Solving Day to Day Problems

•      Communication

•      Daily Grooming

•      Dressing

•      Driving

•      Mealtime

•      Sleeping Problems

•      "Sundowning"

•      Toileting

•      Wandering

•      Catastrophic Behavior

 
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Solving day-to-day problems

Communication

As Alzheimer's disease progresses, the patient may not understand clearly what is happening around them or what is wanted from them. This is a difficult problem for both the patient and caregiver. Some techniques that might help communication include:

• Speak directly to your patient, looking at them to ensure that he or she has heard you.
• Speak slowly and in a calm tone of voice.
• Use short sentences with one idea at a time. Instead of asking the patient what he or she wants, which can confuse her, use declarative sentences line, "It's time to eat now."
• Try not to discuss topics that the patient can no longer remember. Encourage talk of familiar things and times.
• Eliminate distractions, such as noise and activities when speaking. It may be difficult for the patient to sort things out.

Daily grooming

On occasion your patient may refuse to bathe. The reason for this may be that the bathing has become too complicated to complete, or the patient becomes afraid of water. Vision problems also make it difficult to distinguish the shape of the tub or shower. The person may have forgotten how to operate the water control knobs or may no longer remember what to do with the soap and washcloth. As Alzheimer's disease progresses, coordination becomes affected and this adds to safety concerns.

Whatever the reasons, avoid discussing with your patient whether or not a bath is needed. Simply say that it is "bath time." This can work more effectively if you are adhering to established routines such as time and place for a bath.

Remember to remove the lock from the bathroom door and remove razors and electrical appliances (hair dryer, curling iron) from the cabinets. Here are a few tips that might help bath time go more smoothly:

• Have everything you need prior to starting. This reduces distractions. Make sure that the room is warm enough.
• Fill tub with only a few inches of water. Make sure to check the temperature of the water.
• Avoid using bath oils or any additive that will make the surface of the tub slippery.
• Break activity into steps. Try this approach: "Here's the washcloth, wash your arm."
• Be calm and gentle, but firm; avoid distractions or discussions. It is best to focus on the task at hand.
• NEVER HURRY
• Check for skin rashes or sores. Consider using cornstarch instead of powder.
• Place a towel over the shoulders of the bather for warmth and a sense of privacy.
• Be flexible... if your loved one refuses to step into the tub, consider a sponge bath in the bedroom.

Dressing

Patients should be encouraged to continue to dress themselves as long as they are able. The past grooming habits of the patient should be considered. Routines often work the best in all daily activities.

Here are a few suggestions that might extend your patient's independence:

• Lay out or hang all clothes in the order they should be put on.
• Use numbers or magazine pictures to label clothing drawers.
• Don't ask for choice preferences.
• Remove seldom-used clothing to reduce choices. Never hurry your patient.
• Use simple garments. Velcro can replace many fasteners. Cardigan sweaters are easier to use than pull on sweaters. Jogging outfits are both fashionable and easy to put on.
• Place brushes and combs in clear view.
• Clothing can become a hazard if it does not fit properly. Be sure that the clothes being worn will not trip your patient.

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Driving

When should the Alzheimer's patient stop driving? This question is more complex than it seems. The reason: Driving is a habitual skill, and many Alzheimer's patients can appear capable of driving competently well into the disease.

Nevertheless, some troubling questions remain. For example, could the patient react instantly in an emergency? Are reflexes and muscular coordination still good? Are eyesight and hearing unimpaired? Can decisions still be made quickly and accurately? If there is any doubt about the answer to any of these questions, then the risks of driving are probably too high.

Driving tends to be an emotional subject because it represents personal independence, so try to discuss the situation calmly with the patient. Possible reactions include relief, anger and stubbornness. Offer sympathy and understanding. The Alzheimer's patient will need to express these legitimate feelings of distress and loss. But, for safety's sake, you'll have to remain firm.

It may be hard for you to "lay down the law" to a spouse or parent. However, since a confused driver is a danger to everyone, you really have no choice. If the patient insists on having the car keys, you can disable the car by unscrewing the distributor cap. (Some caregivers solve the problem by parking the car away from the house for a while.)

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Mealtime

Meals can be the high point of an Alzheimer's patient's day. You can increase the enjoyment by establishing a regular routine, minimizing distractions, and serving dishes that take the patient's limitations into account. Here are some strategies that may help:

• Serve one food at a time so your Alzheimer's patient won't have to decide which to eat first.
• Use a bowl instead of a plate to help prevent spills.
• To minimize frustration, cut food into bite-size pieces.
• Has your Alzheimer's patient forgotten how to use a fork? Watching you demonstrate the technique may bring the skill back. If not, offer the patient a spoon, or consider serving nutritious finger foods.
• Giving your patient a smaller spoon will encourage him or her to take smaller bites and avoid choking and digestion problems.
• A plastic apron and tablecloth will make cleanup simpler.
• Avoid very hot beverages to avoid the risk of scalding.

What about the patient who raids the refrigerator? You may have to lock it, especially if it contains foods forbidden for medical reasons. Or you may need to find another place to store certain foods-a small refrigerator in the basement, for example. Try to keep healthy snacks on hand to forestall indiscriminate munching.

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  Sleeping problems

Your Alzheimer's patient will probably experience changes in his or her sleeping patterns as the disease progresses. Restlessness and sleeplessness at night are common and can be stressful for the caregiver, as this can lead to the wandering behavior described later in this chapter. Some tips to minimize sleeping problems are:

• Avoid daytime naps if the patient is not sleeping through the night.
• Make use of excess energy by getting some exercise every day.
• Consult the patient's doctor about any medications that might cause sleeplessness, and before giving your patient any kind of over-the-counter sleeping aid.
• Avoid caffeine in all forms, if possible.
• Make sure your patient has used the bathroom before going to bed.
• Try to keep a consistent time and normal routine for going to bed.

Social Interaction

Many patients, especially in the early stages of the disease, go through bouts of depression as they begin to realize that Alzheimer's disease is changing their personalities and their lives. Social interaction during these early stages can sometimes ward off depression and be stimulating. Do not force your patient to interact with others, but encourage him or her to be as socially active as possible. Encourage participation in a non-demanding task or job, or in simple activities that provided enjoyment in the past.

A recent development that provides structured social interaction is the support group designed specifically for Alzheimer's patients. These groups give patients a chance to talk to others who are going through the same types of changes and are experiencing the same emotions. They can be themselves without worrying about making a mistake and feeling foolish or out of place. The groups are not available in every community, but you should check with the local hospital, churches and adult day care centers, or perhaps consider starting one in your community.

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"Sundowning"

For unknown reasons, many Alzheimer's patients became restless and agitated in the early evening, around sundown. This is called "sundowning." Some suggestions to minimize these symptoms include:

• A nap or some quiet time in the afternoon if it doesn't interfere with sleeping at night.
• An early dinner or late afternoon snack.
• Good lighting inside the house to compensate for the decrease in sunlight outside.
• Schedule more difficult activities, such as baths, earlier in the day.

Toileting

Alzheimer's patients sometimes have difficulty getting to the bathroom in time. A physical exam will allow the doctor to determine if there is an underlying medical problem.

If there is no underlying medical problem, then the accidents are due to confusion caused by Alzheimer's disease. The patient may have trouble remembering what to do when the urge to urinate occurs. Some patients have trouble remembering where the bathroom is-or remembering in time to get there. The following can help:

• Establish a regular schedule for taking the Alzheimer's patient to the bathroom. Start with two-hour intervals-as well as first thing in the morning and after naps. Adjust intervals as necessary.
• Put nightlights in the bedroom, corridor and bathroom.
• Paint the bathroom door a bright color or put an eye-catching sign on it.
• Try protective bedding and adult diapers (a nurse can help you select these products).
• You will probably need to plan on using adult diapers for your patient at some point during the illness.

Wandering

Wandering is one behavior exhibited by an Alzheimer's patient that may be difficult to understand. The consequences of this behavior could be disastrous if the patient leaves a safe and secure area. However, wandering or pacing within a secure area will not harm anyone, and can even have a calming effect on some patients. If this activity is not harmful to the patient nor particularly bothersome for you, all that is necessary is a clear pathway in the home.  

If wandering becomes a concern and the patient's safety is in jeopardy, some means of prevention must be sought. The caregiver should observe the patient to determine whether the wandering seems aimless or has a purpose. Since Alzheimer's patients usually have difficulty communicating, it is not an easy task to discover the reason for the wandering. Try keeping a written diary for a few days to help uncover a reason for the wandering. Observing the patient will usually give some clues:

• Is the path being taken for positive stimulation?
• Is your patient reacting to a new medication?
• Does your patient appear to be looking for something?
• Is your patient wandering at the same time each day such as after awakening or late in the evening?
• Is your patient wandering after a stressful situation such as arguing, loud noises, bright lights, etc.?
• Could this be a reaction to fear? Is your patient seeking security because of this fear?
• Have there been disruptions in the normal daily routine on this day?
  
  If the cause can be determined, preventing wandering becomes easier. Whatever the cause, certain preventive measures can be used to inhibit the person from wandering away from a secure area. Exercise with your patient each day. Taking walks can prevent some restlessness and agitation. It is good for both of you!
  

  Even after you've eliminated some of the triggers that cause the patient to wander, you will probably not be able to stop the behavior completely. The following are tips for coping with wandering behavior.

• Have your patient wear an ID bracelet that indicates that this is a "memory impaired" person. A name and phone number should appear on this ID.
• Notify the neighbors that you care for a memory impaired person. Explain what is to be done if they ever see your patient out alone.
• Reflective tape can be placed on clothing. This will make your patient a little more visible to others. ID should be worn by all Alzheimer's patients. Name tags sewn or ironed on to clothing can provide a name and phone number.
• Some individuals won't leave anywhere without certain personal items like glasses, shoes, their purse, etc. Use this knowledge to your advantage by placing these items in a secure place known only to you.
• If your patient does wander off, call the police immediately. Having a recent photo (and video, if possible) and a description of the patient ready for the police will save time. Most importantly, when your patient does return home, greet him/her with love and affection.

Catastrophic behavior

As the disease progresses, changes occur in the brain and body. At times, Alzheimer's patients will become overwhelmed by confusion and will become extremely upset. Oftentimes, behavior problems occur in the evening. Perhaps dealing with a confusing and seemingly threatening environment all day has tired the patient, causing negative emotions to surface. The best way to stop catastrophic behavior before it happens is to try to determine the source of the problem. If your patient has a catastrophic reaction:

• Remain calm and quietly remove the patient from the upsetting situation.
• Remember that hostile behavior can result from feeling frustrated with limitations, misunderstanding what is going on in the environment, or simply forgetting the appropriate behavior.
• Try to determine what causes this reaction. Is there a pattern?
• Avoid arguing or reasoning and provide a kind word or touch.
• Consult your patient's physician. Irritability and hostility can be a direct result of some physical pain that the patient is unable to describe.

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