Lecture # 412:
Progressive Neurological Diseases - Alzheimer's Disease

copyright 2008 Cheryl K. Hosken, BSN, MS Psych.

Shirley's husband talks to you one day about the person his wife used to be. At the age of 50, she was a successful florist. She owned her own business consisting of a flower shop and greenhouse. She supervised two gardeners, an accountant, receptionist, and a driver. Three years later, she moved to even larger facilities and had 15 employees.

Gradually, though, she became more and more forgetful. She forgot her keys and forgot to keep appointments. By the time she was 55, she accused her husband and employees of taking her eyeglasses, jewelry, and other items. She couldn't manage the business anymore. Her driving was erratic and we feared an accident.

One day, she got lost driving to work. A policeman saw her weaving in and out of the traffic lanes. He stopped her and asked to see her documents. Shirley became angry with him and asked his name and why he used his siren. She agreed to go to the hospital for tests. The family came to see her. She sat up in bed and looked at all of them and asked, "Who are you?" She did not recognize her own husband and children.

Meditate Word By Word On These Verses:
1 Cor. 12:21-27.

Why do Alzheimer's Victims Become Confused?
When the ability to know, think, understand, remember, solve problems, and create decreases, these mental activities, called cognitive function, result in confusion. Confusion is a symptom of memory loss, a condition that occurs when a person has cognitive impairment.

Some people think that confusion from memory loss is the result of the aging process. However, most people over the age of 65 do not behave in a confused way. Healthy, older people are able to think and remember about as well as they did when they were younger. Most middle-aged and older adults have the capacity to learn, remember, and solve problems.

Cognitive impairment is not part of the aging process, but the result of changes in the body. For example, a person may be confused after taking a new medication. Someone who suffers a vitamin deficiency may suffer memory loss. These cognitive impairments can be reversed. Cognitive impairment can be caused by illnesses such as brain tumor, stroke, depression, hypoglycemia, heart attack, and alcoholism. When these conditions are medically treated, memory usually improves.

Some kinds of cognitive impairment are chronic and cannot be reversed. These conditions are called dementias. The brains of these people cease to function normally. An affected person exhibits changes in personality, becomes confused, is increasingly unaware of surroundings, and eventually is incapacitated.

Question 1: What causes cognitive impairments?

Alzheimer's insidiously weaves itself through the brain, leaving bundles of useless nerve cells and abnormal chemical deposits. Neurologists can accurately diagnose 9 of 10 cases of Alzheimer's disease by clinical symptoms, CAT scan, and laboratory tests. Alzheimer's originates in the hippocampus or memory bank of the brain. Classically, a deficit in short-term or recent memory is the first sign to tell us something is wrong. Mild memory loss is a natural consequence of aging. Usually, a person does not remember a name, but in a few moments, the name is recalled. The problem does not worsen or interfere with activities of daily life.

Next, it attacks the cerebral cortex where information coming in from the senses is processed. Those areas that control language functions, reasoning and abstract thinking are affected. Patients usually do not die of the disease itself, but of complications of the disease. One woman got into the bathtub to wash her father-in-law because he just looked at the soap and washcloth, not knowing what to do with them.

Responding to the Person with Alzheimer's
Oftentimes the persons' behavior seems inappropriate. When you see this type of behavior in an Alzheimer's person, try to think of it as the person trying to tell you something in the only way they can. Our job is to observe and think about this behavior to find out what the person is trying to say. The dysfunctional behavior of an Alzheimer's person has some common patterns. These are called social facade, pacing, rummage and hoard, catastrophic reactions, and confusion as evening approaches. They may say things that are not sensible, things seen that are not real, and believe in things that are not true.

Social Facade
In social situations, the Alzheimer's person may pretend to know familiar faces. This is an attempt to keep dignity and self-respect. Because people do not look ill, they can hide their illness. If this happens to you, how should you respond to such a person? A polite response may be, "You may not remember me. I am Olga Borisovna. We were in the same high school class in 1955." Good communication with Alzheimer's patients means speaking directly to them using eye contact, using short sentences, and speaking slowly. Give information the person needs to respond. For example, "Anna Petrovna, your husband is coming into the house. He looks well today."

Question 2: Loss of ability to think and reason is called ___________ _____________.

Pacing and Wandering
The person may walk aimlessly in an area and then walk away. The pacing and wandering may have several causes. There may be over-stimulation from too much noise or talking. The person may be looking for something or someone. The person may not like what is happening around him. Here are some things you can do to defuse this behavior:

• Reassure the person. Listen to what he says. Ask if you can walk with him and guide him to a place where he seems more comfortable.
• Distraction may help. Offer a snack, take a walk, do something to stop the pacing so anxiety does not increase.
• Take the person to the toilet.
• Observe for signs of restlessness and fidgeting. Give him a ball or another smooth object to manipulate with his hands.
• Remove his shoes. Sometimes this prompts an old memory, meaning the person should sit or lie down.
• Help the person to locate his bedroom or toilet by placing a familiar object on the door of the room.
• Take steps to prevent a person from leaving the house by changing the type of lock.

Rummaging and Hoarding
This behavior is exhibited when there is a feeling of being lost or simply that a person cannot find what he wants. The person opens drawers and takes things out to hide in another spot. Here are some suggestions:

• Try distracting him. Offer another activity. Show him where his things are located.
• Take him to the toilet. He may have been searching for it and got distracted.
• Keep a set of keys in a place out of his reach. Put valuables away.
• Learn where the hiding places are so that you can find lost items.
• Provide a drawer that is for rummaging filled with interesting, safe items.

Question 3: Anna Petrovna keeps taking things from around the apartment and hiding them in different places. Today, you cannot find the keys to the apartment door. You should:
(Only one of the following answers is correct.)
scold her so that she will feel badly and not take things.
keep her confined to her room so that she doe not have the opportunity to take things.
try to keep important items like keys out of sight and inaccessible to Anna.

Catastrophic Reactions
You may start working with your Alzheimer's person and suddenly he begins to yell and call you names. He tries to hit you. This is called a catastrophic reaction. Whenever a situation overwhelms his ability to think or react, the tendency is to overreact because there is an inability to control impulses that come from the brain. At times the person will physically strike out against others. Here is what you do:

• Tell the person who you are, "This is Lena, your helper."
• Acknowledge the anger by saying something like, "You seem very upset. What is upsetting you?" or "Are you frightened of something?" or "You seem uncomfortable, is something making you feel uncomfortable?" or "Do you have pain?" After each question, wait for a verbal or nonverbal response.
• Reassure the person that you will not hurt them.
• Let the person know there are limits to this behavior that could hurt another person by saying, "It is not alright to hit someone. That hurts."

Sundowning
As late afternoon approaches, you may notice that the person gets more and more restless or confused. He may be more demanding, upset, and suspicious. This may be "sundowning," which is common to people with Alzheimer's. During the day, this person may become tired as the hours pass and less able to cope with daily activities. Approaching darkness may cause him to be afraid. Instead of communicating his needs, he may have the following behavior:

• a restlessness, worried expression
• reluctance to enter his room or brightly lighted areas
• crying
• taking off his clothing
• pushing others out of his way
• gritting his teeth and wringing his hands

These signals may mean there are real physical needs such as going to the toilet, being hungry, or having pain. They may also mean that the person remembers that loved ones are not around him.

It is important to respond to these people in a loving way. Talk quietly with him, Don't turn on lights brightly, tell him that you will stay with him for a while, rub his back if he allows it. Play soothing music or give him something to do or hold. For example, we give our Alzheimer's people magazines with pictures or simple wooden blocks they can stack or arrange in patterns. Maybe there is some activity they liked doing before that you can give them to do. One of our ladies liked music so we gave her a radio tuned into only one station. Some people simply like to walk back and forth in a room.

Find out his previous daily schedule and try to follow that pattern. For example, if the person got up early and after lunch, took a nap, do follow the same schedule now. Don't argue or ask the person to make decisions during this anxious time. A person who reacts this way is responding to something internally or externally in his environment. This behavior is not done to make life difficult for the caregiver.

Question 4: Mr. Karkhov has Alzheimer's Disease. Each evening, between 5-9 P.M. he paces the apartment and pulls at his clothes. He empties his closet, screams if anyone tries to confine him, and begs visitors to take him home. What is not a beneficial approach to managing his behavior?
(Only one of the following answers is correct.)
Keep Mr. Karkhov active in the mornings and encourage him to rest after lunch to minimize fatigue.
Take him for a walk after dinner.
Give him something to hold or keep his hands occupied so that he will not pull at his clothes.
Help him to a soft chair after supper and make the lights dim.

Alzheimer's disease gets worse over time and the demands on the person giving care increase as well. A person with Alzheimer's still needs happiness in life and needs to be encouraged to do as much as possible for himself. Simple pleasures such as a comfortable bed, a gentle massage, bright colors, and flowers can add to a person's life. Compassionate care helps them feel secure. Keep these general guidelines in mind:

• be creative and flexible, if one thing doesn't work to calm a person, try something else,
• avoid situations where the person has to make difficult choices,
• keep the environment calm and organized,
• talk about past pleasant events,
• be patient.

Care-giving tips:
Communication

• Stand directly in front of the person to talk, touch his arm or shoulder to focus attention on what you say.
• Use simple words or sentences.
• Use direct statements when you want him to do something. For example, "It is time for breakfast".
• Allow extra time for his brain to process and answer your questions. If you don't get an answer, ask the question again using the same words you did previously.
• Use humor if you can.
• Because a person with Alzheimer's is more comfortable in his own reality than in the present, don't argue with him. If he believes it is 1968 and he 19 years old, don't tell him he is wrong. Respond to the emotions he expresses. For example, he may believe that on a summer day, he is just 19 and seeing Moscow for the first time. Focus your thoughts on the excitement he felt as he walked in the city.
• Always give the person the date, time and place of where he is. For example, "Good morning, Sergei. You are at home and it is 7 o'clock - time to get out of bed. Today is Thursday. We are going for a walk in the park today."

Question 5: Behavior is a form of _______________. The person is trying to tell you something.

Behavioral Problems

• Don't accuse him of lying or stealing when he rummages. His thoughts are different than yours.
• Use distraction to change the subject if there he argues. Distraction often makes an Alzheimer's person forget what was causing a problem. For example, Sergei may want to go outside, but you cannot take him at that time. Then you give him a cup of tea to distract him.

Tips for Safety

• Follow a set routine. Introducing change can be confusing.
• Show him how to do things. For example, move your arm to your mouth to demonstrate tooth brushing or move your arm to your head to demonstrate hair combing.
• Do activities in small steps. His attention span is short.
• Remove hazards in the environment - put away dangerous items, hide a spare key outside the apartment, supervise smoking, you may need to replace locks so that he cannot get out independently.

Care-giving Techniques for Daily Living

• Bathing - have everything ready before starting - shampoo, soap, towel, chair for after the bath. Use statements such as "It feels good to be clean."
• Avoid using the shower from above the person's head - often they are frightened of this.
• Remove locks from the bathroom and toilet doors. Put electrical appliances such as hairdryers, radios, and electric razors out of his sight.
• Lay out clothing items one at a time in the order they are to be put on.
• Encourage independence by using front fasteners such as zippers, large buttons, or self-fasteners.
• Have him wear slip-on shoes with non-skid soles.

Mealtimes
A person who has Alzheimer's may not remember eating, how much was eaten, or what was eaten. He may not remember how to use utensils for eating. He may have to be reminded to chew or swallow. Here are other suggestions:

• Offer foods that can be eaten with fingers.
• If the person chokes easily, grind or chop the food.
• Try to serve the foods the person likes.
• Use plates without a design on them to avoid confusion. Try to contrast the color of the plate and the food. For example, when serving rice, put it on a darker colored plate rather than a white one.
• Fill the drinking glass or cup 1/2 full.
• Serve the food warm - not hot to burn his mouth.
• Put only one food in front of the person at a time.
• Use simple instructions such as, "Pick up your fork, put the food on it."
• Keep things that look like food out of sight, such things as doggie biscuits, marbles, beads, and flower bulbs.
• Avoid placing too many things on the table such as ketchup, salt and pepper until the person asks for them. The person may be distracted from the food and rather touch or focus on these things.

Question 6: What kinds of foods can be eaten with the fingers?

Elimination
The signals from the brain may not work well enough to signal that the Alzheimer's person needs to use the toilet. He may not remember where the toilet is located or what to do when he gets there. Here are some suggestions to help him:

• Set a regular schedule for toileting, and include using the bathroom right after eating.
• Watch for signs of restlessness that may mean he needs the toilet.
• Encourage the person to eat a diet that is high in fiber - grains and fruits.
• Help the person remove and adjust clothing as necessary.
• Turn on the light before the person enters the toilet.

Ten Warning Signs of Alzheimer's Disease
We need some sort of guidelines to help us determine if a person is declining mentally due to Alzheimer's Disease. Here are ten signals listed below:

1. Recent, frequent memory loss - forgetting telephone numbers, people's names, work assignments.
2. Misplacing things: not merely losing the keys to the apartment, but stashing items in inappropriate places such as a watch in a sugar bowl or the keys in the freezer.
3. Difficulty performing familiar tasks: preparing a meal and forgetting to serve it.
4. Language problems: forgetting simple words, using incorrect words, or an inability to speak a coherent sentence.
5. Disorientation to time and place: not knowing the day of the week, forgetting destinations, or becoming lost in familiar places.
6. Impaired judgment: wearing several shirts or blouses at once.
7. Problems with abstract thinking: being unable to budget monthly payments for electricity, gas, etc.
8. Abrupt mood swings: going from calm to anger and tears for no apparent reason.
9. Changes in personality: uncharacteristic confusion, fear, paranoia.
10. A passive demeanor and loss of initiative: retreating inside one's self.

If more than two of these symptoms apply, see a doctor. Even without a cure, there are things that can be done to aid in feeding and caring for these persons. The most important reason not to ignore evidence of dementia is that one in five suspected cases of Alzheimer's turns out to be another medical condition that is treatable.