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Alzheimer's Caregiving

Behavior changes and communication in Alzheimer’s

Communicating with a Confused Patient

Working with patients who are cognitively impaired presents an ongoing communication challenge. For instance, they likely will have trouble following any instructions about their care, including how and when to take prescriptions. Make sure someone can closely monitor care management, and try to involve a care partner whenever possible.

Here are some tips for effectively working with and communicating with cognitively impaired patients.

  • Try to address the person directly, even if his or her cognitive capacity is diminished.
  • Gain the person’s attention. Sit in front of and at the same level as him or her and maintain eye contact.
  • Speak distinctly and at a natural rate of speed. Resist the temptation to speak loudly.
  • Help orient the patient. Explain (or re-explain) who you are and what you will be doing
  • If possible, meet in surroundings familiar to the patient. Consider having a family member or other familiar person present at first.
  • Support and reassure the person. Acknowledge when responses are correct
  • If the person gropes for a word, gently provide assistance
  • Make it clear that the encounter is not a “test” but rather a search for information to help the patient
  • Use simple, direct wording. Present one question, instruction, or statement at a time
  • If the patient hears you but does not understand you, rephrase your statement.
  • Although open-ended question are advisable in most interview situations, patients with cognitive impairments often have difficulty coping with them. Consider using a yes-or-no or multiple-choice format
  • Remember that many older people have hearing or vision problems, which can add to their confusion
  • Consider having someone call the patient to follow up on instructions after outpatient visits
  • If the patient can read, provide written instructions and other background information about the problem and options for solutions
  • Address potential issues of driving, getting lost, and home safety each time you see the patient. And, encourage regular physical activity, social activity, hobbies, and intellectual stimulation, as well as a healthy diet. Some studies link these approaches to the maintenance of cognitive function.

Coping with Agitation and Aggression in Alzheimer’s disease

People with Alzheimer’s disease may become agitated or aggressive as the disease gets worse. Agitation means that a person is restless or worried. He or she didn’t seem to be able to settle down. Agitation may cause pacing, sleeplessness, or aggression, which is when a person lashes out verbally or tries to hit or hurt someone.

Causes of Agitation and Aggression

Most of the time, agitation and aggression happen for a reason. When they happen, try to find the cause. If you deal with the causes, the behavior may stop. For example, the person may have:

  • Pain, depression, or stress
  • Too little rest or sleep
  • Constipation
  • Soiled underwear or diaper
  • Sudden change in a well-known place, routine or person
  • A feeling of loss – for example, the person may miss the freedom to drive
  • Too much noise or confusion or too many people in the room
  • Being pushed by others to do something – for example, to bathe or to remember events or people – when Alzheimer’s has made the activity very hard or impossible
  • Feeling lonely and not having enough contact with other people
  • Interaction of medicines

Look for early signs of agitation or aggression. If you see the signs, you can deal with the cause before problem behaviors start. Try not to ignore the problem. Doing nothing can make things worse.

A doctor may be able to help. He or she can give the person a medical exam to find any problems that may cause agitation and aggression. Also, ask the doctor if medicine is needed to prevent or reduce agitation or aggression.

Tips for Coping with Agitation or Aggression

Here are some ways you can cope with agitation or aggression:

  • Reassure the person. Speak calmly. Listen to his or her concerns and frustrations. Try to show that you understand if the person is angry or fearful
  • Allow the person to keep as much control in his or her life as possible
  • Try to keep a routine, such as bathing, dressing, and eating at the same time each day
  • Build quiet times into the day, along with activities
  • Keep well-loved objects and photographs around the house to help the person feel more secure
  • Try gentle touching, soothing music, reading, or walks
  • Reduce noise, clutter, or the number of people in the room
  • Try to distract the person with a favorite snack, object, or activity
  • Limit the amount of caffeine, sugar and “junk food” the person drinks and eats

Here are some things you can do:

  • Slow down and try to relax if you think your own worries may be affecting the person with Alzheimer’s
  • Try to find a way to take a break from caregiving

Safety Concerns

When the person is aggressive, protect yourself and others. If you have to, stay at a safe distance from the person until the behavior stops. Also try to protect the person from hurting himself or herself.

Rummaging and Hiding Things

Someone with Alzheimer’s disease may start rummaging or searching through cabinets, drawers, closets, the refrigerator, and other places where things are stored. He or she also may hide items around the house. This behavior can be annoying or even dangerous for the caregiver or family members. If you get angry, try to remember that this behavior is part of the disease.

In some cases, there might be a logical reason for this behavior. For instance, the person may be looking for something specific, although he or she may not be able to tell you what it is. He or she may be hungry or bored. Try to understand what is causing the behavior so you can fit your response to the cause.

Rummaging – with Safety

You can take steps that allow the person with Alzheimer’s to rummage while protecting your belongings and keeping the person safe. Try these tips:

  • Lock up dangerous or toxic products, or place them out of the person’s sight and reach
  • Remove spoiled food from the refrigerator and cabinets. Someone with Alzheimer’s may look for snacks but lack the judgment or sense of taste to stay away from spoiled foods.
  • Remove valuable items that could be misplaced or hidden by the person, like important papers, checkbooks, charge cards, jewelry, and keys.
  • People with Alzheimer’s often hide, lose, or throw away mail. If this is a serious problem, consider getting a post office box. If you have a yard with a fence and a locked gate, place your mailbox outside the gate.

You also can create a special place where the person with Alzheimer’s can rummage freely or sort things. This could be a chest of drawers, a bag of objects, or a basket of clothing fold or unfold. Give him or her a personal box, chest, or cupboard to store special objects. You may have to remind the person where to find his or her personal storage space.

  • Keep the person with Alzheimer’s from going into unused rooms. This limits his or her rummaging through and hiding things.
  • Search the house to learn where the person often hides things. Once you find these places, check them often, out of sight of the person.
  • Keep all trash cans covered or out of sight. People with Alzheimer’s may not remember the purpose of the container or may rummage through it.
  • Check trash containers before you empty them, in case something has been hidden there or thrown away by accident.

Tips for Coping with Sundowning

Late afternoon and early evening can be difficult for some people with Alzheimer’s disease. They may experience sundowning – restlessness, agitation, irritability, or confusion that can begin or worsen as daylight begins to fade – often just when tired caregivers need a break.

Sundowning can continue into the night, making it hard for people with Alzheimer’s to fall asleep and stay in bed. As a result, they and their caregivers may have trouble getting enough sleep and functioning well during the day.

Possible Causes

The causes of sundowning are not well understood. One possibility is that Alzheimer’s-related brain changes can affect a person’s “biological clock,” leading to confused sleep-wake cycles. This may result in agitation and other sundowning behaviors.

Other possible causes of sundowning include:

  • Being overly tired
  • Unmet needs such as hunger or thirst
  • Depression
  • Pain
  • Boredom

Coping with Sundowning

Look for signs of sundowning in the late afternoon and early evening. These signs may include increased confusion or anxiety and behaviors such as pacing, wandering, or yelling. If you can, try to find the cause of the person’s behavior.

If the person with Alzheimer’s becomes agitated, listen calmly to his or her concerns and frustrations. Try to reassure the person that everything is OK and distract him or her from stressful or upsetting events.

You can also try these tips:

  • Reduce noise, clutter, or the number of people in the room
  • Try to distract the person with a favorite snack, object, or activity. For example, offer a drink, suggest a simple task like folding towels, or turn on a familiar TV show (but not the news or other shows that might be upsetting).
  • Make early evening a quiet time of day. You might play soothing music, read, or go for a walk. You could also have a family member or friend call during this time.
  • Close the curtains or blinds at dusk to minimize shadows and the confusion they may cause. Turn on lights to help minimize shadows.

Preventing Sundowning

Being too tired can increase late-afternoon and early-evening restlessness. Try to avoid this situation by helping the person:

  • Go outside or at least sit by the window – exposure to bright light can help reset the person’s body clock
  • Get physical activity or exercise each day
  • Get daytime rest if needed, but keep naps short and not too late in the day
  • Get enough rest at night

Avoid things that seem to make sundowning worse:

  • Do not serve coffee, cola, or other drinks with caffeine late in the day
  • Do not serve alcoholic drinks. They may add to confusion and anxiety.
  • Do not plan too many activities during the day. A full schedule can be tiring.

If Problems Persist

If sundowning continues to be a problem, seek medical advice. A medical exam may identify the cause of sundowning, such as pain, a sleep disorder or other illness, or a medication side effect.

If medication is prescribed to help the person relax and sleep better at night, be sure to find out about possible side effects. Some medications can increase the chances of dizziness, falls, and confusion. Doctors recommend using them only for short periods of time.

Managing Personality and Behavior Changes in Alzheimer’s

Alzheimer’s disease causes brain cells to die, so the brain works less well over time. This changes how a person acts. This article has suggestions that may help you understand and cope with changes in personality and behavior in a person with Alzheimer’s disease.

Common Changes in Personality and Behavior

Common personality and behavior changes you may see include:

  • Getting upset, worried, and angry more easily
  • Acting depressed or not interested in things
  • Hiding things or believing other people are hiding things
  • Imagining things that aren’t there
  • Wandering away from home
  • Pacing a lot
  • Showing unusual sexual behavior
  • Hitting you or other people
  • Misunderstanding what he or she sees or hears

You may also notice that the person stops caring about how he or she looks, stops bathing, and wants to wear the same clothes every day.

Other Facts that can Affect Behavior

In addition to changes in the brain, other things may affect how people with Alzheimer’s behave:

  • Feelings such as sadness, fear, stress, confusion, or anxiety
  • Health-related problems, including illness, pain, new medications, or lack of sleep
  • Other physical issues like infections, constipation, hunger or thirst, or problems seeing or hearing

Other problems in their surroundings may affect behavior for a person with Alzheimer’s disease. Too much noise, such as TV, radio, or many people talking all at once can cause frustration and confusion. Stepping from one type of flooring to another or the way the floor looks may make the person think he or she needs to take step down. Mirrors may make them think that a mirror image is another person in the room.

 If you don’t know what’s causing the problem, call the doctor. It could be caused by a physical or medical issue.

Keep things Simple…and Other Tips

Caregivers cannot stop Alzheimer’s-related changes in personality and behavior, but they can learn to cope with them. Here are some tips:

  • Keep things simple, ask or say one thing at a time
  • Have a daily routine, so the person knows when certain things will happen
  • Reassure the person that he or she is safe and you are there to help
  • Focus on his or her feelings rather than words. For example, say, “You seem worried.”
  • Don’t argue or try to reason with the person
  • Try not to show your frustration or anger. If you get upset, take deep breaths and count to 10. If it’s safe, leave the room for a few minutes.
  • Use humor when you can.
  • Give people who pace a lot of safe place to walk. Provide comfortable, sturdy shoes. Give them light snacks as they walk, so they don’t lose too much weight, and make sure they have enough to drink.
  • Try using music, singing, or dancing to distract the person
  • Ask for help. For instance, say, “Let’s set the table” or “I need help folding the clothes.”

Talk with the person’s doctor about problems like hitting, biting, depression or hallucinations. Medications are available to treat some behavioral symptoms.

Common personality and behavior changes you may see include:

  • Getting upset, worried, and angry more easily
  • Acting depressed or not interested in things
  • Hiding things or believing other people are hiding things
  • Imagining things that aren’t there
  • Wandering away from home
  • Pacing a lot
  • Showing unusual sexual behavior
  • Hitting you or other people
  • Misunderstanding what he or she sees or hears

You may also notice that the person stops caring about how he or she looks, stops bathing, and wants to wear the same clothes every day.