder ensures that the medication
will be taken. Sorted pill boxes, with individual compartments for
each day of the week, are available at most pharmacies and can be
used to monitor medication. However, if the patient cannot manage
his/her medication, the family or other caregiver must assume responsibility.
If the patient will be alone when medication is to be taken, prepare
single doses in advance with the appropriate instructions. These
might be placed in the orientation area. Alternatively, a neighbor
can help by dropping in when it is time for the medication to be
taken.
Personal Belongings
Whenever possible, keep frequently used personal belongings in
the orientation area. A label, and perhaps an outline of the object
marked on a shelf in the area, increases the chance of it being
returned and easily located the next time. If necessary, have the
patient practice placing the item over its outline. Misplacing eyeglasses
is a common problem. If eyeglasses cannot be kept in the orientation
area, especially if they are worn fairly often,
patients can wear them around their necks on a strap or chain. While
some patients complain that the strap is unattractive, remember
that this technique spares the frequent disruption of a house search.
Finances
Financial issues may be very threatening to some patients, particularly
the idea of not having complete control of their money. At some
point, however, you must decide whether the patient should handle
his/her own finances. At that time, legal advice may help determine
if financial responsibility should be shifted to another family
member.
Driving
Many patients in the early stages of the disease successfully drive
automobiles. However, this activity should be monitored closely.
A piece of paper with the patient's name, address, and telephone
number should be taped to the dashboard for easy access in case
the patient does become lost or confused. Although not feasible
for all individuals due to cost, a portable
phone could help a lost patient get help quickly. At some point,
the patient may become lost, especially in unfamiliar places, or
fail to respond to traffic signals. The family must then decide
whether the patient should continue driving. Withdrawing the privilege
of driving is a sensitive issue. Family members often discuss this
difficult decision with the patient's physician.
An objective driving evaluation can be helpful, particularly if
it is conducted by an individual or organization familiar with the
symptoms of dementia. Generally, driving evaluations are provided
by rehabilitation facilities. This evaluation takes the burden from
the family of "being the bad guy." However, driving evaluations
tend to be costly and typically are not covered by insurance plans.
In addition, if a driving evaluation is requested, the family must
be prepared to accept the recommendations of the evaluator. If the
family or the patient's healthcare provider have already determined
that the patient no longer is able to drive safely, a driving evaluation
may not be necessary. Some patients may forget that they have had
an evaluation and may argue with the family each time they are reminded
that they can no longer drive. A simplified letter from the evaluation
team or the patient's physician stating clearly and simply that
the patient is no longer permitted to drive, might help to refresh
the patient's memory and curtail arguments with family members over
this issue.
Exercise
Exercise is essential for good health in all individuals, and particularly
the patient with Alzheimer's disease. Exercise also relieves tension.
Incorporate exercise, such as walking or aerobics, into your family
member's daily routine, scheduling it at the same time each day.
Exercise with him or her if you can or must.
Recreation
Patients with Alzheimer's disease may still participate in games
and other activities; however, some adjustments may have to be made.
They may, for example, be able to play golf but not keep score.
On the other hand, less complex activities that require a shorter
attention span may be more enjoyable. Listening to familiar music
is often an enjoyable recreational activity for patients as pleasant
memories about events, places, and people of the past are recalled.
Travel must be planned carefully since the change in environment
may trigger confusion, which may be severe.
Communication
Patients with Alzheimer's disease often have trouble with conversation.
Poor concentration is one source of difficulty. Your family member
may have particular problems if more than one person is speaking.
- Try to be sure you have his/her attention. Call him/her by name.
- Let the person see your face as you talk. Hearing is easier
when looking at the person who is talking.
- Reduce or eliminate competing sounds. For example, turn down
the TV or radio; if noise is coming from the next room, close
the door to shut it out.
- Reduce the time listening is required. The patient may be able
to concentrate well for a short period and, after a rest, may
be ready to concentrate again.
- Alzheimer's patients may have difficulty understanding what
they hear.
- Speak more slowly than usual. Repeat or reword what you have
said when it is not understood.
- Use normal facial expressions and gestures to accompany what
you say.
- What is being said may be too difficult for patients to grasp.
They may follow one-step directions (such as, "Turn the light
on, please.") but have trouble with multi-step directions
(such as, "Please put the magazine away and then help me
set the table."). For multistep directions, give one step
at a time. When one step is completed, give he next one. If patients
have trouble listening to complicated information, such as a news
report, review the information with them, breaking it down into
terms that they can follow.
- Routine family-oriented conversation is highly recommended.
It will interest them and, because of its familiarity, should
be easier to follow. Your family member may not be able to choose
words or pronounce them as well as in the past. If he or she has
trouble talking, try to get the gist of what he or she is saying.
If you have an idea of what the person is trying to say, ask:
"Do you mean ___________?" You may need to try several
possibilities before determining the message. If you do not, ask
the person to give the message in another way. Encourage use of
alternative words, gestures, or writing. Be patient. Allow patients
time to express themselves.
- If your family member has trouble remembering what he/she has
said, remind him or her of the information if it is pertinent.
If he or she repeats the information, it is best not to say anything
about it. Patients may only feel embarrassed and frustrated unnecessarily.
If your relative hears better when you talk louder, he or she
may be experiencing a hearing loss. If you suspect that this may
be the case, bring the patient for an ear examination to a physician
who specializes in ear, nose, and throat problems and an audiologist
(one who tests hearing). These two specialists generally work
together in the same office, clinic, or hospital. If the hearing
loss is treatable, receiving treatment could improve the patient's
sense of well-being.
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