CHCAC319A Provide Support To People Living With Dementia WBK

C
C
H
H
C
C
A
A
C
C
3
3
1
1
9
9
A
A
.
.

P
P
r
r
o
o
v
v
i
i
d
d
e
e
s
s
u
u
p
p
p
p
o
o
r
r
t
t
t
t
o
o

p
p
e
e
o
o
p
p
l
l
e
e
l
l
i
i
v
v
i
i
n
n
g
g
w
w
i
i
t
t
h
h

D
D
e
e
m
m
e
e
n
n
t
t
i
i
a
a

Document Name: CHCAC319A Provide support to people living with dementia WBK Created Date: 10 Dec 2008
Document No: Version No: V1 Last Modified Date: 25 Feb 2009
John Bailey 2009 Page Sequence: Page 2 of 155

CHCAC319A.
Provide support to people living with dementia
Author
John Bailey
Copyright

Text copyright 2009 by John N. Bailey.
Illustration, layout and design copyright 2009 by John N. Bailey.

Under Australia's Copyright Act 1968 (the Act), except for any fair dealing for the
purposes of study, research, criticism or review, no part of this book may be
reproduced, stored in a retrieval system, or transmitted in any form or by any means
without prior written permission from John N. Bailey. All inquiries should be directed
in the first instance to the publisher at the address below.

Copying for Education Purposes
The Act allows a maximum of one chapter or 10% of this book, whichever is the
greater, to be copied by an educational institution for its educational purposes
provided that that educational institution (or the body that administers it) has given a
remuneration notice to JNB Publications,

Disclaimer
All reasonable efforts have been made to ensure the quality and accuracy of this
publication. JNB Publications assumes no responsibility for any errors or omissions
and no warranties are made with regard to this publication. Neither JNB Publications
nor any authorised distributors shall be held responsible for any direct, incidental or
consequential damages resulting from the use of this publication.

To Order this Publication
This publication can be ordered in a wire bound format or as an electronic copy for
unlimited copying and editing in an RTO. For distribution details, please visit our
website at www.jnbweb.com. or email me at johnb@jnbweb.com .

Published in Australia by:
JNB Publications
PO Box 268
Macarthur Square NSW 2560
Australia
www.jnbweb.com


CHCAC319A. Provide support to
people living with dementia
CONTENTS

DESCRIPTION: ............................................................................................................................................................. 8
EMPLOYABILITY SKILLS .................................................................................................................................................. 8
APPLICATION .............................................................................................................................................................. 8
ABOUT THIS UNIT OF STUDY INTRODUCTION. .................................................................................................................... 8
THIS LEARNING GUIDE COVERS: .................................................................................................................................... 8
LEARNING PROGRAM: .................................................................................................................................................. 8
Additional Learning Support .......................................................................................................................... 9
Facilitation ..................................................................................................................................................... 9
Flexible Learning .......................................................................................................................................... 10
Space ............................................................................................................................................................ 10
Study Resources ........................................................................................................................................... 10
Time ............................................................................................................................................................. 11
Study Strategies ........................................................................................................................................... 11
Using This Learning Guide. ........................................................................................................................... 11
THE ICON KEY ................................................................................................................................................ 12
THE SUPPLEMENTARY ICONS ......................................................................................................................... 13
HOW TO GET THE MOST OUT OF YOUR LEARNING GUIDE: ................................................................................................. 14
Additional Research, Reading and Note Taking ........................................................................................... 14
EMPLOYABILITY SKILLS ................................................................................................................................ 15
SKILLS AND KNOWLEDGE ............................................................................................................................... 21
Required Skills .............................................................................................................................................. 21
Required Knowledge .................................................................................................................................... 22
RANGE STATEMENT. ...................................................................................................................................... 23
EVIDENCE GUIDE ............................................................................................................................................ 26
1. PROVIDE SUPPORT TO THOSE AFFECTED BY DEMENTIA ........................................................................ 28
A BASIC UNDERSTANDING OF DEMENTIA. ....................................................................................................................... 28
Activity 1. ..................................................................................................................................................... 29
Activity 2 ...................................................................................................................................................... 29
MEDICAL CONDITIONS THAT MAY CAUSE DEMENTIA ........................................................................................................ 30
HIV/AIDS ...................................................................................................................................................... 30
Head Trauma ............................................................................................................................................... 30
Parkinson's Disease ...................................................................................................................................... 30
Huntington's Disease ................................................................................................................................... 30
Pick's Disease ............................................................................................................................................... 31
Creutzfeldt - Jakob disease (CJD).................................................................................................................. 31
Normal Pressure Hydrocephalus .................................................................................................................. 31
Wernicke-Korsakoff Syndrome ..................................................................................................................... 31
Mixed Dementia ........................................................................................................................................... 32
Activity 3. ..................................................................................................................................................... 32
ALZHEIMER'S DISEASE ................................................................................................................................................ 33
Activity 4. ..................................................................................................................................................... 35
PREVALENCE AND CAUSES OF ALZHEIMER'S DISEASE ........................................................................................................ 35


Causes of Alzheimer's Disease ..................................................................................................................... 35
Activity 5. ..................................................................................................................................................... 36
The Aging Brain ............................................................................................................................................ 37
Activity 6 ...................................................................................................................................................... 37
Illustration 1 ................................................................................................................................................. 38
Activity 7 ...................................................................................................................................................... 39
Activity 8. ..................................................................................................................................................... 40
The AD Brain - Plaques and Tangles ............................................................................................................ 40
The AD Brain - Free Radicals ........................................................................................................................ 40
The AD Brain - Neurotransmitters ................................................................................................................ 41
The AD Brain - The Path of Destruction ....................................................................................................... 41
Activity 9. ..................................................................................................................................................... 41
Risk Factors for Alzheimer's Disease ............................................................................................................ 43
Activity 10. ................................................................................................................................................... 43
Symptoms of Alzheimer's Disease ................................................................................................................ 44
Symptoms of Alzheimer's Disease ................................................................................................................ 44
Activity 11. ................................................................................................................................................... 45
Warning Signs of Alzheimer's Disease ......................................................................................................... 46
Activity 12. ................................................................................................................................................... 47
Illustration 2 ................................................................................................................................................. 48
Stages of Alzheimer's Disease ...................................................................................................................... 48
Activity 13. ................................................................................................................................................... 50
Diagnosis of Alzheimer's Disease ................................................................................................................. 50
Activity 14. ................................................................................................................................................... 51
VASCULAR DEMENTIA ................................................................................................................................................. 52
Prevalence of Vascular Dementia ................................................................................................................ 52
Causes of Vascular Dementia ....................................................................................................................... 52
Activity 15. ................................................................................................................................................... 52
Risk Factors for Vascular Dementia ............................................................................................................. 53
Activity 16. ................................................................................................................................................... 53
Symptoms of Vascular Dementia ................................................................................................................. 53
Activity 17. ................................................................................................................................................... 54
Comparing AD and Vascular Dementia ........................................................................................................ 54
LEWY BODY DEMENTIA ............................................................................................................................................... 55
Activity 18. ................................................................................................................................................... 55
Prevalence of Lewy Body Dementia ............................................................................................................. 55
Activity 19. ................................................................................................................................................... 55
Causes of Lewy Body Dementia ................................................................................................................... 56
Risk Factors for Lewy Body Dementia .......................................................................................................... 56
Activity 20. ................................................................................................................................................... 56
Symptoms of Lewy Body Dementia .............................................................................................................. 57
Activity 21. ................................................................................................................................................... 58
SUPPORT INDIVIDUAL NEEDS OF PEOPLE WITH DEMENTIA USING A PERSON-CENTRED APPROACH TO CARE AND ADDRESS
INDIVIDUAL NEEDS FOR A STABLE FAMILIAR ENVIRONMENT ................................................................................................. 59
Coping Skills for Dementia Caregivers ......................................................................................................... 59
Activity 22. ................................................................................................................................................... 61
WORKING WITH THE AWARENESS OF THE IMPACT OF PHYSICAL, SOCIAL AND EMOTIONAL ASPECTS OF THE ENVIRONMENT ON
THE PERSON WITH DEMENTIA AND WORKING WITH AWARENESS OF THE IMPACTS THAT DEMENTIA MAY HAVE ON FAMILY,
CARERS AND SIGNIFICANT OTHERS ................................................................................................................................. 62
WORKING WITH THE AWARENESS OF THE IMPACT OF PHYSICAL, SOCIAL AND EMOTIONAL ASPECTS OF THE ENVIRONMENT ON
THE PERSON WITH DEMENTIA AND WORKING WITH AWARENESS OF THE IMPACTS THAT DEMENTIA MAY HAVE ON FAMILY,
CARERS AND SIGNIFICANT OTHERS ................................................................................................................................. 62
Services for Dementia Caregivers................................................................................................................. 62
Activity 23. ................................................................................................................................................... 63
RECOGNISE WITNESSED SIGNS CONSISTENT WITH FINANCIAL, PHYSICAL OR EMOTIONAL ABUSE OR NEGLECT OF THE CLIENT
AND REPORT TO AN APPROPRIATE PERSON ...................................................................................................................... 64
Legal considerations .................................................................................................................................... 64


Advance Directives ....................................................................................................................................... 64
Activity 24. ................................................................................................................................................... 65
What constitutes elder abuse ...................................................................................................................... 66
Activity 25. ................................................................................................................................................... 66
Challenges of Mandated Reporting for the Professional ............................................................................. 67
Case Study 1 ................................................................................................................................................. 67
Elder Abuse Prevention Information ............................................................................................................ 70
2. USE COMMUNICATION STRATEGIES WHICH TAKE ACCOUNT OF THE PROGRESSIVE AND VARIABLE
NATURE OF DEMENTIA .................................................................................................................................. 71
COMMUNICATION STRATEGIES TO MAXIMISE ENGAGEMENT OF THE PERSON WITH DEMENTIA. .................................................. 71
Communication Tips for Dementia Caregivers ............................................................................................. 72
GAIN COOPERATION AND PROVIDE REASSURANCE AS APPROPRIATE TO INDIVIDUAL CLIENTS BY USING REALITY ORIENTATION
INCLUDING: .............................................................................................................................................................. 74
USE A RANGE OF VALIDATION STRATEGIES TO RELIEVE DISTRESS AND AGITATION IN CLIENTS SUCH AS: ......................................... 74
Case Study 2 ................................................................................................................................................. 74
The Social Faade or "Well He Looks Fine to Me!"....................................................................................... 75
Vignette........................................................................................................................................................ 75
How Does the Social Facade Work? ............................................................................................................. 75
Helpful Staff Responses ................................................................................................................................ 75
With the Client: ............................................................................................................................................ 75
With the Visitor: ........................................................................................................................................... 76
In Activity Planning: ..................................................................................................................................... 76
With the Facility Environment: ..................................................................................................................... 76
Depression-Apathy-Withdrawal or "Why Doesn't He Care About Anything Anymore?" ............................. 77
Vignette........................................................................................................................................................ 77
How Does Depression Affect Alzheimer's Patients? ..................................................................................... 77
Helping Strategies ........................................................................................................................................ 78
With the Client: ............................................................................................................................................ 78
With the Family: ........................................................................................................................................... 78
With Activity Programming: ........................................................................................................................ 78
With the Facility: .......................................................................................................................................... 79
Rummaging, Pillaging, and Hoarding or "Why Does Mrs. Dougherty Take the Dining Room
Silverware?" ................................................................................................................................................. 80
Vignette........................................................................................................................................................ 80
What Causes Patients to Mess Around in Other People's Things? ............................................................... 80
With the Client: ............................................................................................................................................ 81
With the Family: ........................................................................................................................................... 81
With Activity Programming: ........................................................................................................................ 82
How the Facility Can Handle Rummaging, Pillaging and Hoarding: ............................................................ 82
What Causes Wandering? ............................................................................................................................ 83
1) How to help the client; ........................................................................................................................ 84
2) How to help the client's family; ........................................................................................................... 84
3) How to handle the behaviour in activity programming ...................................................................... 85
4) How to handle the behaviour through facility-wide changes. ................................................................. 85
3. PROVIDE APPROPRIATE ACTIVITIES TO MAINTAIN DIGNITY, SKILLS AND HEALTH OF CLIENT AT
OPTIMUM LEVEL ............................................................................................................................................ 86
PROVIDE ACTIVITIES WHICH AIM TO MAINTAIN INDEPENDENCE, USING FAMILIAR ROUTINES AND EXISTING SKILLS .......................... 86
Encouraging independence .......................................................................................................................... 86
Why are activities so important? ................................................................................................................. 87
Activity 26. ................................................................................................................................................... 87
How to plan activities................................................................................................................................... 87
Activity 27. ................................................................................................................................................... 88
Things to keep in mind ................................................................................................................................. 88


Activity 28. ................................................................................................................................................... 89
Activity 29. ................................................................................................................................................... 89
Activity 30. ................................................................................................................................................... 90
Activity 31. ................................................................................................................................................... 90
Activity 32. ................................................................................................................................................... 91
Activity 33. ................................................................................................................................................... 91
Activity 34. ................................................................................................................................................... 92
Activity 35. ................................................................................................................................................... 92
Activity 36. ................................................................................................................................................... 93
Activity 37. ................................................................................................................................................... 93
Activity 38. ................................................................................................................................................... 94
Activity 39. ................................................................................................................................................... 94
Activity 40. ................................................................................................................................................... 96
Creative activities ......................................................................................................................................... 96
Activity 41. ................................................................................................................................................... 98
Going out and about .................................................................................................................................... 98
Activity 42. ................................................................................................................................................... 99
ENSURE ALL ACTIVITIES PROVIDED FOCUS ON ENSURING THE SAFETY AND COMFORT OF THE CLIENT BALANCED WITH
AUTONOMY AND RISK TAKING..................................................................................................................................... 100
Activity 43. ................................................................................................................................................. 101
USE PURPOSEFUL AND MEANINGFUL ACTIVITY TO ENHANCE SELF-ESTEEM AND PLEASURE IN LIFE, TO MINIMISE BOREDOM
AND TO DISTRACT FROM OR ELIMINATE BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA ..................................... 101
Table 1 Creating a supportive environment ............................................................................................... 101
Activity 44. ................................................................................................................................................. 102
USE FAMILY CARERS AND SIGNIFICANT OTHERS AS A RESOURCE, WHERE APPROPRIATE, TO ASSIST IN DEVELOPING
APPROPRIATE ACTIVITIES BY ACCESSING INFORMATION ABOUT CLIENT REMINISCENCES AND ROUTINES ALSO PROVIDE SUPPORT
AND GUIDANCE TO FAMILY CARERS AND SIGNIFICANT OTHERS WHERE APPROPRIATE TO ASSIST THEM TO UNDERSTAND THE
DISEASE, ITS IMPACT ON THE PERSON AND SOME APPROACHES TO PROVIDING CARE .............................................................. 103
Activity 45. ................................................................................................................................................. 104
Ideas On Adapting Activities ...................................................................................................................... 104
Exercise Activity: Making A Cup Of Coffee ................................................................................................. 105
Activity 46. ................................................................................................................................................. 106
Environment ............................................................................................................................................... 108
Table 2: Strategies and Guidelines ............................................................................................................. 108
4. IMPLEMENT STRATEGIES WHICH MINIMISE THE IMPACT OF BEHAVIOURS OF CONCERN ................... 113
BEHAVIOUR MANAGEMENT FOR DEMENTIA CAREGIVERS ................................................................................................ 113
Identify behaviours of concern ................................................................................................................... 113
IDENTIFY POTENTIAL TRIGGERS FOR BEHAVIOURS OF CONCERN FOR SPECIFIC INDIVIDUALS ...................................................... 114
Agitation .................................................................................................................................................... 114
Vocal Outbursts .......................................................................................................................................... 115
Wandering ................................................................................................................................................. 116
Activity 47 .................................................................................................................................................. 118
CONTRIBUTE TO TEAM DISCUSSION ON CARE PLANNING AND CARE PLAN REVIEW TO MINIMISE BEHAVIOURS BY
IMPLEMENTING STRATEGIES TO MINIMISE THE LIKELIHOOD OF AND REDUCE THE IMPACT OF BEHAVIOURS ON THE PERSON AND
OTHERS .................................................................................................................................................................. 119
The A-B-C Behaviour Chain ........................................................................................................................ 119
Using the A-B-C Behaviour Chain ............................................................................................................... 120
ABC Chain ................................................................................................................................................... 120
Example of Using the A-B-C behaviour Chain ............................................................................................ 122
Activity 48 .................................................................................................................................................. 123
Tips for Dealing with Specific Dementia Problematic Behaviours .............................................................. 125
Activity 49. ................................................................................................................................................. 127
COMMUNICATION STRATEGIES ................................................................................................................................... 128
Talking with Clients .................................................................................................................................... 128
COMMUNICATIONS WITH FAMILIES ............................................................................................................................. 131
Why Is Communication with Families So Important? ................................................................................ 131


How to Communicate with Families .......................................................................................................... 132
Activity 50. ................................................................................................................................................. 132
Staff Communication and Coordination of Care ........................................................................................ 133
Communication with Outside Providers ..................................................................................................... 134
CONTRIBUTE TO TEAM DISCUSSION ON CARE PLANNING AND CARE PLAN REVIEW TO MINIMISE BEHAVIOURS .............................. 134
Principles .................................................................................................................................................... 134
Developing Care Plans................................................................................................................................ 135
Activity 51 .................................................................................................................................................. 138
IMPLEMENT STRATEGIES TO MINIMISE THE LIKELIHOOD OF AND REDUCE THE IMPACT OF BEHAVIOURS ON THE PERSON AND
OTHERS THEN REGULARLY REVIEW STRATEGIES THAT ARE IMPLEMENTED TO ENSURE MAXIMUM EFFECTIVENESS AND REFLECT
CHANGES IN THE CARE PLAN ....................................................................................................................................... 139
From an ADRDA Newsletter - Anderson ..................................................................................................... 139
From an ADRDA Newsletter-Guise ............................................................................................................. 140
Activities for A.D. Clients ............................................................................................................................ 140
Techniques ................................................................................................................................................. 140
Staffing ....................................................................................................................................................... 141
Stress Management for Staff ..................................................................................................................... 141
Activity 52. ................................................................................................................................................. 142
5. IMPLEMENT SELF CARE STRATEGIES .................................................................................................... 145
MONITORING OWN STRESS LEVEL IN RELATION TO WORKING WITH PEOPLE WITH DEMENTIA AND THEN USE APPROPRIATE SELF
CARE STRATEGIES AND SEEK SUPPORT IF REQUIRED ......................................................................................................... 145
Activity 53, ................................................................................................................................................. 146
USE APPROPRIATE SELF CARE STRATEGIES AND SEEK SUPPORT IF REQUIRED .......................................................................... 147
Stress Management for Staff ..................................................................................................................... 147
Taking Care of Yourself .............................................................................................................................. 147
Activity 54. ................................................................................................................................................. 148
Creative Solutions to Nursing Care Problems ............................................................................................. 149
Caregiver Tips ............................................................................................................................................. 149
COGNITIVE DISORDERS BOOK RESOURCES .................................................................................................................... 151
Perspectives from Individuals with Dementia ............................................................................................ 151
About Caregiving........................................................................................................................................ 151
APPENDIX 1: EXCERPTS FROM DEALING WITH INCONTINENCE .................................................................... 152
Aids for Managing Incontinence: ............................................................................................................... 154


Provide support to people living with
dementia CHCAC319A.

Description:
This unit describes the knowledge and skills required to provide support to
clients with dementia in a variety of settings including family homes,
community day settings and residential care
Employability Skills
This unit contains employability skills
Application
This unit applies to workers in a range of aged and community services
contexts working with people with dementia.

About this Unit of Study Introduction.
As a worker, a trainee, or a future worker you want to enjoy your work and
become known as a valuable team member. This unit of competency will help
you acquire the knowledge and skills to work effectively as an individual and in
groups. It will give you the basis to contribute to the goals of the organisation
which employs you.
It is essential that you begin your training by becoming familiar with the
industry standards to which organisations must conform.
This unit of competency introduces you to some of the key issues and
responsibilities of workers and organisations in this area. The unit also
provides you with opportunities to develop the competencies necessary for
employees to operate as team members.

This Learning Guide Covers:
Provide support to those affected by dementia
Use communication strategies which take account of the progressive and
variable nature of dementia
Provide appropriate activities to maintain dignity, skills and health of
client at optimum level
Implement strategies which minimise the impact of behaviours of concern
Implement self care strategies

Learning Program:
As you progress through this unit of study you will develop skills in locating
and understanding an organisations policies and procedures. You will build
up a sound knowledge of the industry standards within which organisations
must operate. You will become more aware of the effect that your own skills
in dealing with people has on your success or otherwise in the workplace.


Knowledge of your skills and capabilities will help you make informed choices
about your further study and career options.

Additional Learning Support

To obtain additional support you may:
search for other resources in the Learning Resource Centre (LRC) of
your learning institution. You may find books, journals, videos and other
materials which provide additional information about topics in this unit.
search for other resources in your local library. Most libraries keep
information about government departments and other organisations,
services and programs. The librarian should be able to help you locate
such resources.
contact information services such as Infolink, Equal Opportunity
Commission, Commissioner of Workplace Agreements, Union
organisations, and public relations and information services provided by
various government departments. Many of these services are listed in
the telephone directory.
contact your local shire or council office. Many councils have a
community development or welfare officer as well as an information and
referral service.
contact the relevant facilitator by telephone, mail or facsimile.

Facilitation

Your training organisation will provide you with a flexible learning facilitator.
Your facilitator will play an active role in supporting your learning. Your
facilitator will make regular contact with you and, if you have face to-face
access, should arrange to see you at least once. Your facilitator will contact
you by telephone or letter as soon as possible after you have enrolled to let
you know:
how and when to make contact,
what you need to do to complete this unit of study, and
what support will be provided.

Here are some of the things your facilitator can do to make your study easier:
Give you a clear visual timetable of events for the semester or term in
which you are enrolled, including any deadlines for assessments.
Check that you know how to access library facilities and services.
Conduct small 'interest groups' for some of the topics
Use 'action sheets' to remind you about tasks you need to complete, and
updates on websites.


Set up a 'chat line'. If you have access to telephone conferencing or
video conferencing, your facilitator can use these for specific topics or
discussion sessions.
Circulate a newsletter to keep you informed of events, topics and
resources of interest to you.
Keep in touch with you by telephone or e-mail during your studies.

Flexible Learning
Studying to become a competent worker is an interesting and exciting thing to
do. You will learn about current issues in this area. You will establish
relationships with other candidates, fellow workers, and clients. You will learn
about your own ideas, attitudes and values. You will also have fun. (Most of
the time!)
At other times, study can seem overwhelming and impossibly demanding,
particularly when you have an assignment to do and you aren't sure how to
tackle it ... and your family and friends want you to spend time with them...and
a movie you want to see is on television...
Sometimes being a candidate can be hard.

Here are some ideas to help you through the hard times. To study effectively,
you need space, resources and time.

Space
Try to set up a place at home or at work where:
you can keep your study materials,
you can be reasonably quiet and free from interruptions, and
you can be reasonably comfortable, with good lighting, seating and
a flat surface for writing.
If it is impossible for you to set up a study space, perhaps you could use your
local library. You will not be able to store your study materials there, but you
will have quiet, a desk and chair, and easy access to the other facilities.

Study Resources
The most basic resources you will need are:
a chair
a desk or table
a reading lamp or good light
a folder or file to keep your notes and study materials together
materials to record information (pen and paper or notebooks, or a
computer and printer)
reference materials, including a dictionary.
Do not forget that other people can be valuable study resources. Your fellow
workers, work supervisor, other candidates, your flexible learning facilitator,
your local librarian, and workers in this area can also help you.


Time
It is important to plan your study time. Work out a time that suits you and plan
around it. Most people find that studying in short, concentrated blocks of time
(an hour or two) at regular intervals (daily, every second day, once a week) is
more effective than trying to cram a lot of learning into a whole day. You need
time to 'digest' the information in one section before you move on to the next,
and everyone needs regular breaks from study to avoid overload. Be realistic
in allocating time for study. Look at what is required for the unit and look at
your other commitments.
Make up a study timetable and stick to it. Build in 'deadlines' and set yourself
goals for completing study tasks. Allow time for reading and completing
activities. Remember that it is the quality of the time you spend studying
rather than the quantity that is important.

Study Strategies
Different people have different learning 'styles'. Some people learn best by
listening or repeating things out loud. Some learn best by 'doing', some by
reading and making notes. Assess your own learning style, and try to identify
any barriers to learning which might affect you. Are you easily distracted? Are
you afraid you will fail? Are you taking study too seriously? Not seriously
enough? Do you have supportive friends and family? Here are some ideas for
effective study strategies:
Make notes. This often helps you to remember new or unfamiliar information.
Do not worry about spelling or neatness, as long as you can read your own
notes. Keep your notes with the rest of your study materials and add to them
as you go. Use pictures and diagrams if this helps.
Underline key words when you are reading the materials in this learning
guide. (Do not underline things in other people's books.) This also helps you
to remember important points.
Talk to other people (fellow workers, fellow candidates, friends, family, your
facilitator) about what you are learning. As well as helping you to clarify and
understand new ideas, talking also gives you a chance to find out extra
information and to get fresh ideas and different points of view.

Using This Learning Guide.

A learning guide is just that, a guide to help you learn. A learning guide is not
a text book. Your learning guide will:
describe the skills you need to demonstrate to achieve competency for
this unit;
provide information and knowledge to help you develop your skills;
provide you with structured learning activities to help you absorb
knowledge and information and practice your skills;
direct you to other sources of additional knowledge and information about
topics for this unit.


The Icon Key

Key Points
Explains the actions taken by a competent person.

Example
Illustrates the concept or competency by providing examples.

Activity
Provides activities to reinforce understanding of the action.

Chart
Provides images that represent data symbolically. They are
used to present complex information and numerical data in a
simple, compact format.

Intended Outcomes or Objectives
Statements of intended outcomes or objectives are
descriptions of the work that will be done.

Assessment
Strategies with which information will be collected in order to
validate each intended outcome or objective.


The Supplementary Icons

PowerPoint
Any PowerPoint associated with a unit will have this icon next
to them

Forms and Care Plans
If there is a form or care plan associated with a unit there will
be an icon like this with the relevant number of the form or
care plan in the format FFACF-015

Where the employability skills are shown to be embedded in
the unit and relates to the table in the front of each unit eg: T1,
S1, E1.

Readings
Provides backup and reasoning to the underpinning
knowledge and skills

Primary Skills Assessments
Where the Primary Skills Assessments are applicable there
will be an icon in the format PSA - XX

World Wide Web
Where the world wide web is used for an activity in the unit
you will find this icon.

Resource Document
Where the Resource documents are applicable there will be
an icon in the format RDN - XX


How to Get the Most out of Your Learning Guide:
1. Read through the information in the learning guide carefully. Make
sure you understand the material.
Some sections are quite long and cover complex ideas and information.
If you come across anything you do not understand:
talk to your facilitator;
research the area using the books and materials listed under
Resources;
discuss the issue with other people (your workplace supervisor,
fellow workers, fellow candidates);
try to relate the information presented in this learning guide to your
own experience and to what you already know.
Ask yourself questions as you go. For example 'Have I seen this
happening anywhere?' 'Could this apply to me?' 'What if....'. This will
help you to 'make sense' of new material, and to build on your existing
knowledge.
2. Talk to people about your study.
Talking is a great way to reinforce what you are learning.
3. Make notes.
4. Work through the activities.
Even if you are tempted to skip some activities, do them anyway. They are
there for a reason, and even if you already have the knowledge or skills
relating to a particular activity, doing them will help to reinforce what you
already know. If you do not understand an activity, think carefully about
the way the questions or instructions are phrased. Read the section
again to see if you can make sense of it. If you are still confused, contact
your facilitator or discuss the activity with other candidates, fellow
workers or with your workplace supervisor.
Additional Research, Reading and Note Taking
If you are using the additional references and resources suggested in the
learning guide to take your knowledge a step further, there are a few simple
things to keep in mind to make this kind of research easier.

Always make a note of the author's name, the title of the book or article, the
edition, when it was published, where it was published, and the name of the
publisher. If you are taking notes about specific ideas or information, you will
need to put the page number as well. This is called the reference information.
You will need this for some assessment tasks, and it will help you to find the
book again if you need to.
Keep your notes short and to the point. Relate your notes to the material in
your learning guide. Put things into your own words. This will give you a better
understanding of the material.
Start off with a question you want answered when you are exploring
additional resource materials. This will structure your reading and save you
time.


Certificate III in Aged Care
EMPLOYABILITY
SKILLS
FACETS ADDRESSED: Industry/enterprise requirements
for this qualification include the following facets:
Code
Communication
1. Listening to and understanding work instructions,
directions and feedback
C1
2. Speaking clearly/directly to relay information
C2
3. Reading and interpreting workplace related
documentation, such as prescribed programs
C3
4. Writing to address audience needs, such as forms,
case notes and reports
C4
5. Interpreting the needs of internal/ external clients from
clear information and feedback
C5
6. Applying basic numeracy skills to workplace
requirements involving measuring and counting
C6
8. Sharing information (eg. with other staff, working as
part of an allied health team)
C8
9. Negotiating responsively (eg. re own work role and/or
conditions, possibly with clients)
C9
11. Being appropriately assertive (eg. in relation to safe or
ethical work practices and own work role)
C11
12. Empathising (eg. in relation to others)
C12
Teamwork
1. Working as an individual and a team member T1
2. Working with diverse individuals and groups T2
3. Applying knowledge of own role as part of a team T3
4. Applying teamwork skills to a limited range of situations
T4
5. Identifying and utilising the strengths of other team
members
T5
6. Giving feedback T6


EMPLOYABILITY
SKILLS
Code
Problem solving
1. Developing practical solutions to workplace problems
(i.e. within scope of own role)
P1
2. Showing independence and initiative in identifying
problems (i.e. within scope of own role)
P2
3. Solving problems individually or in teams (i.e. within
scope of own role)
P3
5. Using numeracy skills to solve problems (eg. time
management, simple calculations, shift handover)
P5
6. Testing assumptions and taking context into account
(i.e. with an awareness of assumptions made and
work context)
P6
7. Listening to and resolving concerns in relation to
workplace issues
P7
8. Resolving client concerns relative to workplace
responsibilities (i.e. if role has direct client contact)
P8
Initiative and
enterprise
1. Adapting to new situations (i.e. within scope of own
role)
I1
2. Being creative in response to workplace challenges (i.e.
within relevant guidelines and protocols)
I2
3. Identifying opportunities that might not be obvious to
others (i.e. within a team or supervised work context)
I3
5. Translating ideas into action (i.e. within own work role)
I5
6. Developing innovative solutions (i.e. within a team or
supervised work context and within established
guidelines)
I6


EMPLOYABILITY
SKILLS
Code
Planning and
organising
1. Collecting, analysing and organising information (i.e.
within scope of own role)
O1
2. Using basic systems for planning and organising (i.e. if
applicable to own role)
O2
3. Being appropriately resourceful O3
4. Taking limited initiative and making decisions within
workplace role (i.e. within authorised limits)
O4
5. Participating in continuous improvement and planning
processes (i.e. within scope of own role)
O5
6. Working within clear work goals and deliverables O6
7. Determining or applying required resources (i.e. within
scope of own role)
O7
8. Allocating people and other resources to tasks and
workplace requirements (only for team leader or
leading hand roles)
O8
9. Managing time and priorities (i.e. in relation to tasks
required for own role)
O9
10. Adapting resource allocations to cope with
contingencies (i.e. if relevant to own role)
O10
Self management 1. Being self-motivated (i.e. in relation to requirements
of own work role)
S1
2. Articulating own ideas (i.e. within a team or
supervised work context)
S2
3. Balancing own ideas and values with workplace values
and requirements
S3
4. Monitoring and evaluating own performance (i.e. within
a team or supervised work context)
S4
5. Taking responsibility at the appropriate level S5


EMPLOYABILITY
SKILLS
Code
Learning 1. Being open to learning new ideas and techniques) L1
2. Learning in a range of settings including informal
learning
L2
3. Participating in ongoing learning L3
4. Learning in order to accommodate change L4
5. Learning new skills and techniques L5
6. Taking responsibility for own learning (i.e. within scope
of own work role)
L6
7. Contributing to the learning of others (eg. by sharing
information)
L7
8. Applying a range of learning approaches (i.e. as
provided)
L8
10. Participating in developing own learning plans (eg. as
part of performance management)
L10
Technology 1. Using technology and related workplace equipment (i.e.
if within scope of own role)
E1
2. Using basic technology skills to organise data E2
3. Adapting to new technology skill requirements (i.e.
within scope of own role)
E3
4. Applying OHS knowledge when using technology E4


Provide support to people living with dementia CHCAC319A.
Element Performance Criteria
1. Provide support to those affected by dementia

1.1
Work with a basic understanding of dementia
1.2
Support individual needs of people with dementia using a person-
centred approach to care and address individual needs for a
stable familiar environment
1.3
Work with awareness of the impact of physical, social and
emotional aspects of the environment on the person with
dementia
1.4
Work with awareness of the impacts that dementia may have on
family, carers and significant others
1.5
Recognise witnessed signs consistent with financial, physical or
emotional abuse or neglect of the client and report to an
appropriate person
2. Use communication strategies which take account of
the progressive and variable nature of dementia

2.1
Use a range of communication strategies to maximise
engagement of the person with dementia such as eye contact,
gentle touch (where appropriate), short simple statements
2.2
Gain cooperation and provide reassurance as appropriate to
individual clients by using reality orientation including:
- reminders of the day, the time, relationships, occasions
- reassuring words, phrases and body language
2.3
Use a range of validation strategies to relieve distress and
agitation in clients such as:
- Empathy
- Acceptance of the persons reality
- Acknowledgment
- Allowing expressions of distress
- Providing verbal and/or physical reassurance
- Use reminiscences frequently to connect with clients


3. Provide appropriate activities to maintain dignity, skills
and health of client at optimum level

3.1
Provide activities which aim to maintain independence, using
familiar routines and existing skills
3.2
Provide activities that are appropriate to the individual, reflecting
their cultural likes and dislikes, in order to bring back pleasurable
memories
3.3
Ensure all activities provided focus on ensuring the safety and
comfort of the client balanced with autonomy and risk taking
3.4
Use purposeful and meaningful activity to enhance self-esteem and
pleasure in life, to minimise boredom and to distract from or
eliminate behavioural and psychological symptoms of dementia
3.5
Use family carers and significant others as a resource, where
appropriate, to assist in developing appropriate activities by
accessing information about client reminiscences and routines
3.6
Provide support and guidance to family carers and significant
others where appropriate to assist them to understand the disease,
its impact on the person and some approaches to providing care
4.
Implement strategies which minimise the impact of
behaviours of concern

4.1
Identify behaviours of concern
4.2
Identify potential triggers for behaviours of concern for specific
individuals
4.3
Contribute to team discussion on care planning and care plan
review to minimise behaviours
4.4
Implement strategies to minimise the likelihood of and reduce the
impact of behaviours on the person and others
4.5
Regularly review strategies that are implemented to ensure
maximum effectiveness and reflect changes in the care plan
5. Implement self care strategies

5.1
Monitor own stress level in relation to working with people with
dementia
5.2
Use appropriate self care strategies and seek support if required


Skills and Knowledge

Required Skills
It is critical that the candidate demonstrate the ability to:
Communicate effectively with clients with dementia
Utilise creative, least restrictive approaches to behaviours of
clients with dementia

In addition, the candidate must be able to demonstrate relevant task
skills; task management skills; contingency management skills and
job/role environment skills
These include the ability to:
Demonstrate a broad range of communication approaches e.g.
reminiscences
Establish and maintain a relationship that takes into account
client and family individual differences (e.g. cognitive abilities, cultural
background, language skills)
Apply verbal communication skills (language skills) and non-
verbal communication skills (e.g. touch, smiling, gestures) necessary to
develop a trusting relationship with a person who has dementia and their
family
Use communication techniques to enhance communication
and facilitate clients interaction within their environment
Adapt activities to meet individual needs
Provide opportunities for enjoyment
Demonstrate cultural sensitivity
Undertake observation and analysis of client needs
Respond appropriately to indications of neglect or abuse
Facilitate self-monitoring and self care
Facilitate cooperative behaviour


Required Knowledge
The candidate must be able to demonstrate essential knowledge
required to effectively perform task skills; task management skills;
contingency management skills and job/role environment skills as
outlined in elements and performance criteria of this unit
These include foundation knowledge of:
Dementia as a progressive neurological condition
Common indicators and symptoms of dementia
Progression of dementia and potential impact on the person
with dementia, their family and significant others
Relationship between brain changes and behaviour in people
with dementia
Specific impacts of dementia related to cultural, personal and
historical background
Indications of neglect or abuse
Current research on dementia
Principles of person-centred approach to care
Support services available
Plan of care for the clients
Organisation protocols and policies related to own area of work
The importance of the physical, social and emotional
environment for people with dementia
Importance of relevant activities and communication when
working with people with dementia
Limitations and legal ramifications of physical, chemical and
psychological restraint
The range of appropriate strategies to be implemented when
working with people with dementia
The social model of disability
The impact of social devaluation on an individuals quality of
life
Competency and image enhancement as a means of
addressing devaluation


Range Statement.

Understanding of dementia
may include:
Knowledge of different manifestations of dementia,
including:
Alzheimers disease
Huntingtons disease
Picks disease
Vascular dementia
Basic understanding of pathological features,
including:
Amyloid plaques
Neurofibrillary tangles
Loss of connection between cells and cell death
Impacts that dementia may
have on family carers and
significant others may
include:
Depression
Loss and grieving
Anger
Despair
Social embarrassment a family member might feel
Isolation
Financial burden on the family
Impacts of dementia on
the wider community may
include:
Inappropriate behaviour
Anxiety
Dependence on others
Disorientation
Significant others may
include:
Spouse
Family
Friends
Strategies to respond to
include:
Distraction
Current events
Reminiscences
Music, dancing
Walking
Talking reassuringly about familiar and favourite
topics
Behaviour modification (if appropriate)
Addressing physical triggers to behaviour including
pain
Alternative therapies


Activities include:
Daily living activities such as:
- maintaining personal safety
- communication (speech, writing, non-verbal
communication)
- eating and drinking
- mobilising and transferring (moving from place
to place and position to position)
- attending to personal hygiene (bathing,
laundering personal linen)
- dressing and undressing
- attending own spiritual needs
- grooming
- expressing sexuality
Instrumental activities
such as:
Accessing financial resources and allowances
Paying bills and regular outgoings
Shopping
Preparing meals
Climbing stairs
Maintaining household (cleaning, laundry, dcor,
repairs)
Travelling by private and public transport
Interacting with others and socialising
Accessing leisure, recreational and sporting
activities
Recreational and sporting activities
Craft and creative activities
Socialising
Reminiscing activities
Spiritual activities
Ensuring the safety
and comfort of client
while addressing the
risks associated with:
Ability to find their own way
Ability to negotiate traffic
Wandering or other behaviours relating to agitation
Behaviours relating to psychotic experiences or
mood disorders
Ability to safely prepare, cook and store food and
drink
Ability to control temperature of water
Ability to use home appliances
Ability to maintain personal and home security
Ability to manage own finances
Ability to recognise dangers in their environment
Ability to recognise the safety of others


Environmental
strategies may
include:
Orientation to day, date, time of day, place, person,
carer, family relationships, weather
Adequate lighting to decrease risk of misinterpreting
their environment
Manipulate stimuli such as activity, noise, music,
lighting, decor
Provision of space (to pace, wander)
Provision of individuals own belongings such as
photos, books, clothes
Security
Safe storage of toxic chemicals
Behaviours of
concern:
Refer to:
Changed behaviour or BPSD (Behavioural and
Psychological Symptoms of Dementia)
And may include but are not limited to:
Physical aggression
Social withdrawal
Verbal disruption
Repetitive actions or questions
Resistance to personal care
Sexually inappropriate behaviour
Refusal to accept services
Problems associated with eating
Socially inappropriate behaviour
Wandering or intrusiveness
Sleep disturbances


Evidence Guide

Critical aspects for
assessment and evidence
required to demonstrate this
unit of competency:
The individual being assessed must provide
evidence of specified essential knowledge as
well as skills
This unit is most appropriately assessed in
the workplace under the normal range of
workplace conditions but partial assessment
could be undertaken under simulated
conditions
Assessment may include observations,
questioning and evidence gathered from the
workplace on more than one occasion
Where, for reasons of safety, space, or
access to equipment and resources,
assessment takes place away from the
workplace, the assessment environment
should represent workplace conditions as
closely as possible
Access and equity
considerations:
All workers in community services should be
aware of access, equity and human rights
issues in relation to their own area of work
All workers should develop their ability to
work in a culturally diverse environment
In recognition of particular issues facing
Aboriginal and Torres Strait Islander
communities, workers should be aware of
cultural, historical and current issues
impacting on Aboriginal and Torres Strait
Islander people
Assessors and trainers must take into
account relevant access and equity issues,
in particular relating to factors impacting on
Aboriginal and/or Torres Strait Islander
clients and communities
Context of and specific
resources for assessment:
This unit can be assessed independently,
however holistic assessment practice with
other community services units of
competency is encouraged
Resources required for assessment include:
- access to appropriate workplace where
assessment can take place


Method of assessment:
In cases where the learner does not have
the opportunity to cover all relevant aspects
in the work environment, the remainder
should be assessed through realistic
simulations, projects, previous relevant
experience or oral questioning on What if?
scenarios
Assessment of this unit of competence will
usually include observation of processes and
procedures, oral and/or written questioning
on Essential knowledge and skills and
consideration of required attitudes
Where performance is not directly observed
and/or is required to be demonstrated over a
period of time and/or in a number of
locations, any evidence should be
authenticated by colleagues, supervisors,
clients or other appropriate persons


1. Provide support to those
affected by dementia

1.1
Work with a basic understanding of dementia
1.2
Support individual needs of people with dementia using a
person-centred approach to care and address individual
needs for a stable familiar environment
1.3
Work with awareness of the impact of physical, social and
emotional aspects of the environment on the person with
dementia
1.4
Work with awareness of the impacts that dementia may have
on family, carers and significant others
1.5
Recognise witnessed signs consistent with financial, physical
or emotional abuse or neglect of the client and report to an
appropriate person

A basic understanding of Dementia.

Many people mistakenly use dementia as a synonym for Alzheimer's
Disease. This use of the word is inaccurate; "dementia" is an umbrella-like
term that refers to any brain syndrome that causes multiple cognitive
deficits. In other words, saying someone has "dementia" is similar to
saying that someone has a fever; you are not specifying the exact cause of
the symptoms.
A person with dementia can experience all sorts of problems, including:
Impaired Memory (especially the ability to remember recent events and
newly learned facts)
Impaired Language Skills (decreased ability to communicate to others
and understand what is being communicated)
Impaired Orientation (not knowing who one is, where one is, and/or
what time it is)
Impaired Judgment (impaired ability to make decisions regarding
personal, interpersonal, financial, and/or medical affairs)
Impaired Executive Functioning (impaired ability to plan and carry out
daily tasks and make decisions).


Activity 1.

What sorts of problems face a person who has dementia?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Dementia can be caused by one medical condition or by multiple medical
problems. Most dementias are caused by one of the following:
Alzheimer's Disease, which accounts for 50-70% of all dementia cases
Vascular Disease, which accounts for 15-20% of all dementia cases
and includes strokes (disruptions in the blood supply to the brain) and
transient ischemic attacks (TIAs, or mini strokes)
Lewy Body Disease, which accounts for up to 20% of all dementia
cases
We will concentrate most of our discussion on dementia due to
Alzheimer's Disease, Vascular Disease, and Lewy Body Disease
because these conditions are most common. However, there are other
medical conditions worth mentioning that can also cause dementia (at
a much lower rate). They include HIV/AIDS, head trauma, Parkinson's
Disease, Huntington's Disease, Pick's Disease, Creutzfeldt-Jakob
Disease, normal pressure hydrocephalus, and Wernicke-Korsakoff
Syndrome. Each is discussed following.

Activity 2
Most dementias are caused by?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Medical Conditions that May Cause Dementia
HIV/AIDS
HIV/AIDS is a disorder of the immune system (the part of the body that
fights off disease and infection) caused by a virus that can also destroy
brain tissue. Dementia due to HIV/AIDS is characterized by forgetfulness,
slowness, and difficulties with concentration and problem solving. It can
also include apathy (a lack of energy, interest, and/or emotion) and
psychotic symptoms, such as delusions (fixed, false beliefs) and
hallucinations (hearing, seeing, touching, tasting, or smelling things that
are not truly present). Because HIV/AIDS affects people of all ages,
dementia due to HIV/AIDS can occur in children as well as adults.

Head Trauma
Dementia due to head trauma can result from a single major head injury
(such as a blow to the head during a car accident) or from a repeated
series of head injuries, such those sustained by football players or boxers
(sometimes called dementia pugilistica). The degree and nature of
cognitive impairment due to head trauma depends on the location and
severity of the brain injury. People with this type of dementia often
experience amnesia (an inability to learn and recall new information and/or
remember previously learned information or past events), persistent
memory loss, irritability, problems sustaining attention, depression, apathy,
and other personality changes. This kind of dementia is most common
among young men who engage in highly risky behaviours such as riding a
motorcycle without a helmet and driving while intoxicated.
Parkinson's Disease
Parkinson's Disease is caused by a lack of cells that produce dopamine (a
neurotransmitter, or chemical that transmits messages in the brain and
nervous system). This disorder affects movement by creating tremors
(shaking or trembling, sometimes limited to a certain part of the body such
as arms or legs), rigidity, and other problems with balance and motor skills.
About 20-60% of people with Parkinson's Disease also develop dementia.
Dementia due to Parkinson's Disease causes difficulty retrieving
memories, depression, and problems making decisions and carrying out
daily tasks. Interestingly, the brains of people with dementia due to
Parkinson's Disease often appear to have damage that is similar to the
brains of people with Alzheimer's Disease or Lewy Body Disease when
they are examined during an autopsy.

Huntington's Disease
Huntington's Disease is a genetic (inherited) condition that affects
cognition, emotion, and movement. It can start as early as 4 years of age
or as late as 85 years of age, but most commonly affects people in their
late 30s or early 40s. When Huntington's causes dementia, a primary
symptom is difficulty retrieving memories. For instance, people with
dementia due to Huntington's might have trouble remembering where they
went to college or what they did on their last birthday. Other symptoms
include problems with executive functioning (the ability to plan and carry


out daily tasks), and impaired judgment. Memory deficits become more
severe as the disease progresses, and some people experience delusions
(fixed, false beliefs) and hallucinations (sensing things that are not truly
present). Children of parents with Huntington's Disease have a 50%
chance of developing the disease themselves.
Pick's Disease
Pick's Disease is the most common of the frontotemporal dementias, a
long word which simply means that the frontal (near the forehead) and
temporal (side) portions of the brain are affected. Most commonly
occurring in people who are between 50 and 60 years old, Pick's Disease
is characterized by drastic personality changes, a deterioration of social
skills, and emotional blunting (a lack of empathy and emotion). These
signs usually occur before problems with memory and other symptoms
emerge. In the advanced stages of the disease, people with Pick's Disease
may become extremely apathetic or highly agitated, to the point that
conducting a psychological assessment (for diagnostic purposes) is
impossible because they cannot participate or focus on answering
questions.

Creutzfeldt - Jakob disease (CJD)
Sometimes referred to as "mad cow disease," CJD is caused by "slow
viruses" called prions, which are folded proteins that interfere with the
brain's ability to function. The disorder usually affects adults between 40
and 60 years of age, but can occur at any age. Anywhere from 5-15% of
CJD cases have a genetic component; however, many people have no
family history of the disorder. In individuals with no family history of CJD,
the disease is often transmitted through infected medical equipment in
procedures such as transplantation of the cornea of the eye. Dementia
caused by CJD often progresses rapidly over several months and is
characterized by problems with attention, concentration, appetite, vision,
and coordination.

Normal Pressure Hydrocephalus
Normal Pressure Hydrocephalus occurs when there is an abnormal
increase in the level of cerebrospinal fluid (the fluid in and around the brain
and spinal cord which serves a protective, nourishing function) in the
brain's hollow spaces (called ventricles). This increased fluid level
squeezes the brain, which can cause subsequent damage. In addition to
dementia, people with this disorder often experience problems walking and
controlling their bladder.

Wernicke-Korsakoff Syndrome

Wernicke-Korsakoff Syndrome results from a deficiency in thiamine
(Vitamin B1) and is often the result of chronic, severe alcoholism. This
syndrome can also result from general malnutrition, severe eating
disorders, or the effects of chemotherapy (often used in cancer treatment).
Dementia due to Wernicke-Korsakoff Syndrome is characterized by
confusion, apathy (a lack of energy, interest, and/or emotion), an inability


to engage in meaningful conversation (i.e., impaired ability to discuss
current events or one's outlook on life), hallucinations (sensing things that
are not truly present), and severe memory impairment.

Mixed Dementia

Dementia caused by multiple medical conditions is called Mixed Dementia
or - in the DSM-IV - dementia due to "multiple aetiologies." The most
common form of Mixed Dementia is dementia due to both Alzheimer's and
Vascular Disease, both of which we describe below.
Dementia can also be caused by the persisting effects of a substance
(e.g., an illegal drug; over-the-counter or prescription medication; or a toxin
such as mercury, lead, or carbon monoxide).
In cases where a clear reason for the dementia cannot be determined, the
dementia is referred to as Dementia NOS (not otherwise specified). There
are a couple of reasons a diagnosis of Dementia NOS might be given. For
example, a person may clearly show signs of dementia, but the clinician
does not have enough information to make an accurate diagnosis. In this
case, the NOS are a temporary diagnosis that will be changed once the
clinician has gathered more information. In rare cases, every known cause
of dementia is ruled out (e.g., found not to be a cause), so a diagnosis of
Dementia NOS is given because the reason for the person's symptoms is
truly unknown.

Activity 3.
What medical conditions may cause dementia?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Alzheimer's Disease
Alzheimer's Disease (AD) is the most frequent cause of dementia. For
many decades, people thought that "senility" was a natural part of getting
older; consequently, AD did not receive much attention as a real medical
disorder. It is now considered a major public health problem that is causing
serious issues for families and society.
According to the CSIRO, Alzheimer's disease costs the Australian health
system $3.2 billion a year in direct costs, a figure expected to reach $6
billion within five years. Indirect costs are also considerable. However,
positively, if lifestyle or other interventions can delay the onset of the
disease by even five months, there would be a five per cent reduction in
the cost of Alzheimer's disease to the economy.
.

Alzheimer's disease is not a normal part of aging or "just what happens
when we get old." If AD was part of the natural aging process, we'd have a
very large group of people (every person over 65) walking around today
with this disorder! As we age, we do experience minor changes in memory
and thinking. But, these changes do not seriously impair our daily
functioning or our ability to live independently and take care of ourselves.
There are several differences between normal aging and Alzheimer's
Disease:
Forgetfulness - People aging normally might forget part of an
experience (I can't remember what I had for breakfast yesterday).
People with Alzheimer's Disease will forget the entire experience (I
can't remember yesterday morning at all).
Remembering - People aging normally may forget something (such as
a movie recommendation for a friend), but they will eventually recall the
desired information (e.g., later in the evening or the next day). People
with Alzheimer's will not recall the information at a later time.


Comprehension - People aging normally can usually follow verbal or
written instructions with no problem (e.g., filling out a sweepstakes
entry or following a recipe). People with Alzheimer's Disease become
less and less able to follow instructions (or multiple step directions) as
the disease progresses.
Memory Aids - People aging normally will usually benefit from using
notes and other reminders (e.g., a grocery list). People with Alzheimer's
gradually become less able to benefit from memory aids (e.g., they will
forget that they have a list, or forget how to use the list).
Self-Care - People aging normally may be stiff or have some aches and
pains, but they can still complete personal care tasks (e.g., bathing,
dressing, styling hair, going to the bathroom, etc.). People with
Alzheimer's lose the ability to perform these kinds of tasks because
they cannot remember the steps involved, and eventually, they won't
remember when these tasks are appropriate.

There are different terms that health care professionals use to further
specify different types of Alzheimer's Disease. "Familial AD" runs in
families (i.e., is passed on from generation to generation). Individuals who
develop AD before age 65 are said to have "early-onset Alzheimer's
Disease." Early-onset familial Alzheimer's Disease is the most aggressive
form of AD; those affected by it suffer a swifter cognitive decline than
individuals with late-onset Alzheimer's Disease (occurring after age 65).


Activity 4.
What are the differences between aging and Alzheimers Disease? Fill in
the table below
Aging Alzheimers Disease
Forgetfulness

Remembering

Comprehension

Memory Aids

Self-Care

Prevalence and Causes of Alzheimer's Disease
According to a recent national study by the CSIRO, In 2003, 162,000
people in Australia were diagnosed with Alzheimer's disease, representing
0.8 per cent of the population. By the time they turn 85, one in five
Australians could have the disease. What begins as occasional
forgetfulness slowly degenerates into a state where a person no longer
recognises close friends and family, and requires constant, attentive care
The risk of developing AD increases dramatically with age; almost 50% of
individuals over 85 are coping with this disorder. Estimates suggest that if
a cure or an effective prevention strategy for Alzheimer's is not found by
the year 2050, anywhere between 11 and 16 million people age 65 and
older will be affected in the United States alone.

Causes of Alzheimer's Disease
Despite the increasing interest in research focused on the causes of
Alzheimer's Disease, scientists are still uncertain about the true reason (or
reasons) why individuals develop the illness. Most likely, there is no one
single factor that we can pinpoint as a culprit. Most experts think that
several factors are working together to ultimately determine whether
someone goes on to develop AD.
Before we explain the brain changes that occur with Alzheimer's Disease,
it's important to understand what happens to people's brains as they age.
Remember, we said before that AD is a disease process rather than


normal aging. Therefore, it is important to continue our "compare/contrast"
between normal aging and Alzheimer's to further illustrate what happens to
people's brains when they have the disease.

Activity 5.
Answer yes or no to the following questions
a. As of 2003 162,000 people in Australia were diagnosed with
Alzheimers disease. YES/NO
b. One in five Australians could have the disease by the time they are
85 YES/NO
c. The risk of developing Alzheimers disease increases dramatically
with age YES/NO
d. Alzheimers Disease is a disease process rather than normal
aging. YES/NO


The Aging Brain
Three major processes happen to people's brains as they get older. First,
some neurons (nerve cells in the brain and spinal cord) shrink. Second,
plaques and tangles develop. Third, free radical damage increases. These
factors combine to cause a slowing of reaction time and some minor
impairment in a person's ability to remember and to learn new things.
These changes are part of the normal aging process.
Activity 6
What are the 3 major processes that happen to peoples brains as they are
getting older.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Plaques
Plaques are deposits of a protein called beta-amyloid that accumulate in
the spaces between neurons in the brain. Beta-amyloid fragments break
off of a larger protein called amyloid precursor protein (APP). When people
are young, APP helps damaged neurons repair themselves as well as
stimulating neurons to regrow after injury (if necessary). As people age,
APP breaks up into beta-amyloid fragments and mixes with molecules,
neurons, and other types of cells, creating clumps (plaques). These
clumps can interfere with the neurons' ability to communicate with each
other and perform important brain functions.

Three decades of research have begun to shed light on how AD steadily
destroys brain function. A protein called amyloid precursor protein (APP),
produced by healthy neurons, is severed by two enzymes, called beta and
gamma secretase. This process creates a short, sticky protein called beta
amyloid.
Instead of dissolving in the fluid that surrounds the neurons, beta amyloid
protein folds into insoluble clumps called fibrils. The fibrils stick together,
resulting in plaques on the surface of the neuron. Beta amyloid plaques
are one of two characteristic lesions of AD.


Illustration 1
Development of Plaque

A beta-amyloid protein in a healthy cell.
Ref: Alzheimer's Disease Education and Referral Centre.

The beta-amyloid protein being cleaved by beta and gamma secretase
enzymes.

A beta-amyloid plaque forming outside the cell.


Activity 7
Fill in the missing words;
Plaques are ___________of a protein called _______________that
accumulate in the spaces between _________in the brain. Beta-amyloid
fragments break off of a larger protein called ____________________
(APP). When people are young, ______helps damaged
_____________________as well as stimulating neurons to
____________________(if necessary).
Tangles
Neurofibrillary tangles are deposits of a protein called tau. Tau's job is to
help make long fibres called microtubules which act as miniature scaffolds,
holding the neuron in its proper shape and also helping transport nutrients
within the neuron. As people age, tau stops working properly in some
neurons and starts to accumulate and twist around inside the cells. As a
result, the microtubules collapse, causing impaired communication
between neurons, and eventually, cell death. The fibre tangles remain in
the brain long after the dead neuron has been cleared away.
Free radicals are unstable molecules that are created during metabolism
(when the body breaks down food into nutrients), immune system
reactions (when the body is trying to fight off viruses and bacteria), and
exposure to certain environmental factors (e.g., pollution, radiation,
cigarette smoke). Free radicals typically attack the nearest stable
molecule, causing it to become unstable itself, in turn creating another free
radical, and so on (a process called oxidation). When we are young, the
body is usually able to cope with free radicals by mobilizing antioxidants
(nutrients that prevent oxidation such as Vitamins C and E). However, as
we age, free radical damage accumulates, creating cell and tissue damage
(causing wrinkles, hearing loss, etc.).

A Neurofibrillary tangle, which forms inside the cell.
Ref: Alzheimer's Disease Education and Referral Centre


Activity 8.
Fill in the missing words:

As _____________, tau stops working properly in some __________
and starts to _____________________ around inside the cells. As a
result, the ________________________, causing
___________________ between neurons, and eventually, cell death.
The ___________________ remain in the brain long after the
_______________has been cleared away
The AD Brain - Plaques and Tangles
When compared to the brains of people who are aging normally, the brains
of people who have AD contain large numbers of plaques, particularly in
the hippocampus, the region of the brain that controls memory. In addition,
individuals with AD have a significant amount of Neurofibrillary tangles
spread throughout the brain.
Interestingly, doctors have found some people who showed no symptoms
of Alzheimer's disease and still had a significant number of plaques and
tangles in their brains at autopsy. These people may have developed a so
called "cognitive reserve," or a large number of connections between brain
cells due to healthy lifestyle habits (discussed later) and a high level of
education which acted like a "buffer" to stave off the symptoms of the
disease. Another theory is that plaques and tangles begin to form several
years before Alzheimer's symptoms actually appear so people who have
plaques and tangles but no signs of AD may have died of another cause
before living long enough to become cognitively impaired.
Because of this mystery (why some people with large amounts of plaques
and tangles don't have AD symptoms), many scientists believe there is
more to Alzheimer's Disease than abnormal protein accumulations,
although these do seem to play a significant role in the development of the
disease.
The AD Brain - Free Radicals
Individuals with Alzheimer's Disease seem to have double the amount of
destruction created by free radicals in the frontal and temporal (side)
portions of the brain when compared to people aging normally. Both of
these brain areas are important for memory and other advanced cognitive
functions.


The AD Brain - Neurotransmitters
Neurotransmitters are chemicals that carry messages between neurons so
that the cells can function properly. If the brain produces too much or too
little of a particular neurotransmitter, problems such as memory
impairment, confusion, or depression can occur. While most scientists do
not think that changes in neurotransmitter levels cause AD,
neurotransmitter levels are affected by the illness and contribute to the
thinking problems that accompany it. Several medications used to treat
symptoms of Alzheimer's Disease target neurotransmitters, which provides
indirect evidence that these brain chemicals are somehow involved.
Two neurotransmitters seem to play a role in Alzheimer's Disease:
acetylcholine and glutamate. Acetylcholine (ACh) activates muscles and
helps with arousal, short-term memory, and learning. Individuals with AD
have low levels of ACh. Some research suggests that plaques may be one
of the reasons for low levels of ACh because they increase the activity of a
chemical called acetyl cholinesterase, which is involved in breaking down
ACh. Too much acetyl cholinesterase has the overall effect of decreasing
ACh levels, which contributes to the characteristic symptoms of AD.
Glutamate is the most common neurotransmitter in the brain and is
involved in learning and memory. As the brain cells of someone with
Alzheimer's Disease die, they release excess amounts of glutamate. The
excess glutamate becomes harmful because it overstimulates healthy
brain cells (a phenomenon called excitotoxicity), causing them to become
damaged or to die.
The AD Brain - The Path of Destruction
AD starts in a part of the brain called the entorhinal cortex (EC), which
sends signals to the hippocampus that help form and store memories.
Plaques and tangles then spread to the hippocampus and other parts of
the brain that control memory, language, and reasoning. As brain regions
are destroyed, they atrophy or shrink. As a result, the fluid-filled chambers
of the brain (called ventricles) enlarge, and sulci (tissue indentations)
widen. Eventually, large portions of the brain are completely destroyed by
AD.

Activity 9.
Answer the following statements True or False
a) Individuals with Alzheimer's Disease seem to have no difference in the
amount of destruction created by free radicals in the frontal and
temporal (side) portions of the brain True / False
If the answer is false what is the correct answer? _______________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________

b) Neurotransmitters are chemicals that carry messages between
neurons so that the cells can function properly. If the brain produces


too much or too little of a particular neurotransmitter, problems such as
memory impairment, confusion, or depression can occur. True / False
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
c) Two neurotransmitters seem not to play a role in Alzheimer's Disease:
acetylcholine and glutamate. Acetylcholine (ACh) activates muscles
and helps with arousal, short-term memory, and learning True / False
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
d) AD starts in a part of the brain called the entorhinal cortex (EC), which
sends signals to the hippocampus that help form and store memories.
True / False
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________


Risk Factors for Alzheimer's Disease
There are two known risk factors for developing Alzheimer's Disease: age
and family history. Advancing age is the number one risk factor for
developing AD; the probability of being diagnosed with the illness nearly
doubles every five years after the age of 65.
People who have a parent or sibling affected by Alzheimer's are two to
three times more likely to develop the disease than those with no family
history of AD. If more than one close relative has been affected by the
disease, the risk increases even more.
Two different kinds of genes can be passed from one generation to the
next that increase a person's chances of developing Alzheimer's: risk
genes and deterministic genes. Risk (or susceptibility) genes increase a
person's likelihood of developing Alzheimer's, but they do not guarantee a
future diagnosis. In other words, even if you carry this gene, there is not a
100% likelihood that you will go on to develop the disease. The gene
APOE-e4 found on chromosome 19 is the primary risk gene that is thought
to be associated with AD. APOE attaches tightly to beta amyloid and
seems to cause an excessive number of plaques to develop in a person's
brain. Besides APOE, researchers think there may be up to a dozen more
risk genes for AD.
Deterministic genes are much rarer than risk genes and are only found in a
few hundred extended families around the world. If a deterministic gene is
inherited, there is 100% certainty that the person will develop Alzheimer's,
probably before the age of 65. Scientists have discovered three
deterministic genes thus far: an abnormal amyloid precursor protein on
chromosome 21 (this increases beta amyloid, which can cause excessive
plaques); an abnormal protein on chromosomes called presenilin 1 (which
seems to cause beta amyloid to be created); and an abnormal protein on
chromosome 1 called presenilin 2.
Obviously, age and family history are not under our control. Still, we may
be able to reduce our risk of developing Alzheimer's by employing healthy
lifestyle habits. An increasing amount of evidence suggests that lifestyle
factors such as diet/nutrition, exercise, intellectual activity, and social
engagement can affect someone's Alzheimer's risk. Lifestyle factors are
covered in more detail in a later section on prevention.

Activity 10.
What are the two known risk factors for developing Alzheimer's
Disease?
___________________________________________________________
___________________________________________________________
How might we be able to reduce our risk of developing Alzheimers
disease?
___________________________________________________________
___________________________________________________________


Symptoms of Alzheimer's Disease
Alzheimer's Disease is difficult to diagnose because symptoms frequently
resemble the symptoms of many other diseases, such as the dementias
mentioned earlier (e.g., Vascular Dementia, Lewy Body Dementia). To
attempt address this difficulty in diagnosing AD, the DSM-IV contains a
detailed set of criteria that must be met in order for someone to receive the
diagnosis.
First, the person must display multiple cognitive deficits, one of which must
be memory impairment. In addition to problems with memory, the person
must also have one or more of the following symptoms:
Aphasia - This is a deterioration of language abilities, which can look
different across different people. For example, individuals might have
difficulty coming up with the correct names for people or objects that
were previously familiar (e.g., they might not be able to remember that
an object is called a "key"). People with AD often have vague speech,
using the words "it" or "whatchamacallit" excessively. They may also
have difficulty understanding what is being said to them, repeating back
what has been heard, or comprehending what they read. In the later
stages of the disease, people with Alzheimer's Disease might repeat a
specific word or sound over and over, or echo things that they just
heard.
Apraxia - This is a problem with motor activities, even though people's
movement, senses, and ability to comprehend language are still intact.
Apraxia is basically a disconnect between the idea of a performing a
task (I want to do it) and the execution of it (I can't remember how to do
it). For example, individuals with Alzheimer's may have the physical
and sensory abilities necessary to button a coat, but there is a mental
gap between wanting to button the coat and actually being able to do it.
As you can imagine, Apraxia often affects the ability to carry out daily
tasks such as cooking, dressing, and grooming.
Agnosia - This is an impaired ability to recognize or identify objects,
even though sensory abilities are intact. For example, people with
Alzheimer's might have adequate vision but cannot correctly identify
what they are seeing as a lamp. Or, they might not be able to identify a
coin by touch even though they have adequate sensation in their
hands. Agnosia can lead to an inability to recognize family members or
one's own reflection in the mirror.
Problems with executive functioning interfere with activities such as
planning tasks, making decisions, organizing projects, or carrying out
activities in the proper sequence. For example, a person with
Alzheimer's who once hosted large dinner parties on a regular basis
would gradually become unable to organize, plan, and carry out the
tasks associated with making dinner for a small family (or him or
herself).


According to the DSM-IV, in order to meet the criteria for an Alzheimer's
disease diagnosis, a person's cognitive deficits must cause significant
impairment in occupational and/or social functioning. In other words, the
impairments must affect one's ability to hold a job or volunteer position,
carry out daily life/work tasks, and/or maintain social relationships. The
deficits must also be a significant decline from the person's previous level
of functioning.
Also, in order to receive a diagnosis of Alzheimer's, a person's symptoms
must not be caused by another medical condition, such as an central
nervous system disorder (e.g., Parkinson's Disease), systemic conditions
(e.g., thyroid problem, infection), or a substance-related condition (e.g.,
alcoholism). In addition, the cognitive deficits must not occur exclusively
during an episode of delirium (a temporary cognitive disorder covered later
in this paper). Finally, the deficits should not be caused by another mental
disorder, such as depression or schizophrenia.

Activity 11.

What are the symptoms of Alzheimers disease? And what do the
terms mean?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
True or false?
a) In order to receive a diagnosis of Alzheimer's, a person's symptoms
must not be caused by another medical condition, such as an central
nervous system disorder (e.g., Parkinson's Disease), systemic
conditions (e.g., thyroid problem, infection), or a substance-related
condition (e.g., alcoholism). True / False
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________


Warning Signs of Alzheimer's Disease
Warning signs are often the first things people notice - either in themselves
or a relative - that may indicate that someone has Alzheimer's Disease.
According to the Alzheimer's Association, the ten classic warning signs of
AD are:
1. Memory loss - People with Alzheimer's Disease show signs of memory
problems, particularly difficulty with remembering recently learned
information (e.g., a news story from earlier that morning). While it is
normal to occasionally forget phone numbers or appointments, those
with AD gradually forget more and more, and are unable to recall
forgotten information at a later time.
2. Problems carrying out familiar tasks - People with Alzheimer's start
having problems planning and completing chores such as fixing meals
or paying bills. While it is normal to occasionally become sidetracked or
distracted while you are doing something, those with Alzheimer's will
be unable to regain their bearings or follow through with a task.
3. Language/communication difficulties - Mild aphasia (a difficulty with
naming common objects or people) is a common warning sign of
Alzheimer's Disease. While it is normal to have trouble coming up with
the right word to express your thoughts periodically, people with AD
have significant trouble communicating and understanding what is
being communicated to them.
4. Disorientation - People with Alzheimer's often become confused about
time and place. For example, they may not know the current time, day,
date, month, season, and/or year. They may also be confused about,
or unaware of, where they are in regard to a building/residence, a
particular street, city, state, or country. While it is normal to temporarily
forget where you are headed, or to forget the date, those with
Alzheimer's might become lost on the way to the grocery store and be
unable to make it back home.
5. Lapses in judgment - Individuals showing early signs of Alzheimer's
may start making unwise personal, social, or financial decisions. For
example, they might wear a winter coat during the summer or make
sexual advances toward a restaurant server. While we all make
questionable choices from time to time, people with AD have major
lapses in judgment that are departures from their previous behaviour.
6. Decreased ability to think abstractly - People with Alzheimer's will have
problems completing complex intellectual tasks, such as estimating the
total cost of several items at the store. While it is normal to momentarily
forget the answer to an arithmetic problem or to make an error while
balancing the cheque book, individuals with AD not only can't
balance a chequebook, but they no longer understand what the
numbers in the register represent.
7. Misplacing objects - A common early sign of Alzheimer's disease is
losing common possessions and not being able to find them again,
usually because the object has been put in an illogical place. For
instance, people with AD might lose a hair dryer because they put it in
the washing machine and forgot it was there. It is PERFECTLY
NORMAL to lose your keys or wallet occasionally! However, people
with AD are not able to find the item again.


8. Alterations in mood and/or behaviour - People with Alzheimer's may
become extremely moody, switching between emotions such as anger
and elation within a matter of seconds. While it is normal to
occasionally feel down in the dumps or giddy, individuals with AD may
show inexplicable emotions and/or shift between them unpredictably.
9. Sudden shifts in personality - Individuals with Alzheimer's often exhibit
a drastic change in personality. For instance, people who were always
very independent and confident may become overly dependent and
suspicious. While it is normal to occasionally feel out of sorts and act
differently (particularly when we are sick, are stressed, or have suffered
a loss), this feeling is usually temporary. People with AD experience
permanent changes in their general behaviour or ways of relating to
others.
10. Apathy/loss of initiative - Increased passivity is a common early sign of
Alzheimer's. For instance, people with AD might watch television for
several hours a day, avoid participating in activities they used to enjoy,
or sleep most of the time. While it is normal to feel tired now and then,
people with Alzheimer's will exhibit apathy to a degree that negatively
affects their ability to complete daily tasks and chores.

Activity 12.

What are the warning signs of Alzheimer's Disease?
1 __________________________________________________________
2 __________________________________________________________
3 __________________________________________________________
4 __________________________________________________________
5 __________________________________________________________
6 __________________________________________________________
7 __________________________________________________________
8 __________________________________________________________
9 __________________________________________________________
10 _________________________________________________________


Illustration 2
Differences between a normal brain and a brain with Alzheimers
Disease

Stages of Alzheimer's Disease
Although each person with Alzheimer's is different, most individuals
progress through a series of stages characterized by gradually increased
impairment and changes in behaviour. Mental health professionals
generally categorize AD into seven stages, but these are often
consolidated into early/middle/late stages or mild/moderate/severe stages.
Each stage is described below in regard to common symptoms and level of
cognitive functioning:
Stage 1 (No Impairment) - The person does not report or display any
problems with memory, orientation, judgment, communication, or daily
activities. The person is a normally functioning adult.
Stage 2 (Very Mild Decline) - The person reports some lapses in
memory, such as frequently misplacing familiar objects or forgetting the
names of familiar people (e.g., neighbours). However, neither family
nor friends are able to detect any changes, and a psychological exam
would probably not reveal any problems, either.
Stage 3 (Mild Cognitive Impairment) - Family members and friends
start to recognize that the person has mild changes in memory,
communication patterns, or behaviour. Common symptoms in this
stage include problems remembering names or the right words for
objects, getting lost more frequently, difficulty functioning in
employment or social settings, forgetting material that has just been
read, misplacing important objects with increasing frequency, a


decrease in planning or organizational skills, decreased concentration,
and increased anxiety about the symptoms.
Stage 4 (Mild/Early-Stage Alzheimer's) - Now, the person's cognitive
problems are more obvious. The person may become more forgetful of
recent events or personal details. Other problems include impaired
mathematical ability (e.g., counting backwards from 100 by 7s), a
diminished ability to carry out complex tasks (e.g., managing money),
denial about the disease, and social withdrawal (e.g., a reluctance to
interact with other people, often out of shame or embarrassment due to
the symptoms).
Stage 5 (Moderate/Middle-Stage Alzheimer's) - In this stage, some
assistance with daily tasks is required. Problems with memory and
thinking are quite noticeable, including an inability to recall key details
about one's history (e.g., one's birthplace, schools attended),
disorientation to time and/or place (i.e., not knowing the time or where
one is), and decreased judgment and skills in regard to personal care
(e.g., inability to dress or groom oneself appropriately). Even though
symptoms are worsening, people in this stage usually still know their
own name and the names of key family members; they also can eat
and use the bathroom without assistance.
Stage 6 (Moderate/Middle-Stage to Severe/Late-Stage Alzheimer's)
- This stage is characterized by drastic personality and behaviour
changes and is often the most difficult for caregivers. A person's
memory continues to decline, and assistance is required for most daily
activities. The most common symptoms associated with this stage
include reduced awareness of one's surroundings and of recent
events, problems recognizing one's spouse and other close family
members, sundowning (i.e., increased restlessness and agitation in the
late afternoon and evening), difficulty using the bathroom
independently, bowel and bladder incontinence, suspicion, repetitive
verbal and nonverbal behaviour (repeating the same word or phrase
over and over, or repeating a motion like clapping), and wandering.
Stage 7 (Severe/Late-Stage Alzheimer's) - In the final stage, people
can no longer respond to the surrounding environment. They may be
able to speak words or short phrases, but communication is extremely
limited. Basic functions begin to shut down, such as motor coordination
and the ability to swallow. Total care is required around the clock.
Although the stages described above are a helpful blueprint for
understanding the progression of Alzheimer's disease, individuals do not
always move through the stages in a linear way. For instance, it can seem
like a person is in two stages at once, or that the person is switching back
and forth between stages in a cyclical fashion. Also, there is no average
length of time spent in each stage - the progression through the stages is
highly individual.


Activity 13.
What are the stages of Alzheimers disease and what do they cover? ____
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Diagnosis of Alzheimer's Disease
Previously, the plaques and tangles that accumulate in the brain
(described previously) with Alzheimer's disease could only be definitively
identified through autopsy. In other words, there was no available test or
procedure to "pull out" a small sample of the brain to determine whether
someone had developed plaques or tangles while they were still alive.
Currently, scientists are working on imaging procedures (described below,
procedures that provide information about the structure and function of the
brain) that will allow us to use brain scans and computers to aid in
diagnosis. However, because using imaging technology to diagnose AD is
still relatively new, the old standard of using a battery of tests for diagnosis
is still the accepted procedure. The good news is that when a qualified
physician does a thorough examination - which usually takes more than
one visit - Alzheimer's disease can be diagnosed while the person is still
alive, and we can be over 90% sure that the diagnosis is correct.
An even better method than relying on a single physician for diagnosis -
although not always available outside of metropolitan areas with large
research and teaching hospitals - is to approach diagnosis and treatment
with an interdisciplinary team that includes a geriatrician (i.e., a physician
who specializes in working with older people), a neurologist (i.e., a
physician who specializes in diseases of the nervous system), a
psychologist (i.e., a doctor who specializes in mood and behavioural
disorders), a neuropsychologist (i.e., a doctor who can perform testing to
identify the nature and level of cognitive symptoms), and a social worker
(i.e., a social services professional who can link individuals and families to
community services).
The goal of a diagnostic workup is to rule out any other possible condition
(reversible or irreversible) that could be creating the Alzheimer's-like
symptoms. Appropriate diagnosis is crucial to making treatment
recommendations (particularly if the condition can be reversed) that are
likely to be beneficial. There are several components in a diagnostic
workup, including:
Medical history - This includes questions about prior illnesses,
previous injuries and surgeries, and current chronic conditions in order


to identify other possible causes for Alzheimer's-like symptoms. For
instance, a serious head injury - even from long ago - could account for
problems with memory or concentration, or heart disease could be
reducing blood flow to the brain and causing forgetfulness.
Medication history - This includes questions about allergies, side
effects from past medications, and a list of current medications and
dosages. Not only will this information help guide any future
prescription decisions, it also might reveal a medication interaction
(when two or more medications work against or compound the effects
of each other) or overdosage that accounts for confusion and other
symptoms.
Complete physical exam - This includes an assessment of hearing,
vision, blood pressure, pulse, and other basic indicators of health and
disease. A current physical exam can detect acute medical conditions
such as an infection that might be causing confusion and other
Alzheimer's-like symptoms.
Laboratory tests - This may include a battery of tests, depending on
the individual's medical history and current symptoms. For example, a
blood glucose test might be ordered if the person is exhibiting
symptoms of diabetes such as frequent urination, blurred vision, or
increased thirst. Symptoms that came on suddenly and include severe
confusion would warrant a urinalysis to rule out a urinary tract infection.
Some scientists are currently refining a procedure that would allow a
doctor to analyse a sample of cerebrospinal fluid (the fluid that
surrounds and protects the brain and spinal cord) for the characteristic
abnormal proteins that build up with Alzheimer's Disease.
Neurological exam - This is a specific type of exam that is used to
identify problems with the brain and nervous system. The evaluation
should include an examination of the motor system (i.e., movement),
reflexes, gait (i.e., walking), sensory functioning, and coordination in
order to detect nervous system problems that may be causing
difficulties with thinking and behaviour.

Activity 14.
What are the components in a diagnostic workup?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Vascular Dementia
Vascular Dementia is one of the second most common types of dementia,
along with Lewy Body Dementia. Formerly called "multi-infarct dementia,"
this disease was once thought to only be caused by series of small
strokes. However, the name was later changed to "Vascular Dementia" to
reflect the wide array of conditions that can lead to this form of dementia.
Vascular Dementia often occurs at the same time as Alzheimer's Disease,
resulting in a condition called "Mixed Dementia".
Prevalence of Vascular Dementia
It is estimated that approximately 200,000 people in Australia have
dementia. (Access Economics 2005). And Vascular dementia, formerly
referred to as multi-infarct dementia, accounts for 10-20% of cases.
Vascular dementia often coexists with Alzheimers dementia referred to as
a mixed dementia. Between 1% and 4% of people over the age of 65
have this disease. The risk of developing this form of dementia increases
dramatically with age.
Causes of Vascular Dementia
Vascular Dementia results from impaired blood flow to the brain. This can
occur either from a narrowing or a complete blockage of blood vessels in
the brain, which deprives neurons (cells in the brain and spinal cord) from
obtaining the nutrients and oxygen they need to function properly.
Often, Vascular Dementia results from several small strokes - also called
infarcts or transient ischemic attacks (TIAs) - that occur over time. Strokes
are disruptions in the blood supply to the brain (for more information on
strokes, click here to visit our related topic centre). Vascular Dementia that
is caused by TIAs develops gradually, because several TIAs can occur
before any dementia-like symptoms become apparent.
Vascular Dementia can also occur after a single major stroke, which is
sometimes referred to as "post-stroke dementia." Not all strokes lead to
dementia, but up to one third of those who have a stroke will develop
dementia within six months. Conditions that do not completely block blood
vessels, but simply narrow them (e.g., diabetes and high blood pressure)
can also lead to vascular dementia.

Activity 15.
What are the causes of Vascular Dementia?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Risk Factors for Vascular Dementia

Individuals who develop Vascular Dementia often have a history of one or
more of the following conditions: heart attack, previous stroke, TIAs,
extremely high or low blood pressure, diabetes, brain haemorrhage, blood
vessel damage from a disorder such as lupus (a disease caused by a
malfunctioning immune system), or high cholesterol.
If a person has a history of TIAs, the risk of developing Vascular Dementia
increases with the number of TIAs experienced over time. People that
have experienced a stroke which affected their language abilities are also
at an increased risk of developing Vascular Dementia. High blood pressure
induces extra tension in the blood vessels throughout the body - including
in the brain - increasing one's risk for this form of dementia. Finally, those
with diabetes are at a higher risk for Vascular Dementia because high
glucose levels damage blood vessels, increasing the risk for stroke and
other problems that impair blood flow to the brain.

Activity 16.

What are the Risk factors for Vascular Dementia?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Symptoms of Vascular Dementia
The DSM-IV outlines specific criteria for the diagnosis of Vascular
Dementia. First, the individual must display multiple cognitive deficits, one
of which must be memory impairment. In addition, the person must have
one or more of the following symptoms:
Aphasia - A deterioration of language abilities
Apraxia - Difficulty executing motor activities
Agnosia - An impaired ability to recognize or identify objects
Problems with executive functioning (the ability to plan, make
decisions, and carry out daily tasks)
In order to meet the DSM criteria for vascular dementia, a person's
cognitive deficits must cause significant impairment in occupational and/or
social functioning. In other words, the cognitive impairment must affect
one's ability to hold a job or volunteer position, carry out domestic
responsibilities, and/or maintain social relationships. The deficits must also
represent a significant decline from the person's previous level of
functioning.


Part of the diagnosis of Vascular Dementia involves examining a person
for a pattern of problems that health care professionals call "focal
neurological symptoms" (e.g., exaggerated or overly strong reflexes;
walking problems; and/or weakness in the arm, legs, hands, and feet),
which are signs that vascular disease is occurring.
A diagnosing clinician will also make sure that the person's deficits do not
occur only during an episode of delirium (discussed later in this paper), in
which case, the more appropriate diagnosis would be delirium. While not
necessary (according to the DSM-IV) for the diagnosis of Vascular
Dementia, some people also experience other symptoms as part of the
disorder, such as delusions (fixed, false beliefs), confusion, agitation,
urinary problems, and/or depressed mood.

Activity 17.
What are the symptoms of Vascular Dementia?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Comparing AD and Vascular Dementia
The patterns of symptoms across time that people experience are usually
different in AD and Vascular Dementia. Even though memory problems are
a symptom of Vascular Dementia, memory loss often occurs later in the
disease compared to when it emerges in people with Alzheimer's.
Typically, people with AD notice memory problems first. In contrast, people
with Vascular Dementia usually experience problems with reflexes, gait,
and muscle weakness first.
In addition, the courses of the two diseases are different. Vascular
Dementia usually progresses in a "step-wise" fashion. In other words,
people with Vascular Dementia "level out" (i.e., not experience much
decline in functioning) for a period of time, then suddenly get much worse,
then continue to alternate between stable periods and sudden drops in
functioning. Individuals with AD can have good and bad days, but for the
most part, this disease progresses in a more gradual, steadily downward
fashion.


Lewy Body Dementia
Although it is not as familiar to the public as Alzheimer's Disease or
Vascular Dementia, Lewy Body Dementia (LBD) is one of the second most
common types of dementia (along with Vascular Dementia). Even though
this type of dementia was first identified in the 1980s, it does not currently
appear in the DSM-IV. Therefore, a person with LBD currently receives a
DSM diagnosis of "Dementia Due to Lewy Bodies," which fits into the
category "Dementia Due to Other General Medical Conditions." Lewy Body
Dementia is sometimes referred to as Lewy Body Disease, Diffuse Lewy
Body Disease, or Cortical Lewy Body Disease.

Activity 18.
What are some of the names associated with Lewy Body Dementia?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Prevalence of Lewy Body Dementia
Prevalence statistics describing Lewy Body Dementia are somewhat
unclear, primarily because Lewy bodies - the hallmark of this disorder - are
associated with several different diseases. This makes it difficult to
distinguish LBD from other conditions. Keeping this problem in mind, the
Lewy Body Dementia Association reports that up to 20% of all dementia
cases are from LBD (over 800,000 people in the United States). The
disease appears to affect slightly more men than women.

Activity 19.
The above figures relate to the United States. Using the word wide web
(www) search for the amount of people that approximately would have
this condition in Australia. Make sure you reference where you got
this information from.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Causes of Lewy Body Dementia

Lewy Body Dementia is characterized by deposits of a misfolded protein
called alpha-synuclein inside neurons (the primary cells in the brain and
spinal cord). The protein deposits are called "Lewy bodies" after Friederich
H. Lewy, the researcher who first described them in the early 1900s. How
or why these deposits develop in the first place is unknown.
Lewy bodies that form in the brain stem and the rest of the brain decrease
the amount of available dopamine and acetylcholine. Both of these
chemicals are neurotransmitters (chemical messengers in the brain and
nervous system) which work together so that messages controlling motor
movement are properly sent and received. These deficits in
neurotransmitters cause movement problems referred to as "Parkinsonian"
symptoms (described below), as well as disrupting memory, learning,
perception, thinking, and behaviour.
Interestingly, Lewy bodies are also found in the brains of those with
Parkinson's Disease and - sometimes - even Alzheimer's Disease, making
diagnosing all of these illnesses much more complicated.

Risk Factors for Lewy Body Dementia

Age is the only definitive risk factor for Lewy Body Dementia. A person's
risk for developing this type of dementia increases as age increases, with
most cases occurring between the ages of 50 and 85. Sometimes, LBD
runs in families, but for the most part, the disease occurs in people with no
family history of the disorder.
As described in more detail below, some researchers also consider REM
Sleep Behaviour Disorder a significant risk factor for developing Lewy
Body Dementia.

Activity 20.
What are the causes of Lewy Body Dementia?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

What is the only definitive risk factor for Lewy Body Dementia?
___________________________________________________________


Symptoms of Lewy Body Dementia

Cognitive: The cognitive symptoms of people with LBD may fluctuate
frequently (moment-to-moment, hour-to-hour, or day-to-day). Individuals
will be alert (and seem "normal"), and then suddenly become extremely
confused, unable to pay attention, or unable to make decisions. Episodes
of cognitive impairment may last hours or days.
In addition to problems with attention and reasoning, people with LBD
often have impaired visuospatial skills (e.g., impaired depth perception or
the ability to see the world in three dimensions; impaired object orientation
or understanding how objects appear in space; impaired ability to navigate
about the world; and/or illusions, such as mistaking a coat rack for a
person).
People with LBD eventually develop impaired memory, but this type of
problem does not usually occur until they have had the disease for a
period of time. In other words, unlike Alzheimer's Disease, memory
symptoms are not the first problem that people with Lewy Body Dementia
(or family members) notice.
Movement: People with Lewy Body Dementia "look" somewhat different
from people with Alzheimer's Disease and Vascular Dementia, primarily
because they have Parkinson's-like symptoms. Parkinson's Disease is a
slowly progressive neurological condition that affects the brain and spinal
cord, creating symptoms such as tremors (shaking) and rigidity (stiffness).
Parkinsonian symptoms in LBD include slow movements, a stooped
posture, stiffness in the arms or legs, tremors, a shuffling walking pattern,
a mask-like appearance and/or a blank stare, and frequent falls.

Other symptoms: Other characteristic symptoms that are often disturbing
for both affected individuals and their family members set Lewy Body
Dementia apart from other types of dementia:
Recurrent, vivid visual hallucinations (seeing things that are not really
there, such as an attacker in the bedroom) that are extremely difficult to
separate from reality. Hallucinations occur most often when people are
most confused and can also include sounds, tastes, and smells that
aren't truly present.
Fluctuating alertness periods (extreme drowsiness followed by sudden
bursts of energy) that make it difficult for family members to predict or
assess how their relative is doing. People with LBD may also faint
repeatedly and without warning.
Severe sleep problems (called REM Sleep Behaviour Disorder or
RBD). During REM sleep (the stage of deep sleep characterized by
rapid eye movements), people with LBD will move, gesture, and/or
speak. They often seem to be acting out their dreams, and may
accidentally hit a spouse or fall out of bed. In addition, some people
become extremely confused when they first wake up (and not know the
difference between a dream and reality). REM Sleep Behaviour
Disorder can occur years before people start to show signs of dementia
and impaired motor movements. As mentioned above, RBD may be a
significant risk factor for developing Lewy Body Dementia.


Severe sensitivity to neuroleptics (also called antipsychotic drugs,
these medications are often used to treat psychotic disorders like
schizophrenia) occurs in up to 50% of individuals with LBD. These
medications can worsen cognitive and movement symptoms and/or
increase hallucinations. People with LBD can also develop Neuroleptic
Malignant Syndrome, which is a life-threatening illness characterized
by muscle rigidity, high fever, problems with the autonomic system (see
below), and severe confusion and fluctuating alertness.
The autonomic nervous system keeps our bodies in balance, or
homeostasis, by controlling functions such as heart rate, digestion,
breathing rate, perspiration, pupil dilations, the discharge of urine, and
sexual arousal. Individuals with LBD often have autonomic system
dysfunction, which can lead to blood pressure fluctuations, heart rate
variability, sexual dysfunction (e.g., impotence), constipation/urinary
problems, excessive or decreased sweating, dry eyes/mouth, and
difficulty swallowing.
Other psychiatric issues such as delusions (false, fixed beliefs),
aggression, and/or depression are not uncommon in individuals with
LBD. Aggressive behaviour can be triggered by infections (e.g., urinary
tract infections), medications, or misinterpretation of the environment or
interpersonal interactions due to confusion and/or hallucinations.

Activity 21.
What are the symptoms of Lewy Body Dementia?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Support individual needs of people with dementia using a person-centred
approach to care and address individual needs for a stable familiar
environment

Coping Skills for Dementia Caregivers
Not only is a diagnosis of dementia difficult for the person with the disease;
it also poses significant changes and sources of stress for those who care
for the person with the diagnosis. Most individuals with dementia have a
primary caregiver - usually a spouse, partner, or adult child - and some
people have secondary caregivers, such as other relatives or neighbours.
The following coping skills are useful to both primary and secondary
caregivers, but primary caregivers will find them the most relevant due to
the way that their lives have changed.
Learn as much as you can about the disease as soon as possible.
Although you may be reluctant to do so, you will thank yourself down
the road. You will be better prepared to handle the variety of
challenges associated with dementia if you know what to expect and
have some ideas about how other people have handled similar
challenges.
Adjust your expectations by imagining what your loved one is going
through. People do not want to have dementia; it is not their fault that
they developed the disease. Most of all, try to remember that the
person's brain is not working properly. He or she is not engaging in this
behaviour on purpose, or to be difficult or annoying. Caregiving is a
meditation on patience and understanding.
Attend to your own physical and mental health. Make time for sleep,
exercise, proper nutrition, socializing, and private time. If you are run
down, exhausted, socially isolated, etc., you run the risk of becoming
physically ill and overwhelmed and/or depressed yourself. You cannot
help someone else without helping yourself first.
Keep the lines of communication open with family and friends. Share
your feelings about how you are doing in addition to how your loved
one is doing. Those close to you most likely want to know what they
can do to help, but they may not ask because they feel uncomfortable
doing so, or do not know what to say. Even though it may be difficult,
ASK FOR HELP when you need it. If people do not know how to help,
think of some specific tasks that they can do. Try to tailor the request to
the person offering the help. For instance, if neighbours are
uncomfortable being around a person with dementia, ask them for help
with getting groceries or running other errands, rather than pressing
them to provide respite services (when someone spends time with your
loved one so you can have a break). Similarly, if a friend enjoys a more
"hands on" role, allow him or her to provide you with respite time to get
away for a few hours or days.
Make sure that legal and financial issues are in order, and include your
loved one in the decision-making process as much as possible. Ideally,
your loved one will initiate this process in the early stage of the disease
while his or her decision-making abilities are still intact.


Take an active role in your loved one's health care. Form a working
alliance with a physician and other professionals who are experienced
in issues related to dementia and other cognitive disorders.
Plan activities with your loved one that you both enjoy and that can be
adapted to the person's current level of functioning. Good examples of
adaptable activities include walking, taking a drive, gardening, doing
household chores, looking at pictures or magazines, watching movies
or television shows, baking, listening to music, singing, dancing, and
playing cards or other games.
If your loved one can no longer participate in an activity like he or she
used to, remember to relax the rules and definitions of what is
"appropriate." For instance, if the person wants to help with household
chores, let him fold a basket of laundry. Do not worry about whether
things are folded correctly (or that the task is completed quickly). What
is important is that he is participating in an activity that makes him feel
useful. Likewise, if your relative enjoys playing cards but cannot follow
the rules of poker anymore, try sorting a deck of cards into colours and
suits instead.
Monitor yourself for signs of caregiver burnout, such as anger, anxiety,
irritability, depression (e.g., a loss of interest in normally fun activities,
or feelings of worthlessness, guilt, or suicidality), social withdrawal,
denial about your loved one's diagnosis, denial about your role as a
caregiver (e.g., you feel that your life has not changed dramatically
even though you have left your job or given up most of your previous
activities), extreme fatigue, sleep problems, and/or health problems
such as ulcers, migraines, or high blood pressure. To prevent or
address caregiver burnout, try joining a caregiver support group, which
can provide education, emotional support, and connections to local
resources that can help you meet your caregiving responsibilities. See
the list of web resources at the end of this discussion for more
information about support groups.
If self-coping methods are not working, seek mental health care from a
professional who has expertise in addressing caregiver burnout,
depression, and grief. If you are having difficulty dealing with some of
your loved one's behaviours (e.g., suspicion, wandering), seek out
mental health clinicians with expertise in behaviour management
techniques for individuals with dementia.


Activity 22.
What are the coping skills you would need for working as a Dementia
caregiver? For these coping skills you need to give at least 2 examples
you might find in your work place for each of these skills.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Working with the awareness of the impact of physical, social and emotional
aspects of the environment on the person with dementia and working with
awareness of the impacts that dementia may have on family, carers and
significant others

Services for Dementia Caregivers

Several kinds of services are available for caregivers of individuals with
dementia. Try to find out about available services in your community
before you need them. This way, when you feel that you need outside
help, you will already have program information and contact numbers at
your fingertips instead of searching for available services while you are
under excessive stress. Some of the services that may be available in your
neighbourhood include:
Adult day care - Provides supervision and social opportunities for
people with dementia outside of the home for anywhere from a few
hours to a whole day. Adult day care agencies normally do not offer
overnight care. Many can provide personal care, such as assistance
with medications, toileting, and eating. Meals and/or snacks are often
included.
In-home respite care - Provides caregivers with a break while
providing supervision and social engagement to people with dementia.
Some respite providers are not licensed to provide personal care, but
can provide socialization and light meal preparation. These types of
respite care providers are appropriate during the early stages of
Alzheimer's or a related dementia; however, if the disease has
progressed to the point where assistance with personal care is
necessary, be sure to find out whether the respite care provider can
perform these services.
Home health care - Provides medical care services such as injections,
frequent blood pressure checks, or other procedures that you cannot
provide and that in-home respite companions are not licensed to
perform.
Government programs - Several programs may be available to help
meet the needs of people with dementia. For example, Meals-On-
Wheels provides home-delivered meals to older adults in need, and the
National Family Caregiver Support Program provides information,
training, case management, respite, and other supportive services to
primary caregivers.


Activity 23.
What services are available for Dementia sufferers? Go on the net and
list various organisations for each type of service.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Recognise witnessed signs consistent with financial, physical or emotional
abuse or neglect of the client and report to an appropriate person

Abuse of older adults is a well-kept secret in Australia. Thousands of
elders are abused, neglected, and exploited by family members and
others. Many cases go unreported. Abuse may be physical,
verbal/psychological, financial, sexual, or neglect. People with Alzheimer's
disease or other cognitive impairment are at higher risk than other older
adults. Most known perpetrators of abuse and neglect are family members,
usually an adult child or a spouse.
Caring for a person with AD can lead to stress, depression, feelings of
isolation, financial worries, and substance abuse, any or all of which can
lead to elder abuse. Violent behavior by the patient may also lead to
physical abuse by the caregiver.
Respite care for the patient and support group and counseling for the
caregiver can help to prevent elder abuse. In severe cases of abuse, it is
usually necessary to separate the patient from the caregiver, initiate legal
action, and find a safe facility for the patient.
Signs of abuse include bruises, skin wounds, burns or fractures, and lack
of explanation for falls and injuries. Physical signs of neglect include
severe weight loss, dehydration, poor personal hygiene, and pressure
ulcers (bedsores).

Legal considerations
Getting legal affairs in orderdrawing up advance directives, powers of
attorney, wills, or trusts should be done as soon as possible after
diagnosis, while the patient is able to express personal wishes and
participate in decisions. Referral to the local chapter of the Alzheimer's
Association can help families find attorneys who specialize in elder law or
estate planning.
This referral should not be made abruptly but as a suggestion,
emphasizing that every adult, regardless of health status, should make
such a plan. This helps ensure that one's wishes are respected in end-of-
life care and disposition of property after death. Otherwise, families will
need to make difficult decisions without knowing the patient's wishes.

Advance Directives
An advance directive specifies a person's preferences for care in the event
that he or she is unable to communicate those wishesfor example, in the
advanced stages of AD. A living will is one type of advance directive. In an
advance directive, the person can also name a representative to see that
his or her wishes concerning care are carried out. This is sometimes called
a durable power of attorney for healthcare.
Physicians should have copies of advance directives available or be able
to refer families to a source for the appropriate forms. In the US Federal
law requires hospitals to inform patients that they have a right to complete
an advance directive (the Patient Self-Determination Act), but advance
directives are regulated by state law and may differ from state to state.


Family Caregiver Alliance (http://www.caregiver.org) can provide state-
specific information and appropriate forms for advance directives. Advance
directives are used by almost half (46.6%) of all Floridians with severe
cognitive impairment, compared with 37.6 percent of their counterparts
nationwide (Brown University, 2004).

Activity 24.

What services are available in Australia and your particular state for the
delivery of rights and welfare for Dementia sufferers? Go on the net
and list various organisations for each type of service and what
services they offer.

Organisation Website Services Offered


What constitutes elder abuse
Physical abuse
Emotional abuse
Sexual abuse
Passive neglect
Willful deprivation
Confinement
Financial exploitation
Self Neglect

Activity 25.

In the table below list some of the ways that different types of abuse
happen.

Physical Abuse

Emotional Abuse

Sexual Abuse

Passive Neglect

Willful Deprivation

Confinement

Financial exploitation

Self-Neglect


Challenges of Mandated Reporting for the Professional
Upfront disclosure to families
When is it appropriate to report?
Identifying situations and addressing them with family caregiver
Offering suggestions and alternatives
To tell or not to tell that a report will be made
o Consequences of telling
o Possible consequences of not telling
Results of reporting

Case Study 1
Mrs. H
o 90-year old woman with dementia
o living with daughter
o Report of financial exploitation
o Results of this report
Mrs. H. was a 90-year-old woman who came to the senior center for
socialization. She had been working with a case manager regarding her
failing health and the need for assistance in activities of daily living. A private
duty caregiver was hired to provide the help during the day and the daughter
with whom she lived was there evenings and weekends.
It was learned by another relative that there was reason to suspect the
daughter was misusing the funds of Mrs. H. It was reported that she was
taking out credit cards in her mothers name and using the cards for herself.
Multiple charges were made on the bill. She also took a second mortgage on
the home to pay off her bills. Mrs. H. was not aware of any of this behavior.
Mrs. H. scores in the mid 20s on the Folstein.
Another case manager investigated the allegations. Mrs. H. was upset and
angry about the situation. Mrs. H. was upset that her children were not getting
along. It was agreed that we could discuss the allegations with the daughter.
The daughter has a history of substance abuse and other addictive behaviors,
e.g. overeating. She sought help for these problems and then turned to
compulsive spending. She justified her actions by stating that her siblings do
not visit her mom and help with her care. Therefore, they dont deserve to
inherit anything when she dies.
The daughter agreed to assistance from the case manager and agreed to a
budget and a plan to try to repay her mother. The daughter had seen a
counselor in the past and was receptive to reconnecting with the counselor to
deal with her moms failing health, her own issues of caregiver stress and
compulsive spending.
The daughter agreed to her brother taking over the finances of her mom and
Mrs. H. was pleased with this. The only charge account allowed was for
groceries and medications. A family meeting was set up with Mrs. H. and her
children to discuss the plan. At that meeting the children told Mrs. H. that she
never told them she loved them. Mrs. H. said but you always knew it. The
meeting was emotional but brought the family together. The situation was


resolved as the only allegations were financial exploitation and therefore, the
case was closed in elder abuse. Mrs. H. continued to be followed by the
original case manager. Mrs. H. soon after the investigation (within 3 months)
died and her children were with her at the time.

After having a look at the policy briefing on the Abuse and Neglect Policies
and Procedures PowerPoint (form the NSW Government) presented in class
or given to you for distance learning. How would you use this information to
handle the above situation?

Relate your answers to the following issues:
Safety issues
Medical issues
Legal issues
Liability issues
Ethical concerns

Safety Issues: _______________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Medical Issues:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Legal Issues:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Liability Issues:
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Ethical Issues:
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________


Elder Abuse Prevention Information

Elder Abuse Prevention, advocacy and information telephone: State and
Territory

ACT - Elder Abuse Prevention Information Line 02 6205 3535
NSW Police Assistance Line 131 444
NT - NT Health Services - 08 8999 2809
QLD Elder Abuse Prevention Unit 1300 651 192 or 07 3250 1955
SA - Aged Rights Advocacy Service - 08 8232 5377 or 1800 700 600
TAS Department of Health and Human Services - 03 6233 8514
VIC Seniors Information Victoria 1300 135 090
WA Advocare Inc - 08 9479 7566 or 1800 655 566


2. Use communication strategies
which take account of the progressive
and variable nature of dementia

2.1 Use a range of communication strategies to maximise
engagement of the person with dementia such as eye
contact, gentle touch (where appropriate), short simple
statements
2.2 Gain cooperation and provide reassurance as appropriate to
individual clients by using reality orientation including:
reminders of the day, the time, relationships, occasions
reassuring words, phrases and body language
2.3 Use a range of validation strategies to relieve distress and
agitation in clients such as:
Empathy
Acceptance of the persons reality
Acknowledgment
Allowing expressions of distress
Providing verbal and/or physical reassurance
Use reminiscences frequently to connect with clients

Communication strategies to maximise engagement of the person with
dementia.
Communicating with the person who has dementia begins with patience,
respect, and understanding. Remember that the patient is not deliberately
being difficult. Face the patient, make eye contact, and speak directly in a
calm, even tone. If patients have hearing problems, be sure they are
wearing a hearing aid. Keep sentences simple; focus on one idea at a
time.
Minimize questions because they may make the patient feel anxious or
threatened. If the patient doesn't understand, offer nonverbal cues, such
as pointing, demonstrating the desired action (eating, drinking), or nodding.
Even though patients may be unable to speak, they may still understand
so do not talk about the patient to others in the patient's presence.
Nonverbal communication, especially touch, between caregiver and patient
is also important. Patients who may be unable to respond verbally will
respond to a smile, kind gesture, and caring touch. Some patients may
need reminders during a meal to begin or continue eating, for example, by
placing the spoon in the patient's hand.
Careful observation of the patient's facial expressions, eye contact or lack
of eye contact, and body language can help the caregiver assess comfort
or pain, anger, hostility, and misunderstanding. For example, increased
motor activity and shaking fists suggest frustration or anger. Experience


and patience over time helps caregivers gain skill interpreting these
nonverbal signals.
Patients with dementia may ask the same question repeatedly because
they do not remember the answer given. Respond to the question, then try
to distract the patient with an activity or a change of topic or a change of
scene. Activities or events should not be discussed with the patient until
they are about to happen; otherwise, the patient may retain the idea that
something is going to happen but forget the details, triggering more
questions.

Communication Tips for Dementia Caregivers
As dementia progresses, it becomes more difficult for individuals to
express their thoughts and feelings, as well as to understand what is being
communicated to them. In order to enhance communication with your
loved one, try the following tips:
Speak slowly, at a normal level (not too loud), using a low-pitched
(rather than a "Minnie Mouse") voice. In addition, try to face the person
when you are speaking to him or her (rather than carrying on a
conversation out of the person's line of sight). Speaking rapidly, loudly,
or in a high-pitched voice can be overwhelming or upsetting for
someone with dementia.
Use short, familiar words and simple sentences that clearly express
what you want to say.
Allow your loved one sufficient time to respond. If he or she does not
respond, it is okay to repeat your question using the same wording as
before. If you ask the question in a different way, your relative might
think that you are asking a different question and become
overwhelmed.
Ask only one question or give one direction at a time. Although it
seems as though this will take longer than combining questions or
instructions, it will actually save time because the person with dementia
is less likely to become overwhelmed or confused.
Give positive instructions; avoid saying "don't" or giving negative
commands. For example, instead of saying, "Don't go in that room," try
saying, "Let's go over here."
Avoid questions that require a lot of thought, memory, and words, or
that put the person "on the spot." For example, asking a person with
dementia, "Can you tell your brother about the movie we saw this
afternoon?" may be overwhelming, because he or she will either be
unable to remember the movie or unable to explain the plot.
Avoid instructions that require your loved one to remember more than
one action at a time. For instance, tooth brushing is made up of many
smaller tasks, such as picking up the toothpaste, taking off the cap,
picking up the toothbrush, putting toothpaste on the brush, etc.
Dementia affects the brain in such a way that a person may not
remember every step or forget the correct order of steps in order to
complete a task. It will save both of you time and frustration in the long
run if you break tasks down into smaller steps that are more
manageable for your loved one.


Avoid arguing or disagreeing with your loved one. In order for two
people to "successfully" have an argument, both parties must be able
to use reason and logic. Because dementia affects reason and logic,
arguing or disagreeing with someone with dementia is futile. For
example, a person with dementia often becomes confused about the
past and think that someone who has died is still alive. It is not helpful -
and could actually be emotionally damaging - to try to convince the
person with dementia that someone is actually dead. Instead, use the
validation techniques described next.
Validation techniques involve addressing the feelings of a person with
dementia rather than focusing on the facts or accuracy of what the
person is saying. For instance, if someone with dementia thinks that
the year is 1970, and this is not harmful or hurting anyone else, let it
go. Avoid trying to "reorient" the person to the correct year. Instead, try
to identify feelings related to 1970. Is the person reminiscing about a
pleasant time in his or her life? Tap into this pleasant feeling by asking
more about it.
On the other hand, is the person upset, thinking she needs to go
"home" because her mother has dinner on the table? Instead of trying
to convince her that her mother is dead, try to discern the feeling
behind the statement. Does she miss her childhood home? Her
mother's cooking? Ask her what her favourite meal was, or ask her
about her old neighbourhood. Chances are that she will start talking
about old memories and forget about being upset. These are ways of
validating the person's feelings rather than trying to reorient the person
to reality.
If your loved one is upset, and validation or other techniques do not
work, remove him or her from the upsetting situation slowly and quietly.
Redirection techniques can work wonders when other communication
techniques are not helpful. For instance, if someone with dementia is
upset or preoccupied, try introducing a new activity that you know he or
she enjoys, such as listening to music or looking at a photo album.
Because of the short-term memory loss associated with dementia, the
person will often move on to the new activity and forget why he or she
was upset in the first place.
Communication is often easier if the environment is calm, simple, safe,
and quiet. For instance, if you are trying to talk to your loved one and
the television is on, the dishwasher is running, and grandchildren are
running through the house, your loved one might be distracted or
agitated by all of the activity and noise. Try keeping things more
peaceful and simple. Along those same lines, try not to have too many
people visit your loved one at once.
Keeping a consistent schedule or daily routine will help keep your
relative more relaxed; predictability can be calming and soothing. It can
also be helpful to add memory cues around the home, such as pictures
of key family members and friends with their phone numbers. You can
also add picture labels on drawers or closets to identify where different
items are kept. Reducing clutter and removing rugs or wires that could
be tripping hazards will reduce your loved one's risk of falling. Finally,
keep the home well-lit using soft natural light. Avoid fluorescent lights,
which can agitate people with dementia.


Gain cooperation and provide reassurance as appropriate to individual
clients by using reality orientation including:
reminders of the day, the time, relationships, occasions
reassuring words, phrases and body language
Use a range of validation strategies to relieve distress and agitation in
clients such as:
Empathy
Acceptance of the persons reality
Acknowledgment
Allowing expressions of distress
Providing verbal and/or physical reassurance
Use reminiscences frequently to connect with clients

Case Study 2

Let us now look at a couple of Vignettes and how one should respond to
them and how you as a caregiver would use your resources to assist in the
care of these residents.
Each problem or group of symptoms is presented with a story or "vignette."
(These stories are composites of patients and families; any similarity to
any person living or dead is purely coincidental and unintended.)
Each story is followed with a description of the symptom and possible
causes.
Helping strategies are listed in four categories:
1) How to help the client;
2) How to help the client's family;
3) How to handle the behaviour in activity programming; and
4) How to handle the behaviour through facility-wide changes.
These suggestions are just a beginning. You should add your ideas to
each list. These suggestions may not fit your style or facility, if not try and
develop others yourself. Brainstorming with other members of your staff
should produce even better ideas. Make this task your own by using your
creativity and "tricks of the trade" gained from experience of others and
knowledge you will acquire as you progress.
At the end of these Vignettes is an area for you to compose one of your
own either by yourself or with a fellow candidate. Once completed it
should be discussed with your trainer to see if your understanding of a
person with dementia is correct.


The Social Faade or "Well He Looks Fine to Me!"
Vignette

Mrs. Mallett, whilst visiting her father at the nursing home, sees her old
high school principal sitting in the dayroom with The Australian. She
approaches him saying, "Mr. Dougherty, you probably don't remember me,
but you were the principal at Burwood High when I was there. Are you
visiting here too?" Mr. Dougherty smiles, chuckles and replies, "Of course I
remember you-you were the pretty one with the great school spirit." They
talk awhile and he gradually explains that he doesn't need to be staying
here-he's just here until his apartment is remodelled because his children
didn't have room for him.
Mrs. Mallett is scandalized, and immediately goes to the nurse asking,
"Why are people who are so obviously `not sick' sent to nursing homes? It
must be so depressing for him!" The nurse knows that Mr. Dougherty sits
with the same issue of The Australian in front of him for a year at a time,
that he has no idea where he's staying, but that he has clear memories of
his days as principal. Although he's been in the facility one year, he doesn't
know where the bathroom is, where his children live, or how old he is. Mrs.
Mallett is correct-he does look well.

How Does the Social Facade Work?

The social facade or "social autopilot" that most families face early may last
through a good part of the illness. It permits Mr. Dougherty to make casual
conversation or general comments based on well-ingrained memories of
expressions practiced throughout a lifetime. In the early stages of Alzheimer's
Disease, patients don't look physically ill, and their apparent vigour can fool a
casual observer.
The social facade works to Mr. Dougherty' advantage. It allows him to retain
feelings of adult dignity and respect with casual acquaintances. It restores his
self esteem when he is occasionally aware of his disability. Our goal in
dealing with a client's social facade is to help the client preserve it as long as
possible.

Helpful Staff Responses
With the Client:
1. Build on all his attempts at adult conversation, whether based on the
old days or not. Ask general questions and/or make general
responses that make him feel understood. "You really seemed to
enjoy your days at Lincoln High. What made Burwood High such a
good school?"
2. Never rub the client's nose in present reality. It's NOT helpful to say,
"Mr. Dougherty, you know you're here because you can't take care of
yourself. You know you can't remember Mrs. Mallett-you're just
conning her."
3. Keep the conversation brief. Mr. Dougherty may tire of attempting to
keep his train of thought, or he may start repeating or drifting off in the


middle of thoughts. A brief, pleasant encounter with a staff member or
visitor will leave a pleasant feeling long after the content of the
conversation is forgotten.

With the Visitor:
Don't discuss the extent of Mr. Dougherty' disability with other visitors or
residents. The client and family may want to enjoy his dignified appearance as
long as possible.
Tell Mrs. Mallett, "I'm sure he enjoyed your stopping to chat. You might look
for him again on your next visit. He is a very pleasant man."
In Activity Planning:
1. Many people with Alzheimer's Disease who had fine skills become embar-
rassed when they realize, on some level, that they can't do those things
as well. Asking Mr. Dougherty to tell other residents about high school
administration or to "lead" a class for "old time's sake" may frustrate and
embarrass him further. He may not be able to find the right words.
2. He may appreciate being introduced to someone in his favorite lounge,
very casually, with a remark like, "Mr. Dougherty, you and Mr. Lugton may
have a lot in common both of you worked in the school system." One-on-
one, they may be comfortable making conversation or re-telling old
stories. If you asked Mr. Dougherty to participate in a group activity that
looks like a classroom, he may think it's beneath him and make excuses.
3. Activity programming for people like Mr. Dougherty should be planned to
fit him. Match him with a program, rather than "fitting him into the
program." His quality of life can be maintained with activities that barely
seem like anything at all. Mr. Dougherty may enjoy watching a ball game
with a teen volunteer or playing pool with an aide rather than participating
in a group crafts activity.
With the Facility Environment:

1. Mr. Dougherty' room should reflect the pieces of his adult history evident
in his "social facade." His room should have some meaningful objects or
mementoes from his former life-not just his most valuable or newest
purchase. Old trophies and awards or class pictures may be more impor-
tant to him than current pictures of his grandchildren whom he can't
recognize anyway. The old things stimulate his long-term memory and
may provide conversation or daydreaming ideas for him.
2. One facility used the skills of the art therapist and the background
knowledge of each confused client's family to help introduce patients to
visitors. Staff took old pictures of the client, prepared a brief historical
sketch and made posters decorated with patients' art work for bulletin
boards or the doors of each client's room. Each poster was different-some
wedding pictures, pictures in costume, or pictures of the client with a
famous person. The posters give unsure visitors something to say to the
client. Stopping to look at these personalized posters improves staff-client
interaction. Some staff may change their impressions of Mr. Dougherty as
a "stubborn, cantankerous man in the shower" to a courageous leader of
his day.


The bright posters provide stimulation, soften the institutional atmosphere and
may improve pride and morale of residents and staff. Hopefully, the posters
will decrease the distance between staff and Alzheimers Disease patients
who are often viewed as "not having much to offer."

Depression-Apathy-Withdrawal or "Why Doesn't He Care About Anything
Anymore?"
Vignette

Mr. Kindlen was admitted to the nursing facility for extensive rehab following
an auto accident in which his wife was killed. The rehabilitation period took
longer than expected. By the time he was ready to go home, it was obvious
that he had memory loss and some personality changes that couldn't entirely
be explained by the accident. A complete work-up revealed a possible early
Alzheimer's. Since there was no one at home to care for Mr. Kindlen, it was
decided to keep him in the facility until his self-care skills permitted
independent living. He never did learn self-care, although his walking skills
improved with physical therapy.
Mr. Kindlen gradually began refusing to attend physical and occupational
therapy. He stopped asking about his wife, other family members, or the state
of his business affairs. He took to his room, often mumbling to himself about
"no reason to live, not much of a man anymore." When he tried to do
something simple and failed, he would curse and scream, "I want to die
please let me die-I'm suffering, suffering too much." Efforts to cheer him up or
motivate him to try harder failed miserably. Staff questioned his suicidal risk
and whether suicide precautions should be taken.

How Does Depression Affect Alzheimer's Patients?

When any older person is depressed, she may withdraw from typically
enjoyable activities, appear listless or restless, have difficulty concentrating,
or feel as if life isn't worth living. This is different from sadness, a temporary,
less disabling feeling that everyone experiences at some time.
Patients with early signs of Alzheimer's Disease may be realistically
depressed. Most Alzheimer's Disease patients have some awareness that
something is not right. They may experience failure or a sense of being "left
out of things" more than they used to. Depression, as an illness, is sometimes
different in older persons than in younger people. However, it must last
awhile, be fairly severe, and not be a grief reaction after the death of a loved
one, before most doctors will call it a depressive illness.
Alzheimer's patients with depression function even more poorly than they
would ordinarily. The constant sad mood affects everything they do as well as
the people around them. An Alzheimer's Disease client's attention span is
short enough, but when depression is added, it's even shorter. Many patients
feel better with tricyclic antidepressant medicine, even if it doesn't improve the
Alzheimer's Disease. This is particularly true if the depression is caused by
the lack of certain chemicals in the brain. Some doctors now use a blood test
to determine whether or not a client will do well on a tricyclic antidepressant.


Helping Strategies
With the Client:

Look for situations that trigger Mr. Kindlen's feelings of worthlessness.
Is he always sad and withdrawn, or do certain people or activities pick
him up?
Alert his doctor; ask about possible medication.
Don't force him to interact or participate. Spend special time just with
him, reassuring him of his value as a person.
Mr. Kindlen may be afraid that if he looks too much better, he'll have to
go home alone-something he may realize is beyond his capability.
Reassure him that he'll be cared for as long as necessary.
Some early Alzheimer's Disease patients get upset because they
recognize they do not look as sick as others at the facility, and they
even feel guilty about taking up space. Let Mr. Kindlen know that his
memory problem is worth working on and taking seriously-that it's a
medical problem and you don't think he's just lazy or malingering.
A special relationship with one person-a staff member,
minister/chaplain or favourite family visitor can significantly relieve the
early depression in dementia. Encourage him to talk freely or spend
time with whoever makes him feel most comfortable. Often, this person
can be a housekeeper or someone in the kitchen who sees him only
briefly each day but takes special notice of him.
Never agree with his wish to die. Just respect his right to "blue" feelings
and reassure him that you're confident he'll feel more like himself soon.
Don't use pep talks. Pep talks "put down" his current feelings and make
him feel less understood.
Alzheimer's Disease patients can rarely organize themselves to carry out
suicide threats. It's still wise to remove potentially dangerous objects and
to check him more frequently. As his confusion worsens, he may become
more repetitive in his statements about dying, but the feeling tone may
appear less intense. Alzheimer's Disease patients are known to repeat
statements frequently just as they often develop repetitive motions with
their hands and feet.

With the Family:

Mr. Kindlen's depression is probably made worse by his recent loss of
family. The goal of care should be to create or recreate a meaningful
substitute family for him within the facility or through community volunteers.

With Activity Programming:

Depressed older persons rarely ask for activities or accept invitations
easily. Mr. Kindlen is more likely to participate in group activities if he first
has a special friend to do things with in his room. Gradually this friend or


special helper can draw him into other activities by offering to accompany
him the first few times. The helper might say, "Let's go see what all that
ruckus is about in the activity room. If it's not interesting, I'll bring you
back." Giving him a graceful way out may encourage him to at least take a
look.
Mr. Kindlen may resist activities that seem "just for fun." His low self-
esteem right now is due to his inability to contribute or to care for himself.
He may enjoy being "given a job" or being asked to assist another man
more physically frail than he. Helping someone else in worse shape is a
powerful antidote to depression.

With the Facility:
The physical environment of a facility can modify feelings of depression in
demented and non-demented patients. (It can also improve morale in
general.) Some facilities try too hard to look like hospitals rather than
places to live, thus making patients feel they must be sick to be there. See
what can be done to make a more homey, less sterile environment.
Consider some of the following:
Use of textures (adds warmth, richness and interest to the
appearance.) Create areas that draw people in and encourage them to
reach out and touch objects. Metal hospital like equipment has the
opposite effect.
Bright colours for accent in an overall moderate colour scheme. Too
many bright colours, graphics, etc. can overwhelm and overstimulate
an Alzheimer's Disease client.
Something old that could trigger memories from the past. (Old pictures
can stimulate conversation.)
Personalized room decor-familiar objects associated with the client or
the poster sketches mentioned earlier.
Soft music in the background can muffle unpleasant noises of
intercoms, screamers or groaners.
Small groups of patients rather than long lines of patients seated in
Geri chairs outside their rooms. Walking down long corridors of sick,
staring patients is depressing for everyone.
A sense of humour, tolerance for confusion, and a sense of fun can be
conveyed by each staff member. It lightens up the feeling atmosphere.
Encourage patients to dress up or dress in unique, favourite costumes.
In one facility a man sleeps in a baseball hat while another man wears
a cowboy hat, boots and jeans. This adds local colour, making the
place look like people live there.
A facility in the Midwest in the US created a sky lighted lounge with
umbrella tables, patio stones, and a small fountain. One Alzheimer's
Disease client thought she went outside each day when she sat under
the skylight, and she thought she was vacationing at a beach resort-a
well-earned rest rather than an "imprisonment" in a nursing home. It
rekindles happier memories from long ago that enrich her present
experience. Running water is soothing and hypnotic, although it can
trigger incontinent episodes.


Take a look at the disinterested or depressed residents in your facility.
How could you change the environment in ways that might stimulate or
interest them? Try special monthly changes in lounge decorations to fit
holidays or seasons.
Favourite foods can be a good diversion for some Alzheimer's Disease
patients. Have these available to serve frequently, and be sure all
shifts know each client's special preferences.

Rummaging, Pillaging, and Hoarding or "Why Does Mrs. Dougherty Take the
Dining Room Silverware?"
Vignette

Mrs. Dougherty was an attractive, sprightly woman in her early 60s
who appeared alert, socially prominent, and sweet to all casual visitors.
She always dressed in a suit and heels every day, and she always
seemed to be on her way someplace. She was often found in other
women's rooms rearranging the drawers, cleaning their closets, or
picking up fruit and candy left by other visitors. Once she even climbed
in another male client's bed, and she seemed outraged when he
started to get in bed with her. She never took things she needed-she
usually had the same thing in her room. She even took silverware from
the dining room after each meal. She didn't respond well to being told
that those things "didn't belong to her." Finally, she would often return
to her room, yelling at her roommate to "Get out of here! You don't
belong here-that's my sister's bed!"

What Causes Patients to Mess Around in Other People's Things?
Many Alzheimer's Disease patients in nursing homes seem driven to
search for something which they believe is "missing." What's missing is
something that looks familiar to Mrs. Dougherty, and the search is often
fruitless. One room looks just like another and even her clothes look
unfamiliar. She's lost the ability to tell the difference between things that
"belong" and things that are "out of place."
In addition, Alzheimer's Disease patients often lose memory of good
manners. Even previously gracious and polite women may enter a room
without knocking, take off their clothes in public places, or use sloppy table
manners.
Mrs. Dougherty' image of herself is that she would never take something
that didn't belong to her, but "others may have taken things from her." Her
independence has been "taken away" by those ungrateful children who put
her in this awful place when she wanted to live with "her daddy." Though
she's not sure what she's looking for, she is sure that it wasn't misplaced!
She knows she's a proper woman and she wouldn't do that. It must have
been someone out there stealing from her, most likely her roommate or
that aide who keeps asking her to take a bath. the nerve of that mere
child!
We can only guess what's going through Mrs. Dougherty' head. It's
common for Alzheimer's Disease patients to search fruitlessly for
something familiar, to accuse those closest to them of stealing, and not to


admit any wrongdoing in going through someone else's things. One bed
looks the same as another, and she probably thought the bed was hers. Or
perhaps she got tired when she was passing that room, and the sight of
the bed was good enough to draw her in. Alzheimer's Disease patients
don't always check the name on the door. Some don't even dress for bed.
An ALZHEIMERS DISEASE client also may not recognize a roommate
she's had for years.

Helping Strategies
With the Client:

The best strategies are preventive. Keep Mrs. Dougherty busy in one place
fiddling with a drawer of her stuff, or assign an aide to watch her. Dutch
doors on her room will keep her fussing with her own things but still allow
her to stand and talk to passers-by.
Alzheimer's Disease patients don't respond to moral admonitions or
rational explanations. Don't say, "You should be ashamed of yourself,
taking that candy from poor Mrs. Lugton. Give it back!" Don't say, "This
isn't your room-see Mrs. Lugton's name on the door. You have candy
of your own."
Distract her when you find her in someone else's room. Ask her to hold
something and when she reaches for it, remove what she has taken
and quietly put it back. Say "Why don't we see what's going on in the
garden?" as you're guiding her out the door.
Learn her hiding places. If others are missing items, Alzheimer's
Disease patients usually hide them in the same place, i.e., in
wastebaskets or under mattresses.
Help her replace a disruptive behaviour like rummaging in other
patients' rooms with one that allows her to continue rummaging, since
it seems to have some purpose for her. Give her one drawer to
rummage in and latch the others. Give a man who unscrews furniture
some plastic pipes to screw and unscrew.
If she keeps sitting in someone else's chair, ask her to come and help
you find her chair-"You always look more comfortable in your chair,
and I bet it will feel more like home."
Wandering in other people's rooms may be part of a search for the
bathroom. Show her to the bathroom, and say, "Perhaps you'd like to
use the toilet while you're here."
With the Family:
Don't confront the family with labels like "Did you know your wife was a
kleptomaniac? She takes silver and food from the dining room at every
meal." She may have done that at the homes of friends before admission,
and the family has suffered enough embarrassment already.
Encourage family members not to dramatize or moralize about her walking
into the wrong room. Tell family visitors to remove what she's taken as
discretely as possible, and ask the staff to find the proper owner.
Remember, this is just as likely to happen with teeth or eye glasses as well
as food, clothing or silver. Families cope better if they understand in


advance that this might happen and that the staff keeps open, tolerant
attitudes toward the problem. Families should be assured that staff protect
the patients from embarrassment as well as exploitation.

With Activity Programming:
Offering discussions for the residents on privacy and how rummaging
and pillaging violates other residents rights rarely changes the Alzheimer's
Disease clients behaviour. She will sit through the presentation, firmly
agree and get up and return and return to the wrong room. All staff need to
keep a calm, flexible sense of humour about such things.

How the Facility Can Handle Rummaging, Pillaging and Hoarding:

All personal items should be marked.
Stale food, dangerous to Alzheimer's Disease patients who can't tell
inedible from edible food, should be removed from all rooms. (This is
easier than enforcing rules about no food in the rooms.) All Alzheimer's
Disease residents will try to put away a bit of the evening snack "for a
rainy day."
Design places in the facility that function as "walled gardens." Places
like this give patients the opportunity to roam from inside out with the
illusion of freedom and without risking the patients wandering off.
Warm, varied-textured or familiar objects from long ago meet some of
the needs of the "searching" Alzheimer's Disease client. Let her have
these objects in her room or in neutral territory like the lounge or day
room.


Now its your turn below is a vignette for you to develop your own
procedures:

Mr. Cuthbert, a 72-year-old former businessman, hung around the front
door of the nursing home politely asking everyone for a "lift home." He
usually said his car was in the shop, and his wife wouldn't help him out.
One time he was seen thumbing a ride in front of the facility, dressed like
an executive golfer on his way to the country club.
When his wife visited him at the facility, he always followed her outside to
her car. A struggle would follow and she usually left in tears. He called her
constantly from the private phone in his room, sometimes telling her that
he was in prison, and she needed to come right over with the bail money.
He often asked the nurses when the next train left for his childhood home.
At these times he told visitors that he was either in a hotel (which burned
down twenty years before) or his country club restaurant. (Much to
everyone's amusement, he never failed to leave a tip in the nursing home
dining room.) Occasionally, his room became "his office" and his bedside
table, "his files."
The staff questioned their liability with his need for constant surveillance.
He had been picked up by the police one cold night wandering in a nearby
neighbourhood in his pyjamas. Exposure or exploitation is a realistic risk.
He called newspapers regularly, stating that he was being held against his
will. He also called the sheriff's office, police station and his attorney at all
hours. Unfortunately, due to his previous prominence, he aroused public
sentiment with his pleas for "justice and freedom." As if this weren't bad
enough, several other memory-impaired residents of the facility began
following him out the door like robots.

What Causes Wandering?
Because wandering is such a problem with dementia patients, more
theories and solutions have been proposed to deal with it than with any
other symptom of the disease. Whatever causes an individual client to
wander, it has major implications for the family, facility, and the
community at large.
Some theories are based on previous lifestyle-wanderers are people who
were "always on the go" or people who couldn't relax or handle stress in
any other way. Some psychologists look for causes of wandering by
observing what is happening immediately before the client takes off. Some
psychologists believe wanderers are running away from an intolerable pre-
sent reality (such as living among strangers in a nursing home), and others
see it as a "feeling of being lost" (and a need to seek the familiar, protected
feeling of earlier happier childhood times at home.) Interestingly, many
families do take the client to visit her original home only to have her say
that "it's a fake." Remember, these behaviours can occur at home as well
as in unfamiliar places.
Some professionals see wandering as an expression of the aimlessness,
excessive restlessness, or the need for self-stimulation that comes from
any brain damaging illness.


Helping Strategies
1) How to help the client;
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

2) How to help the client's family;
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________


3) How to handle the behaviour in activity programming
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
4) How to handle the behaviour through facility-wide changes.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________


3. Provide appropriate activities to
maintain dignity, skills and health
of client at optimum level

3.1
Provide activities which aim to maintain independence, using
familiar routines and existing skills
3.2
Provide activities that are appropriate to the individual,
reflecting their cultural likes and dislikes, in order to bring back
pleasurable memories
3.3
Ensure all activities provided focus on ensuring the safety and
comfort of the client balanced with autonomy and risk taking
3.4
Use purposeful and meaningful activity to enhance self-
esteem and pleasure in life, to minimise boredom and to
distract from or eliminate behavioural and psychological
symptoms of dementia
3.5
Use family carers and significant others as a resource, where
appropriate, to assist in developing appropriate activities by
accessing information about client reminiscences and routines
3.6
Provide support and guidance to family carers and significant
others where appropriate to assist them to understand the
disease, its impact on the person and some approaches to
providing care

Provide activities which aim to maintain independence, using familiar
routines and existing skills

Encouraging independence
Routine and continuity are important in activities. It is especially useful to
encourage daily activities such as getting dressed and washed; buttering
bread; washing up; polishing furniture and folding clothes even if they are
done over and over again. It is important that the person is happy to do the
tasks and activities. Being allowed to carry on with everyday activities for
as long as possible will not only help the person hold on to these skills and
encourage independence, but will allow him or her to feel able to contribute
and know that the help is valued. This sense of purpose and wellbeing
should also ensure the person is less agitated and anxious.


Why are activities so important?
Participating in activities can help to prevent frustration, boredom and
challenging behaviours. Activities can:
help the person maintain his or her independence in and around the
home
help maintain skills
improve self esteem
improve the quality of life for the person with dementia - and you will
also benefit
often compensate for lost abilities
allow the person to express his or her feelings, through art, music,
singing and dance
bring pleasure to both of you as you share these moments together
provide social contact through social activities and outings, keeping
both of you in touch with family and friends.

Activity 26.
In your own words why are activities so important to the continuing health
of the person in your care?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

How to plan activities

Keeping to a routine is very important: planning activities, which can be
part of a regular routine will help you structure the day. If the person you
care for has always gone down to the local shop for the paper, the
chances are he or she will be able to carry on collecting the paper until
quite late on in the illness. Safety issues are of course important; crossing
roads alone will become unsafe as the illness progresses.
Try to plan activities for the person with dementia which you enjoy too.
Dont be afraid to say no to activities if you really cant face doing a
particular activity. The best thing to do is to suggest another activity: Why
not come and help me sort through these photos, or Lets go for a walk.
Have a variety of activities organised that the person with dementia can do
each day, e.g. memory box, looking at photos, looking through a life history
book; have clothes and napkins ready for folding; dusting; knitting or other
activities which are enjoyed. If a certain task does not appeal one day you
will always have another activity which may appeal instead.


Plan tasks and activities which you can do together and also plan
activities the person with dementia can do by him or herself. This
allows you some time to yourself.
Think about what the person has enjoyed doing in the past and plan
activities which will involve things he or she can remember.
It is usually better not to do anything which involves learning new tasks
and skills - stick to what they already know. However, some new tasks
can be learned.
Make sure the person will be safe, by providing an environment which will
allow them to enjoy the activity without worrying about their safety.

Activity 27.
In your own words why is it important to plan your activities for the person
in your care?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Things to keep in mind
Prompting
In order to help the person through the different stages of a task you may
have to help with all the different stages of the process. For example, for
vacuuming, you might need to remind the person where the vacuum
cleaner is kept, where to plug it in and how to switch it on. If you dont help
with all of these stages each time the person will no longer vacuum. While
this may seem like a lot of work for you, it will be of great benefit to the
person you care for. Retaining their skills and providing a way in which
they can be useful will allow them to experience a sense of satisfaction, as
they help with each task.


Activity 28.
Give another 3 examples of prompting for the person in your care
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Time
Remember that many people with dementia have problems concentrating.
He or she may be unable to do certain tasks for any length of time. Plan for
this by having a variety of activities he or she can do.
All activities are likely to take a bit longer to do than before. Try to be
patient and allow more time than you would normally. For example, getting
dressed can be a long process; however if you adapt to this and let the
person do as much as they can, step-by-step, the person will be able to
dress him or herself and will retain these skills.

Activity 29.
Give another 3 examples of using time for the person in your care
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Support
Try not to be critical of how he or she does things. The main aim of
activities is to help the person with dementia achieve what he or she is
capable of and ensure they are stimulated and happy. A perfectly clean
kitchen or a well-made bed is not the goal. It is important that the person
gains a sense of achievement and satisfaction.
Do not over stimulate as this may make him or her anxious and agitated.
Plan quieter activities for when they are tired, anxious or likely to become
disturbed by loud noises, busy places etc. If you enjoy going out for a
coffee or to a restaurant together choose quieter times when you can relax
and enjoy the experience.


Activity 30.
Give another 3 examples of support for the person in your care
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Adapt
Remember that the person with dementia will gradually lose the ability to
do some tasks as the illness progresses, but will retain other skills. Each
person will lose different skills depending on which part of the brain the
dementia affects. Try and be aware of these changes and adapt activities
to suit him or her. This will reduce the amount of distress and anxiety he or
she feels as the dementia progresses. Always remember the person you
care for is still who they always were, but it is just his or her ability to do
things which changes.
If the person becomes frustrated or angry, because he or she cannot cope,
make sure you work out what help he or she needs or change the activity.

Activity 31.
Give another 3 examples of adaptation for the person in your care
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Community
Help the person stay involved in community activities. For example, the
person may have been used to going to the local church, synagogue,
mosque or to local clubs. Make sure that he or she can continue to go if he
or she wants to, as it is important to keep in touch with friends and
maintain a normal routine. This will ensure the person with dementia
remains a part of the community.
Explain to people the person may come into contact with that he or she
has dementia as long as he or she is happy with disclosing this
information. You can outline what difficulties he or she may have and let
them know how they can help. Give friends a copy of the booklet "Ill get by
with a little help from my friends", available from the Dementia Helpline, to
help them understand why their friendship is important and what they can
do.


Activity 32.
Give another 3 examples of community activities for the person in your
care
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

In the home
If you can involve the person you care for in everyday household activities
this will help him or her retain useful skills. Usually he or she will be happy
to help, as long as you give guidance to help him or her through the tasks
one step at a time.
It is usually a good idea to suggest activities by saying something like
Could you give me a hand with the dusting, making a cup of tea etc, or
Would you mind folding these clothes for me? By allowing the person with
dementia to feel useful and included in the day-to-day activities you will
provide an important sense of self-fulfilment. Most people like to feel useful
and needed.
If he or she wants to do certain activities over and over again, as long as
they are not dangerous or likely to harm anyone, let him or her carry on if
you can bear it. As long as the person is happy and content with what he
or she is doing there is no harm in repetition.

Activity 33.
Give another 3 examples of household activities for the person in your care
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Housework
Doing housework may not be to everyones liking, but often it can be an
enjoyable activity as these types of skills are often retained until later in the
illness. Polishing, dusting, tidying stacks of magazines, sweeping, making
the bed, folding clothes are all activities which can often still be done
successfully.
Be sensitive to the persons wishes. If he or she has never liked
housework, he or she may be unwilling to take part in these tasks now!
Try reminiscing at the same time recalling how things were done in the
old days can make tasks more meaningful and enjoyable.


Activity 34.
Give another 3 examples of housework for the person in your care
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Music and dance
Listening to music, singing and dancing are other activities which can be
enjoyed at home right through to the later stages of dementia. Carers have
suggested obtaining a walkman with headphones (as long as the person
with dementia can tolerate them). Listening to familiar music can be of
great comfort.
Many people with moderate to severe dementia can still sing favourite
songs from their childhood and younger days. If the person used to play
the piano or another instrument this will often be another skill he or she
retains.
If the person with dementia finds it hard to communicate during the later
stages of dementia you will often find that he or she can express his or her
emotions through the music.
Record favourite pieces of music and play them when he or she is restless
or upset. This will often calm the person. Carers have suggested playing
the music in the bathroom can help the person relax, especially if bathing
is not enjoyed by the person you care for. Singing can also be good when
you are helping the person with intimate care tasks, such as washing or
dressing. It can help to calm and distract the person. It can also help the
person feel secure - especially useful for people who dont understand why
they need help.

Activity 35.
Give another 3 examples of music and dance activities for the person in
your care
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Massage
Try giving a hand massage or manicure. This is easy to do at home and
can provide a great deal of pleasure and relaxation, as there is social as
well as physical contact. This is often particularly appreciated later in the
illness when verbal communication is limited.


Activity 36.
Give another 3 examples of remedial massage for the person in your care
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Reading
Reading can become difficult for someone with dementia as his or her
concentration and mental ability to read decreases as the illness
progresses. If the person would still like to read papers, magazines and
books you can help by reading aloud and helping him or her go through
the paper.
Reading to the person will allow him or her to keep up with the latest news
and follow interests. Family and friends can also help with this activity.
Audio books are useful as the person can relax and listen to the book on
tape. There are a huge variety of these tapes available from the libraries
and bookshops. In many areas there is a talking newspaper service, which
can keep the person up to date with local events and news.
Keep books with pictures of particular interest around the house which the
person with dementia can look at during quiet moments.

Activity 37.
Give another 3 examples of reading activities for the person in your care
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Watching TV
Many carers say that quiz programmes, old films and programmes about
the persons special interests can be enjoyed by both the person with
dementia and the carer.
Try taping the programme and watching it in parts. This allows the person
with dementia to take a break and you can also discuss what is happening
in the programme.
Games
Dominoes, card games and jigsaws are also enjoyed by many people.
There are special jigsaws with larger pieces available and specially
designed cards for those whose eyesight may be failing or who have
arthritic fingers. Try out games you know they have played and enjoyed in
the past. Although some people will enjoy childrens jigsaws and games,
many people will find them too childish, and prefer more appropriate ones.


Activity 38.
Give another 3 examples of watching Television and Games activities for
the person in your care
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
Reminiscence
Remembering our early childhood experiences is usually an enjoyable
activity, and to some people with dementia it can be the only way that they
can make contact with their own identity. People with dementia often forget
recent events; however when you talk about the past or look at photos you
will often find that these trigger detailed, distant memories.
The person will often show great delight in being able to share these
memories and talk about old times. It is best if you do not test the
persons memory when looking at old objects and photos, as this can
make the person feel frustrated or anxious if they cant remember certain
people or events.

Activity 39.
Give another 3 examples of how to get the person in your care to
reminisce.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

How to help the person remember
On some days the person will remember many events from looking at
photos. He or she may remember who the people are in the photo or
where the photo was taken, but on other days the photos will not trigger
any memories. You can help by labelling photos to identify who and where
the people are. Often a few hints will bring the memories flooding back.
Do take time to talk about past events, as these memories may be the only
ones remaining to the person and are therefore precious. This can be an
enjoyable experience for both of you, especially if you are reminiscing
about the times you have enjoyed together. It can strengthen the bond
between you and remind you of all the good times.
The senses
Smell, touch, taste, sight, sounds, photos, music and movement can all be
part of reminiscing. You can just have an informal chat or you could
prepare a set of objects, photos and music. Often smells like lavender or
smells from work or holidays will bring back very vivid memories and can


start a long discussion about past times. Music is also a very powerful way
of evoking memories.
Family and friends
Often friends and relatives enjoy these types of reminiscence activities and
are willing to bring photos and objects with them. This is a great way of
involving visitors in stimulating activities. Sometimes it can be a bit
stressful for visitors if they are unsure of how they should act or what they
can do with the person with dementia. You can help by preparing them in
advance, especially with tips on communication. Social contact is very
important and you should encourage as many visitors as possible, as long
as the person with dementia enjoys them.
One carer got friends and relatives to tape anecdotes onto a cassette for
the person with dementia to listen to. The tapes can be enjoyed together,
as a chance to reminisce or the person can listen alone.
You may find that the person enjoys visits from grandchildren or friends
children. Children are usually very happy to communicate in any way they
can with people. They may enjoy playing games the person with dementia
remembers from his or her childhood.
Memory boxes
Putting together a memory box is a good way of stimulating and drawing
out memories. Put favourite objects, old photos, and items from the
persons work in the box to be examined. If the person is agitated, looking
at the objects may calm him or her down. During quiet moments when the
person is tired or you dont want to go out somewhere looking at the
photos and objects can be a very relaxing way of being together.
Life story book
In the same way as the memory box you can also put together a life
storybook. You could combine photos with notes about his or her:
mother and father, sisters and brothers
children
work
places he or she has visited or lived in
favourite holidays
friends
hobbies
favourite food, least favourite food
colours
favourite films, music
likes and dislikes
politics.
Photos, post cards, scraps of material from old clothes or bedcovers and
other memorabilia can be added to the storybook. This can be a very
enjoyable activity for both of you. As the persons illness progresses it will


become more important that the memories are all written down and
recorded so that others can help the person recall those important times.
If the person does have to go into a care home this book can be taken and
shown to the staff. It will provide them with a very valuable history and
background of the persons life, which will help them to get to know him or
her.

Activity 40.
Give another 3 examples of of each of the above subsections to the
person in your care to help them remember.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Creative activities
Writing
You may find that the person you care for enjoys writing if he or she has
mild dementia. Perhaps you could suggest he or she writes about school
days, past holidays and family meetings, so that grandchildren will be able
to read about his or her past. These stories could be made into a book with
photos and old postcards. Even later on, writing post-cards and birthday
cards can be a way for the person to keep in touch with friends and family.
Art
Producing artwork is often exciting and interesting. Even if the person has
not painted a picture since his or her school days, being creative with
paints and other craft materials can be very enjoyable and satisfying.
Remember that the end results do not have to look like works of art.


Depending on the persons interests and what he or she enjoys doing
there are many different types of projects you could enjoy together.
Painting on plant pots or wooden photo frames, or even small pieces of
furniture like wooden stools can be very satisfying and produce some great
results. Look around art shops for ideas. There are kits available for sand
art, painting by numbers and collage kits. Art galleries and exhibitions are
also likely to be a source of interest and a subject for discussion. For most
people its best to use adult materials because items obviously meant for
children can offend.
Restoring furniture
Carers have also suggested buying old pieces of furniture to restore.
Sanding and polishing can be very relaxing and the person with dementia
is often absorbed for long periods of time if he or she enjoys this type of
work. However, beware of paint strippers as they can burn the skin;
electrical sanders should also be avoided.
Knitting, sewing and embroidery
If the person you care for has always knitted or done embroidery or
tapestry you may find he or she retains these skills for a long time. You
might have to encourage him or her to start and be prepared to help with
each stage, but it is worth persevering. The end result can give a
wonderful sense of satisfaction.
Gardening
Gardening is another favourite activity enjoyed by many people. Gardening
provides a change of scene and will also ensure you both get some fresh
air and exercise. It may be a good idea for the person to have his or her
own patch of garden to dig and plant in. Weeding, trimming lawn edges,
sweeping paths and general tidying in the garden can all be tasks many
people with dementia can cope with. However, make sure he or she
doesnt use electrical equipment or potentially dangerous tools.
Try to plan the garden so that there are lots of different varieties of plants,
with bright colours and interesting scents for example, lavender and
rosemary. These can be stimulating and enjoyable for people with
dementia even late on in the illness.
If you do not have access to a garden, indoor gardening, such as planting
bulbs and herbs in pots can be an enjoyable activity too.


Activity 41.
Give another 3 examples of each of above subsections to get the person in
your care to reminisce.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Going out and about
Exercise and sports
Getting out for some exercise and a change of scene will help both of you.
Try to incorporate a daily walk in your routine. It doesnt have to be far - it
could just be down to the local newsagent. If the person you care for has
always enjoyed longer walks, keep this up and try to vary the route and
location.
Some people enjoy swimming throughout the course of their illness. Ask at
the swimming pool when the quieter times are, as lots of noise and activity
can make the person anxious. Many pools can also provide assistance so
that you can help the person in and out of the pool.
If the person you care for likes watching sports, he or she may enjoy trips
to watch favourite sports.
Going out for a coffee or a meal
If you both like going out try to make this part of your routine. If you can,
find a quiet caf where you can both relax.
Museums
Going to a museum and looking at objects which the person can relate to
and which are part of his or her past can be very enjoyable. Watch out for
exhibitions which may be of special interest.


Theatre and cinema
If you both like going to the theatre or cinema it is a good idea to keep
going for as long as possible.
Going for a drive
Taking the person you care for out for a drive will often calm him or her
down. Driving round areas remembered childhood, or where the person
worked will often stimulate memories and you can talk about past times.
Public transport
If you dont have access to a car perhaps you could organise family or
friends to help out occasionally or look into other options which would allow
you to get out and about. Most people with dementia will be able to get
free local bus travel at off-peak times. The Scottish Executive says that
every local council must provide free off-peak bus travel to people who are
over 60 or are disabled.
If the person is 60 or over he or she will definitely qualify.
If the person is under 60, he or she might qualify some local
authorities include people with dementia and some dont check with
your local council.
Taxi card schemes
Ask your local council if it has a taxi transport scheme. Many councils
provide cheaper taxi travel or a certain number of free or cheap taxi
journeys a month to disabled people, including people with dementia

Activity 42.
Give another 3 examples of each of the above sub-headings and what sort
of activities you could use to get the person in your care to remember.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Ensure all activities provided focus on ensuring the safety and comfort of
the client balanced with autonomy and risk taking

We do not know to what degree the patient is able to understand at any
stage of this illness, but who is to say that the inability to communicate
represents the real person who may still be struggling inside (Wolanin-
Phillips, 1981). Care of the patient with AD demands ongoing assessment,
planning, intervention, and evaluation throughout the course of the
disease.
A comparative study of two nursing home units using different approaches
to dementia care found that a humanized or person-centred approach not
only improves the quality of life for patients but may also extend the length
of their lives. One unit used a task-oriented maintenance approach to care
that emphasized disease progression and pathology. The other unit used a
more flexible person-centred approach that looked beyond physical and
cognitive abilities and focused instead on a person's will to live and
relationships with others. Those in the person-centred unit were found to
be happier, with better quality of life, and longer life, while those in the unit
emphasizing disability and disease progression were heavily medicated
and often failed to thrive (McLean, 2006).
Another patient-centred approach to care of patients with severe AD is the
Namaste Care program, developed by medical social worker Joyce Simard
(2007). Namaste (Nah-mah-STAY) means "to honour the spirit within."
Namaste programming uses a multisensory approach to care of patients
who can no longer engage with others but still respond to touch, sounds,
and visual cues.
Soft background music plays in the unit when the day begins and
throughout the day. Each morning residents are dressed in soft
comfortable clothing and groomed. Staff check hearing aids, clean
glasses, and assess residents for pain. After breakfast, residents are taken
to the Namaste care room and tucked into comfortable recliner chairs with
soft quilts. The tucking in seems to help residents feel secure. Other
techniques include gentle brushing of residents' hair, use of moisturizers
and massage, and aromatherapy.
At day's end, residents are returned to their rooms and fall asleep listening
to soft music. Families are encouraged to be part of these activities and,
because they see that their loved ones are peaceful rather than agitated or
anxious, they have a more positive experience and visit more often. Staff
in Namaste units receive special training and report improved morale and
special pride in their work (Lourde, 2007).
Fundamental to all care of the person with AD is the creation of a
supportive environment (Table 1). Whether at home or in an institution, the
goals are the same: to maximize the person's functional abilities and
quality of life and to provide competent, compassionate care that
acknowledges and respects the patient and family. Ideally, that care would
be multidisciplinary, including medicine, nursing, and social work. Nurses
contribute a wealth of expertise in Alzheimer's care as caregivers,
counsellors, and case managers.


Activity 43.
Why is it so important to focus on ensuring the safety and comfort of your
client? What sort of activities you could use for the person in your care to
ensure that they are safe and at-ease with their activities?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

Use purposeful and meaningful activity to enhance self-esteem and
pleasure in life, to minimise boredom and to distract from or eliminate
behavioural and psychological symptoms of dementia

Table 1 Creating a supportive environment

To create a supportive environment:

1. Make change very slowly. The person needs to be carefully prepared
for any change in medications, nutrition, therapy, personnel, or
location.
2. Keep the patient active as long as possible. Daily exercise, outdoors if
possible, helps maintain physical and emotional function.
3. Maintain a routine. A dependable world and a structured life are
reassuring.
4. Provide social stimulation without overload. Encourage and maintain
communication through every possible channel.
5. Avoid crowds and large spaces without boundaries. Try to prevent
sensory overload and provide boundaries and interior landmarks that
are easily visible.
6. Monitor nutrition, attention to mouth and teeth, and footwear. Help with
eating and oral hygiene to reduce the risk of infection. Comfortable,
well-fitting shoes with nonslip soles help prevent falls.


7. Keep activities and conversations simple. Avoid complexity; it creates
confusion and anxiety.
8. Provide positive input. Praise and compliments for any achievement
help maintain the person's self-esteem and encourage self-
participation in activities of daily living.
9. Provide reality checkpoints: calendars with large days and dates,
clocks with large numbers marking the hours, and reminders of special
events such as birthdays, anniversaries, and holidays.
10. Support bowel and bladder control. A consistent toileting routine helps
preserve function and control. Use clothing with simple fasteners like
Velcro, or pants with elastic waistbands.
11. Support family caregivers. Commend their efforts, refer them to support
groups, and assist them in creating a helping network. Families caring
for a loved one at home need referrals to agencies offering respite
care.
12. Provide information and referrals for legal assistance. Advance
directives for end-of-life care should be made at the time of diagnosis,
while the person with Alzheimer's can still have a voice in the decisions
made.

Source: Wolanin-Phillips, 1981.

Activity 44.
Why is it so important to use purposeful and meaningful activity to enhance
self-esteem and pleasure in life, to minimise boredom and to distract from
or eliminate behavioural and psychological symptoms of dementia? Using
the table above develop a list of your own examples to each of the
following points.

___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Use family carers and significant others as a resource, where appropriate,
to assist in developing appropriate activities by accessing information
about client reminiscences and routines also provide support and guidance
to family carers and significant others where appropriate to assist them to
understand the disease, its impact on the person and some approaches to
providing care

Dementia is a national health priority for Australia (Australian Government
Department of Health and Ageing [DoHA] 2005). Growth in the prevalence
of dementia has been projected in national population statistics and trend
figures. During 1995, Australia had a population of 18 million and 130,000
people with dementia. It has been projected that in 2041, Australia will
have 25 million people and 460,000 will have dementia (Australian Institute
of Health and Welfare [AIHW], 2007). During that time, the Australian
population will have increased by 40% but the population with dementia
has been projected to increase more than three-fold. The reason for this
disproportionate increase is that older people, who are the age group most
at risk for dementia, will be the fastest growing segment of the population
(AIHW, 2007)

It is this increase in population that makes it appropriate to call on the
family carers and significant others in helping developing activities for the
client. Routines that have been used for the client at home could and
should be attempted to be integrated into the daily life of your client as they
progress through the remainder of their life with dementia.
Case managers are particularly important for patients with AD who live
alone or with a spouse who is unable to act as caregiver. These patients
are at high risk for injury or self-neglect. The case manager can serve as
an advocate and primary support person, accompanying the patient to
medical appointments and coordinating community services. If a person
has advanced AD, the case manager can apply for a court-appointed
conservator to establish guardianship and surrogate decision-making
authority.
The challenges of caring for someone with AD include communicating
effectively with the person; managing behaviour problems such as
agitation, wandering, and sleep disturbance; assisting with ADLs while
helping maintain the person's independence; and planning activities that
will help maintain well-being and prevent boredom. Meeting these
challenges may become more difficult as the disease progresses.
Any activity should involve minimal instruction with repetition as necessary,
allowing for rest periods. You need to aim for a structured activity, but also
have a flexibility to allow for spontaneity.
Aiming for a consistent routine and environment helps to ensure a way to
develop appropriate activities for your client. In other words plan so that
the same things occur regularly at the same time.
Activities should aim to use cognitive, sensory and physical processes.
The activities can be used to validate the persons feelings, emotions and
thoughts and thereby help to orientate them to person, place and time.
Where possible the activity should utilise past skills, experiences and
memories.
Reading:
Medication
Management for
Community-dwelling
Older People with
Dementia and
Chronic Illness;
Debbie Kralik, Kate
Visentin, Geoff
March, Barbara
Anderson, Andrew
Gilbert3 and Merilyn
Boyce


Activity 45.
Take a close look at a relative you know and list their past skills and
experiences and how you could use them to assist in their care.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________

There are many activities that people with Alzheimers disease can enjoy.
But it is often difficult to find enough activities for the person to participate
in over a week. This is okay as repetition is desirable if it works keep
doing it. You need to avoid activities that require learning complex new
skills.
Activities that require using large muscle groups (gross motor movements)
are usually more successful than those using smaller muscle groups (fine
motor movements). You need to use activities that are rhythmical and
repetitive eg. nailing and sanding wood, chopping and peeling vegetables
etc.
Remember, if one approach does not work, abandon it and try something
else.
The type and choice of activity is not limited to leisure and recreation, but
can also include self-care activities and household tasks.
Be creative.
The activity needs to be able to be broken down into small steps.
The activity should be able to be modified and adapted to suit the persons
abilities and needs.

Ideas On Adapting Activities

Activities generally consist of a number of steps which are performed in a
particular sequence, enabling successful completion of the task. In
Alzheimer's disease, the ability to complete entire activities is diminished
over time, which often means carers need to be .able to simplify tasks and
modify the environment. This allows


the individual with Alzheimer's disease to continue participating in activities
and assists them in maintaining their independence, a sense of control
over their life and dignity.
Activity Analysis is the process of breaking activities into steps. In order to
do this successfully, one must physically participate in that activity to
understand the demands of each step required to complete the task.
Following is an example of an activity broken into steps.

Exercise Activity: Making A Cup Of Coffee

1. Enter the kitchen.
2. Collect the necessary materials for the task.
Cup and saucer from the cupboard.
Spoon from the drawer.
Milk from the fridge.
Coffee from the cupboard.
Sugar from the cupboard.
Kettle.
3. Fill the kettle which involves.
Unplugging the kettle.
Taking the kettle to the sink.
Turning the water on.
Filling the kettle with water.
Turning the water off.
Returning the kettle to the bench.
Plugging the kettle in.
Turning the power point on.
Turning the kettle on.
4. Put the ingredients into the cup.
Milk, coffee, sugar.
5. Wait for kettle to boil.
Unplugging kettle.
Picking up the kettle and pouring water into the cup.
6. Stir the coffee with a teaspoon.
7. Drink coffee.
As you can see, what appears to be a simple task, like making a cup of
coffee, can become quite complex for the individual with Alzheimer's
disease, with each step requiring varying degrees of physical (ability to
move body parts eg. being able to move the kettle), cognitive (a mental
process characterised by knowing, thinking, learning and judging eg.


knowing that the water in the boiling kettle is dangerous), sensory (being
able to use touch, vision, hearing, smell and taste eg. being able to hear
when the kettle has boiled) and perceptual skills (recognising and
interpreting the senses eg. realising that the kettle is empty and requires
re-filling). Once the activity has been broken into steps and the demands of
the activity understood, it can then be adapted in varying ways to promote
participation and independence. One way of grading activities for
individuals with Alzheimer's disease is by the degree of individual
involvement. This can range from simply attending to a task that is
presented to the person, to planning, organising and initiating the activity
independently. There are a number of levels of assistance the carer can
provide to help the relative perform an activity as independently as
possible. These include:
i. independent - no assistance required.
ii. supervision - for safety reasons eg. to prevent burns from the
boiling water in the kettle.
iii. verbal and visual prompts eg. saying "the milk is in the fridge" when
the individual is not able to remember where it is kept.
iv. demonstration eg. showing the person how to fill the kettle.
v. physical guidance eg. taking hold of their hand with a teaspoon in it
and placing the coffee and sugar in the cup.
vi. dependent - activity is performed by someone else.

Activity 46.
Your task here is to detail a day to day activity similar to the exercise
above that of making a cup of coffee. You are to detail making a slice of
toast. Remember each and every step each and every detail.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Environment
The environment can also be modified to improve activity participation. Aim
for an environment which is familiar, predictable, consistent and free of
ambiguities. For example, leaving the coffee, sugar, cups and saucers out
on the bench in the same place all the time. Also keep rooms free of
obstacles and reduce the background noise when appropriate.
The following tables look at some characteristics of Alzheimer's disease
with some helpful hints, suggestions and guidelines to compensate for
these characteristics.
Suggestions for common characteristics that affect activity participation
among individuals with Alzheimer's disease:

Table 2: Strategies and Guidelines
Characteristic Strategies/Guidelines
Easily distracted
after short periods
of time
Break the activity into small steps
Provide activities which are short and simple
Minimise distractions in the environment like
background noise
Ensure the activity has purpose and meaning to the
individual
The activity selected should aim to be voluntary and
relevant

Decreased ability to
follow instructions
Provide short and simple instructions both verbal and
non verbal
Use demonstration
Use activities which have a learned sequence, ie.
each step of the activity cues the person to the next
stage
Reduced ability to
communicate:
speaking, reading
and writing
See getting started section of this booklet


Difficulty performing
the steps of an
activity in correct
sequence
Break activity into steps to allow participation one step
at a time in the appropriate sequence
Provide verbal and non-verbal clues and prompts
Use activities that are rhythmical and repetitive
Use activities where one step flows onto the next
Unable to recognise
and use objects
correctly
Label objects
Demonstrate the use of objects
Limit access to dangerous objects
Simplify the task by providing the object required
Difficulty carrying
out skilled
movements
Practice and repetition of task
Use activities that utilise past skills, experiences and
interests
Use activities that require simple movements
Provide assistance
Difficulty making
choices
Use activities which require simple choices and no
complex decision making
Use structured activities
Demands made on
person are greater
than their abilities
Activities which use and focus on the persons abilities
Compensate for deficits (parts of the activity the person
can not do themself) by providing assistance


Difficulty contending
with multiple
distractions
Minimise environmental distractions like
background noise
Keep activities simple
Break activity into small steps and carry out one at
a time
For group activities keep the group small
Give the person time to process what is going on
Tiring easily (fatigue) Provide regular rest breaks by breaking activity into
steps or using activities that can be done in stages
Use short activities
Aim to use activities that are satisfying and
enjoyable
Difficulty planning and
organising activities
Break activity into steps
Keep the activity simple
Plan and organise the activity for the person
Poor motivation and
difficulty starting:
reduced energy and
drive
hesitancy
reduced spontaneity
Provide activities that have purpose and meaning
to the
person
Activities that build on past experiences and skills
Provide failure-free activities that allow for success
Provide a variety of props and materials that are in
line with abilities and old interests eg. providing the
pacing individual with a broom which transforms
aimless wandering into a purposeful task


Loss of memory Use activities which involve past skills and
experiences
Use verbal and visual prompts to trigger memory
Activities which orient the individual to person,
place and time
eg. use of signs, large clocks and calendars, use of
pin up and blackboards listing upcoming events,
weather, day and date.
Reduced strength,
endurance, flexibility
and balance
Regular exercise
Difficulty recognising
errors and making
appropriate correction:
Less alert to possibility
of accidents
Identify and remove hazards eg. sharp objects
Supervise activities
Use activities that have no element of danger
involved
Difficulty learning new
things
Use past skills and experiences to build new ones
Repetition of tasks
Try to maintain a consistent and structured routine
Forecast changes from routine
Reduced ability to
solve problems that
occur
Eliminate need to make decisions and solve
problems in activity
Provide assistance with solving problems by
simplifying the problem and giving a basic choice
for the correct solution
Repetitive behaviour:
verbal
movement
Intervene by providing distraction through activities
Use activities that are rhythmical and repetitive eg.
cleaning, sanding wood, peeling vegetables


Decreased tolerance
for stress at the end of
the day
Reduce the demands made on the person during
this time
Do activities during the day and leave the evening
free for quiet time or occupy with very simple tasks
Maintain a consistent routine and limit change
Allow time for rest in the afternoon to minimise
fatigue and agitation during the evening
Give plenty of reassurance
Decrease the amount of choice and decision
making required during this period
Behavioural -problems
eg.wandering,
restlessness,agitation,
depression, apathy,
withdrawal etc
These behavioural issues can often affect the
persons ability to participate in activity or directly
related to the activity itself. The Alzheimer's
Association has many books available on
behavioural problems which may assist you.


4. Implement strategies which
minimise the impact of

4.1 Identify behaviours of concern
4.2
Identify potential triggers for behaviours of concern for specific
individuals
4.3
Contribute to team discussion on care planning and care plan
review to minimise behaviours
4.4
Implement strategies to minimise the likelihood of and reduce
the impact of behaviours on the person and others
4.5
Regularly review strategies that are implemented to ensure
maximum effectiveness and reflect changes in the care plan

Behaviour Management for Dementia Caregivers

Identify behaviours of concern

In addition to communication changes, a significant part of caregiving
involves managing the challenging behaviours that often accompany
dementia. Most of the time, problem behaviours are the reason for placing
a person with dementia into a nursing home. Behaviour management
techniques are a way to structure the environment to increase safety and
decrease frustrations for a person who can no longer regulate his or her
own behaviour. Using behaviour management techniques to manage
problems like aggression and wandering can often keep a person with
dementia in the home for a longer period of time.

At one time, the recommendation was to bring patients back to reality
by correcting their misconceptions. Now the rule is the opposite. As
one staff member put it: If you can't bring them back to a better reality
than they are experiencing in their heads, let them be.
- Pipher, 1999

Behavioural symptoms of Alzheimer's disease include agitation, vocal
outbursts, wandering, and sleep disturbance. Although medications are
available to treat these disordersantidepressants, antipsychotic drugs,
and sedativesall have side effects and may interact with other
medications, and most show limited efficacy.
A meta-analysis of 15 trials of atypical antipsychotics found other adverse
events, including urinary tract infection, incontinence, worsened cognitive
test scores, and an increased risk of cerebrovascular events including


stroke, especially with risperidone (Schneider et al., 2006). In view of these
findings, nondrug approaches should be attempted before resorting to
medications.

Identify potential triggers for behaviours of concern for specific individuals

Agitation

Agitation is always related to fear or lack of control (Wolanin-Phillips,
1981). Caregivers need education and training to respond effectively to the
agitated patient without becoming agitated themselves.
Speaking softly and calmly, the caregiver can gently and quietly take
control of the situation. Ask the patient if he or she needs to use the
bathroom. If not, try to determine what the patient needs: an extra blanket,
a drink of water, food, or a warm hug.
Another approach to the problem of agitation is the three Rs: repeat,
reassure, and redirect (Sultzer & Cummings, 1993). Using this approach,
the caregiver repeats an instruction or answer to a question, reassures the
patient, and redirects the patient to a different activity to divert attention
from the problem.
Research has shown music therapy to be effective in relieving the
behavioural and psychological symptoms of AD, and in some case
improving cognitive and social skills. In one recent study of patients with
moderate to severe AD, those who received music therapy over a 6-week
period exhibited reduced activity disturbances, aggressiveness, and
anxiety compared to those in the control group (Svansdottir & Snaedal,
2006). In another study, researchers observed the effect of stimulating,
familiar background music on patients with AD. They found that the music
significantly increased positive social behaviours and decreased negative
behaviours related to agitation (Ziv et al., 2007).


Vocal Outbursts

Disruptive vocal outburstsscreaming, swearing, crying, shouting,
negative comments to staff and/or other patients, self-talkbecome
increasingly common as AD progresses. Men generally display more
aggressive vocalizations, such as swearing, while women typically exhibit
more agitated vocalizations, such as crying or complaining. Until these
behaviours diminish in the final stages of the disease, they present an
ongoing challenge to caregivers.
Managing vocal outbursts effectively demands special intervention training
and education for staff. Inadequate behaviour management training for
staff can result in overmedication of the patient, inappropriate use of
restraints, physically combative behaviour, or isolation of the patient. The
staff may suffer stress and burnout, leading to high turnover. Learning to
manage these disruptive outbursts successfully respects the patient's
human dignity and builds confidence, improved morale, and job
satisfaction in the staff.
Staff need to remember that the patient is not deliberately misbehaving;
these are not temper tantrums. Staff should not take remarks or attacks
personally, nor should they try to reason with the patient. Instead of
focusing on the problem, staff need to acknowledge that the dementia is
causing the problems.
Behaviour problems such as vocal outbursts and wandering are major
reasons why family caregivers decide to seek long-term care for their loved
one. Staff can gain valuable insights from the family into the patient's
behavioural history, which will aid in planning effective interventions.
Together with psychological and medical evaluations, this behavioural
history can alert staff to important triggers for behavioural problems.
Experienced staff often can anticipate outbursts and intervene to prevent
them. Signs of an impending outburst vary from person to person, but
these events are often preceded by restlessness, refusals, and blushing.
Emotional triggers can include fear, anger, depression, grief, confusion,
helplessness, loneliness, sadness, impatience, and frustration.
Environmental factors such as poor lighting, seasonal changes, over-
stimulation or lack of stimulation, loud noises, or excessive heat, can also
trigger outbursts.
Outbursts may also signal physical illness or discomfort, including pain,
hunger, thirst, incontinence, constipation, infection, or fatigue. Once the
outburst has subsided, a thorough physical assessment may reveal the
underlying physical problem, which can then be remedied.
Managing outbursts triggered by environmental or physical factors is
simpler than dealing with outbursts that stem from an unknown emotional
or psychological cause. With training and experience, however, staff can
better manage and even prevent vocal outbursts. Interventions begin with
distracting and diverting the patient, taking him or her to a quiet room, or
taking a walk. This disconnects the patient from the problem and makes
possible other interventions such as:


Prompting the patient to reminisce.
Engaging the patient in group activities such as games, singing, or
listening to music.
Touching the patient, hugging or holding hands.
Giving the patient something to hold, a soft doll or a stuffed animal.
Showing movies or interactive videos such as sing-alongs.
Using headphones to listen to soothing sounds such as mountain
brooks or the ocean.
Playing audiotapes of the spouse or other family members recalling
happy times together.
The techniques listed above are most effective as prevention measures.
Once an outburst occurs, distraction is necessary to disconnect the patient
from the problem. Otherwise, there is a risk of reinforcing inappropriate
behaviours, which may result in more frequent outbursts.

Wandering

Wandering is a major behaviour problem in patients with AD, more so than
in patients with other types of dementias.
Agitation, restlessness, and sleep disturbances all lead to wandering,
particularly at night, increasing the risk of injury to the patient and others.
Wandering is generally one of two types: goal-directed, in which the patient
attempts to reach an impossible goal such as going home or going to the
store, and non-goal-directed, in which the patient wanders aimlessly.
Wandering patterns include:
Moving to a specific location
Lapping or circling alone a path or track
Pacing back and forth
Wandering at random

Confusion and failing memory can lead to wandering because the patient
is unable to keep a clear destination in mind. Wandering may also
represent a search for social interaction when the patient can no longer
communicate verbally. Unable to sleep, the patient walks to keep busy, or
to find a loved one. Wandering in the late afternoon or early evening may
be triggered by a fading memory of leaving work to go home.
Wandering may also be caused by a physical need, such as toileting. Staff
can use large-print signs to mark destinations with a drawing of the activity.
Placing a photo of the patient as a younger adult on the room door may
help a wanderer find "home."


Wanderers are more likely to have delusions, hallucinations, and severe
depressions. Long-term use of neuroleptics, such as haloperidol (Haldol),
chlorpromazine (Thorazine), or thioridazine (Mellaril) can induce aimless
wandering. Men are more likely to wander than women are, and wandering
often increases as AD progresses.
The family can help staff identify and anticipate wandering in the newly
admitted resident. Staff needs to learn as much as possible about the
resident's lifestyle prior to diagnosis with AD, what kind of work the person
did, previous patterns of exercise, stress, and response to touch. Once a
wanderer is identified, the facility can have photographs made and
distributed to other units, and assign special clothing or identification
bands.
To prevent wandering outside the facility, staff can conceal or camouflage
doors by:
Placing a Velcro cloth strip or panel across doors
Painting doorknobs the same colour as doors
Installing grid patterns on floors in front of doors
Safety locks, alarm systems, and personal monitoring devices can also
help control persistent wanderers. Staff should use the least-restrictive
methods possible to reduce, redirect, or prevent wandering. Interventions
for goal-directed wandering involve distracting the person. A calm, gentle,
and respectful approach helps to establish trust.
Approach the person from the front and use simple commands to change
direction if necessary and guide the wanderer away from the exit.
Diversions such as listening to music, looking at pictures, or exercising
may be effective. Staff should avoid negative or harsh commands such as
"Don't go out there!" and should not argue with the person.
Wandering in a safe area can be good exercise for the person with AD and
helps manage non-goal-directed wandering. Many facilities are designed
with these safe areas in the form of sheltered courts, gardens, lounges, or
pathways.
Education and training for staff can help them identify and anticipate
problem behaviours and learn diversionary strategies to manage these
behaviours. Gaining competence builds confidence in staff and enhances
the quality of life for residents with AD.


Activity 47

Identify areas of concern and list them below - Underneath each
concern list some ideas to help alleviate these concerns and why you
would use them.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Contribute to team discussion on care planning and care plan review to
minimise behaviours by implementing strategies to minimise the likelihood
of and reduce the impact of behaviours on the person and others

One way to approach challenging behaviours is by using the A-B-C
method of behaviour management. The method is based on the theory that
changing what happens directly before or directly after a problem
behaviour can be used to alter, or at least decrease the frequency of such
behaviour. A large body of research has shown that the A-B-C method can
be used to deal with a wide variety of problematic behaviours (described
below).

The A-B-C Behaviour Chain

The A-B-C Behaviour Chain can be used to track and analyse challenging
behaviours in order to develop new ways to approach and respond to
them. There are three components in the A-B-C Behaviour Chain:

Antecedent - The "A" stands for antecedent, which is anything that
happens before a challenging behaviour or "sets the stage" for it to
happen. Antecedents can be internal (e.g., thoughts or physical
sensations occurring within the person with dementia) or external (e.g.,
environmental characteristics). Some examples of antecedents include
hunger, pain, frustration at not being able to communicate, loud noises,
hot or cold room temperatures, a busy environment, fluorescent lights,
unfamiliar surroundings, or overwhelming tasks.
Behaviour - The "B" stands for the problematic or challenging
behaviour. Examples of challenging behaviours, which will be
discussed in more detail later, include agitation (becoming restless,
anxious, or upset), aggression (shouting, cornering someone, raising a
hand to someone, or actually pushing or hitting), repetition (repeating a
word, question, or action over and over again), hallucinations (sensory
experiences that seem real to the person with dementia, yet they are
not really happening), suspicion (perceiving situations inaccurately and
accusing others of theft, infidelity, or other offenses), apathy (a lack of
interest in anything; not wanting to do anything), confusion (becoming
confused about person, place, and time), sundowning (becoming more
confused and agitated in the late afternoon and early evening), and
wandering (on foot, in a car, or using some other mode of
transportation).
Consequence - The "C" stands for consequence, which is anything
that happens right after the behaviour occurs. Consequences can
"reinforce" the behaviour (i.e., increase the likelihood that the person
will behave in the same or similar fashion in the future) by encouraging
or rewarding it. On the other hand, consequences can also "punish" the
behaviour (i.e., decrease the chances of it being repeated in the
future). Examples of consequences are providing calm reassurance,
offering the person a desirable item like food or a photo album, yelling,


taking something away from the person, or removing the person from
the situation in which the behaviour occurred.
Using the A-B-C Behaviour Chain
The first step in using an A-B-C behaviour Chain is to collect as much
information as possible about difficult behaviours in order to detect
patterns about why they occur, or what function they serve for the person
with dementia. Caregivers should use a simple chart to record
antecedents, behaviours, and consequences for each behaviour. The
sample chart below can be used to track behaviours (each challenging
behaviour should be recorded on a different sheet). Caregivers should fill
out the chart as soon as possible after the behaviour occurs.

Behaviour Example: Yelling/Screaming (be as specific as possible)

BEFORE BEHAVIOUR AFTER
Date/time/location
Who was there?
What was happening?
What did the resident
do?
What did I do/say?
do/say?
What did others
do/say?

ABC Chain
After a behaviour has been recorded for one week, the chart can be
reviewed for patterns among antecedents and consequences. Start by
examining the circumstances that precede problematic behaviour to come
up with reasonable "guesses" about triggers for the behaviour. Identifying
the triggers is important because you can then work to eliminate them from
the environment, or at least try to decrease their impact.


For example, does the person always become aggressive after interacting
with a particular family member or service provider? In this case, a specific
person may be a source of stress, so the solution may be to limit that
individual's contact with the person with dementia.
Does the person with dementia remain calm at home, where it is relatively
quiet and peaceful, but engage in wandering when she is in a busy place
like the supermarket? In this instance, the behaviour may be a way for the
person with dementia to decrease anxiety or stimulation in overwhelming
settings. Changing this antecedent might involve going to the supermarket
at a less busy time of the day, or finding a way for the caregiver to shop
alone.
Does the person start moving repetitively when he has to go to the
bathroom or has an upset stomach? Here, the function of the behaviour is
clearly communicating a need. This could be addressed by creating a
"bathroom schedule" (i.e., taking the person to the bathroom every couple
of hours) or changing the person's diet to something that is easier on the
stomach
Next, examine the chart with an eye for finding patterns in the
consequences of the problem behaviours. How do you and other people
respond to the difficult behaviour? Do you ignore the person when quiet
and composed, but pay attention when he or she is agitated? Perhaps the
function of the behaviour is to gain attention (remember, because the
person's brain isn't working properly, he may not be able to ask for positive
attention). Here, the solution would be to provide more positive forms of
attention (e.g., engaging in pleasant activities together) throughout the day.
Or, is arguing actually escalating or increasing agitated behaviour? In this
case, changing your response to a calm, reassuring one is a good idea.
Be sure to examine the entire environment. If others are involved in the
incident, what do they do? If they yell or scold the person with dementia,
then changing the consequence would involve teaching others how to
remain calm and respond with an encouraging tone.
After the behaviour has been tracked and reviewed, the A-B-C behaviour
Chain can be used to develop new approaches for dealing with the difficult
behaviour. The key is to change or adjust the antecedents and/or
consequences that might be contributing to the behaviour. Remember to
change one antecedent or consequence at a time; it is difficult to tell what
is working if you change a bunch of things simultaneously. It is also
important to be consistent (both you and others who have contact with
your loved one). Changing antecedents or consequences only some of the
time (and therefore, setting up a chaotic, confusing environment) can
actually make the problem worse.
Throughout this process, it is important to remember that people with
dementia cannot control or prevent behaviours on their own, because the
parts of their brains that allow them to do so are damaged. Caregivers
have the ultimate responsibility to change what happens before or after
problematic behaviours in order to set up an appropriate environment. It is
also important to note that the person's brain is CHANGING (i.e., getting
worse), so strategies that work this week may not work forever. Adjusting
the environment across time as the person's level of dementia increases is
typically necessary.


Example of Using the A-B-C behaviour Chain
Laura is taking care of her mother, Elsa, who has Alzheimer's disease.
Lately, Laura has noticed that Elsa becomes extremely agitated in the mid-
morning. In the past, Elsa calmly sat in the sunroom each morning and
looked at old pictures while Laura worked in her home office. Laura used
the A-B-C behaviour Chain to address Elsa's unexplained agitation.
Laura started keeping track of what happened right before and after Elsa's
agitated periods. She shifted her routine and worked on her laptop in the
kitchen so she could see Elsa in the sunroom. Laura noticed that around
10 AM each morning, the mail carrier delivered the mail. The mail carrier
was a new person - a man who seemed nervous and in a rush - instead of
the older female mail carrier that had been coming to their home for years.
Laura called the post office and found out that the previous mail carrier had
retired and that the new man was her replacement. After some detective
work, Laura noticed that as Elsa sat in the sunroom each morning, she
could see the nervous, rushed mail carrier as he stomped up to their front
door and dropped off the mail. She would become agitated shortly
thereafter.
In this situation, an antecedent (the new mail carrier) seemed to be
triggering the behaviour (agitation). The current consequence was that
Laura comforted Elsa and gave her some tea and a snack. This eventually
calmed Elsa down, but it did not actually prevent the agitation from
occurring in the first place. To address the behaviour, Laura eliminated the
antecedent/trigger. Rather than having Elsa in the sunroom when the mail
carrier arrived, Laura switched the schedule. During that time, Elsa and
Laura had tea and a snack in the kitchen. By the time Elsa went back to
the sunroom, the mail carrier was already gone. Elsa's morning episodes
of agitation decreased when the antecedent was removed.


Activity 48

After reading the above procedure look at filling in the behaviour
framework below. Fill in how you would handle each behaviour listed

Behaviour Example: Yelling/Screaming at wife when she visits

Date/time/location

do?
What did I do/say?

Who was there?

do/say?

What was happening?

What did others
do/say?

Behaviour Example: Will not stay in bed at night

Date/time/location

do?
What did I do/say?

Who was there?

do/say?

What was happening?

What did others
do/say?


Behaviour Example: is aggressive at nurses.

Date/time/location

do?
What did I do/say?

Who was there?

do/say?

What was happening?

What did others
do/say?

Behaviour Example: Urinates in public

Date/time/location

do?
What did I do/say?

Who was there?

do/say?

What was happening?

What did others
do/say?


Tips for Dealing with Specific Dementia Problematic Behaviours

Agitation - Individuals with dementia frequently become restless,
anxious, or upset (when filling out a behaviour chart, it is helpful to use
specific, concrete words that clearly describe what your loved one is
doing so you can truly track whether your changes work to decrease the
behaviour). To decrease agitation, listen to the person as he or she
expresses her frustration to get a clue about what kind of antecedent is
a trigger; try to eliminate and/or decrease triggers as much as possible.
Pain, discomfort (being too hot, too cold, hungry, needing to use the
bathroom, etc.), frustration, and overstimulation are all common triggers
of agitation. It is also very important to examine your behaviour in
response to the person. If you are not already doing so, reassure the
person that you are there to provide assistance and comfort. If it seems
like the person needs something to do, try redirection to an enjoyable
activity.
Aggression - Aggressive behaviour can include shouting, cornering
someone, raising a hand to someone, or actually pushing or hitting.
Unfortunately, aggression among people with dementia can happen
suddenly and seemingly without warning. Try to identify what triggered
the aggression so that the antecedent can be eliminated or modified as
soon as possible. As difficult as it may be, react in a calm, reassuring
way and focus on the person's feelings. Reduce environmental
distractions as much as possible, such as loud noises or potentially
frightening shadows or movements. Redirecting an aggressive person
to an enjoyable activity can be remarkably effective.
Repetition - People with dementia often repeat a word, question, or
action over and over again (e.g., saying "What are we doing today?"
repeatedly). This behaviour is usually harmless, but it can be unnerving
and annoying for those who are caring for the person. Repetitive
behaviour is usually a sign of insecurity, since people with dementia are
often looking for something comfortable and familiar - something over
which they have some degree of control. To address repetition, look for
a specific antecedent or reason for the repetition as well as for the
emotion behind it. This can reduce your chances of responding
impatiently with the person. If the repetition is an action, try turning it
into an activity that makes the person feel useful. For example, if the
person is constantly fidgeting with his hands, try giving him some socks
to sort or some knick knacks to clean.
Hallucinations - Hallucinations are sensory experiences that seem
real, but are not. The most common hallucinations are visual (i.e.,
seeing something that is not really there) and auditory (i.e., hearing
something that is not really there), but hallucinations can also occur in
regard to taste, smell, and touch. Because hallucinations seem real to
those with dementia, it is not helpful to try to convince the person that
she is imagining things. Instead, recognize the person's feelings,
reassure the person that you are there to help, and redirect her to a
pleasant activity. Also consider whether the hallucination is actually
bothersome. If it is a "nice" hallucination (e.g., seeing a pretty orchard
outside that is not really there), there may be no benefit in trying to
discourage the behaviour.


Suspicion - Memory loss and disorientation can cause individuals with
dementia to perceive situations inaccurately. They may become
suspicious of others - even those close to them - and accuse them of
theft, infidelity, or other offenses. As hurtful as it may be to be accused
of something you did not do, try not to become offended. Remember
that the behaviour is caused by a disease that is affecting the person's
brain. Try to imagine what it would be like to continuously think your
possessions are being taken or hidden (because you cannot remember
where you put them). Do not try to argue with the person or convince
him or her of your innocence. Instead, share a simple response with the
person (e.g., "I see that you're upset that your purse is missing; I'll do
my best to find it for you.") and avoid giving complicated explanations.
Redirection to another activity can also be effective in these situations.
Another option is to store "back-ups" of commonly misplaced items
(e.g., hats, wallets).
Apathy - Apathy is a lack of interest in or motivation to engage in
activities. While apathy may not seem like a serious behaviour problem,
it is not healthy for someone with dementia to simply sit around
passively. Try to find out what may be triggering the apathy (e.g., being
ignored or becoming overwhelmed with a task) as well as what kinds of
consequences may be reinforcing it (again, being ignored, not having
appropriate choices of pleasant activities). Even though the person is ill,
it is important to keep him or her moving and as active as possible in
order to maintain physical health and to prevent depression. Try
adapting previously pleasurable activities so the person can participate
at a level that is comfortable and not overwhelming. Even a small
amount of activity is better than none at all.
Confusion - Dementia often causes confusion about person, place, and
time. In other words, the person may still know who he or she is, but
may not recognize others and/or the current location, time, date, or
year. An individual with dementia may also become confused about the
purpose of objects, such as forks or pens. As frustrating as this can be
for caregivers, the best way to respond is to stay calm and provide
simple, clear, positive answers when the person asks for help. For
example, if the person seems confused about the purpose of a spoon,
simply say, "Here's your spoon for eating your soup." You could also
calmly show the person how to use the utensil (e.g., by saying "watch
me"). Never scold the person or talk to him or her in a belittling way for
becoming confused.
Sundowning - Sundowning is a term used to describe behaviours that
intensify (e.g., increased confusion and agitation) in the late afternoon
and early evening, and is most common with Alzheimer's disease.
There are several theories about why sundowning occurs, such as
increased fatigue (and as a result, a reduced ability to tolerate stressful
situations, such as a chaotic dinnertime or a rushed bedtime routine) or
increasing confusion due to darkness and shadows. The best way to
approach sundowning is to make late afternoons and evenings as
simple and relaxing as possible. Reduce distractions, unscheduled
activities, and behaviours that could be done at a different time of the
day (e.g., switch to bathing in the morning) and keep rooms well-lit until
bedtime.


Wandering - One of the more dangerous behaviours among individuals
with dementia, wandering may be goal-directed (e.g., the person thinks
that he or she is going to a job or going "home" to a childhood
residence) or non-goal-directed (i.e., the person wanders aimlessly). To
reduce the frequency of wandering, make sure the person has plenty of
supervised activity to channel his or her energy. Redirecting the person
to another activity can also work. Interestingly, dementia sometimes
affects perception in such a way that environmental approaches can
help reduce wandering. For instance, a black square painted on the
floor in front of a doorway - or simply a black doormat - may be
perceived as a hole, which can prevent the person from leaving the
home.

Activity 49.

For each of the specific Dementia problematic behaviours give a
definition of each and also an example of each.

Definition Example
Agitation

Aggression

Repetition

Hallucinations

Suspicion

Apathy

Confusion

Sundowning

Wandering


Communication Strategies

We are often frustrated by clients who can't communicate in ordinary ways.

Talking with Clients

1. Listen to clients: Your interest in their feelings conveys respect and
concern.
2. Begin each conversation by identifying yourself and calling the client by
name. Say, "Good morning, Mrs. Adamson. I'm your nurse, Jane." Not
"Do you remember me?"
3. Use short, specific, familiar words and simple sentences.
"I'm Jane. I'm here to help with your bath."
4. Speak slowly and softly in a low pitched voice-approach gently, with an
open, friendly, relaxed manner. Alzheimers Disease clients tend to
mimic your mood.
5. Give one direction or ask one question at a time. "Are you finished?" or
"Here is the toilet."
6. Wait for an answer and if there is no response, repeat exactly. "Are you
in pain? Are you in pain?"
7. Stand or crouch face-to-face and maintain eye contact.
8. Move slowly and touch gently on the arm or hand to gain attention. Be
careful not to startle.
9. Use facial expressions and hand gestures to demonstrate your
concern or how to do something.
10. Talk in a noise-free, non-distracting place. Turn off the TV when
speaking to the client.
11. Respond to the message, not to the word. "I'm sorry you're upset-I
know this is confusing."
12. Take turns frequently in conversation with a client. Use short
sentences, not paragraphs, and give the client time to answer.
13. Watch for signs of restlessness and withdrawal: increased hand
movement, loudness, restless looking away or frowning. Tell her you
understand it's not a good time to talk and you'll come back.
14. Cue her associations even if she can't find the right word or says a
word close to it.
15. Immediate reassurance or rewards are important. People who live "in
the moment" need reassurance in that moment.
16. Clients commonly get stuck and can't find the word they may say a
word that's close to the word they mean but wrong, or a word that
sounds like the word they mean. It takes a long time to explain a word.
Help them find the word through their associations with it. "It's like I eat
with it . . in here (points to mouth)." Nurse says, "Your teeth?"


17. Clients can read words long after they stop understanding the written
concept. One man in a nursing home walked out of his room to see a
sign in the Kindlen warning "wet floor." The man proceeded to dutifully
wet the floor.
18. Demonstrate or "start the motion" for the client who is without self-care
skills. Take the toothbrush in your hand and his together and start
moving it over his teeth. He may be able to continue on his own.
19. Use a lot of non-verbal praise: nodding, smiling, patting. Touching gets
through to brain damaged adults better than words. It prevents feelings
of rejection, loneliness, and insecurity. Touching builds trust and
communication, and lets her know you care and you're paying
attention. Kneeling down lower than the client lessens her sense of
powerlessness too.
20. Use words she uses, and use names rather than "he, she," etc.
21. Ask questions that can be answered by "yes," "no" or a gesture.
22. Talking at a handshake distance apart feels safer to some clients.
23. Limit the number of "don'ts." State positive directions.
24. Avoid common expressions that Alzheimers Disease clients take too
concretely, i.e., "hop into bed." Client says, "I can't hop.
25. Repeat the client's last words to help him continue his thoughts. Many
lose the train of thought at mid sentence.
26. Show respect for feelings expressed even if facts are incorrect.
27. Assume the client can understand more than she can express. Never
talk about her in front of her.
28. An Alzheimers Disease client becomes more sensitive to the
emotional climate of communication. If you're tense, rushed, annoyed,
or nervous, she'll pick it up.
29. Listen carefully, but if you don't understand, let her know. If you guess,
ask her to say "yes or no." You may need to guess again.
30. Keep promises. If you forget, admit it. Your acceptance of your
mistakes may help her accept hers.
31. Remember, some Alzheimers Disease clients can offer each other as
much as we can offer them:

One day during my usual visit to my husband in the nursing home lounge he was
given a cigarette. He was aware enough to realize that he didn't have a lighter. He
watched a lady across the room reach in her pocket for her lighter. He stood,
walked over to her, smiled, placed the cigarette in his mouth and stooped over.
She lit his cigarette and placed the lighter back in her pocket. He walked back to
me perfectly happy. I had witnessed two people communicate without speaking a
word. They were comfortable in a place with people like themselves and where
nothing was expected. A sense of peace and calm came over me for I became
aware that our family, regardless of our feelings of guilt and loss, had done what
was best for him.
- Bobbie Glaze Personal Communication



Communications with Families

Why Is Communication with Families So Important?
Families of Alzheimers Disease clients won't be able to rely on the client
for factual information. They will depend on you more than any of the other
families in your facility. They experience all the difficult feelings any family
does when a loved one is placed, but Alzheimers Disease makes it even
worse. Some Alzheimers Disease clients "improve" or start looking better
with the structure, predictability, and simple routine of the facility. Families
may have difficulty accepting that "a place with strangers" makes their
relative more comfortable than they could.
Because of the behavioural and communication problems associated with
Alzheimers Disease, families will expect the staff and doctors to routinely
check for all signs of potential illness, infection or injury. Many families feel
more secure once the Alzheimers Disease client is in a health care setting
with staff trained to observe and treat acute conditions. It's "not knowing"
that makes so many families unsure-is she in pain? hungry? scared?
abused? neglected? injured? ill? Your goal will be to share your
understanding of the client and the disease process with the family-
gradually, not all at once.
Families, as well as clients, need orientation to facility routines. They
appreciate written information with names to speak to and what to speak to
them about. They appreciate consistent staff they can learn to trust and
work with over time. They need clear procedures for the "what-if's" of care.
What will be done for acute illnesses or injuries? When will they be
notified? How can they communicate with the attending doctor? Are they
welcome at meals, activities?
On admission, the primary family caregiver can be the best source of
information. Many families prepare letters or written descriptions of routine
care and preferences for the client's chart on admission. Encourage
families to do this, and use it in the initial care plan. The fewer changes in
care routine during the admission adjustment, the more quickly the client
will adjust. Prepare families for the unexpected, i.e., baths are given only
twice a week, meals are served in a dining room and not in her private
room with a private nurse, etc.
The day of admission is not the day to exchange all this information. Most
families remember admission as an emotional blur. One sophisticated
nurse, by the time she admitted her mother-in-law, only remembered one
thing from her care plan conference that day with the team-"green beans
or spinach?" She couldn't remember which the old lady preferred and
thought that it wasn't the most pressing issue in helping her mother-in-law
through the transition. If the family is included in the care plan conference,
try to do it after they know the facility and after you've had some chance to
know them and the client.
Many families feel their questions might appear stupid or might aggravate
the staff in a way which will encourage staff to "take it out on their relative."
Give families opportunities to talk when you're not rushed-either special
meetings for new families, or suggest the best time of day for them to talk
with you. It's your attitude of interest, availability and your willingness to
work with them in the care of their relative that will be evaluated. Most
family members can't evaluate your technical competence. But you tell


them a lot about yourself by your interaction with their relative. You also
can "model" more helpful techniques in this way. The pride you take in
your work will increase family security in leaving their loved ones in your
care.
Be prepared for Alzheimers Disease families to have difficulty with visiting.
Many are disappointed when the client doesn't remember the visits,
accuses them of stealing, is apathetic or withdrawn, or looks messy.
Families appreciate suggestions on how to improve the quality of their
visits for themselves and for the client. Reward their positive attempts and
encourage their regular participation in care. Facilities with active family
visitors are generally seen as ideal places to work or live.

How to Communicate with Families
If you go overboard in one direction, make it in the direction of calling the
family too often. They'll let you know if they don't want to hear from you,
but most do. Open visiting hours better accommodate family schedules.
Families are less likely to be suspicious of your care if your open visiting
policy suggests you have nothing to hide.
Too much time and energy is wasted in accusations between families and
staff. The clients need every bit of attention you have to offer. Find ways to
involve and encourage families to participate in care-not just formalities like
signatures on care plans. An Alzheimers Disease client's condition
probably won't improve, but real miracles are possible by investing in work
with their families. Families usually appreciate your time, attention, and in-
terest, and they can thank you even if the client can't.
Your time is limited, however, and you can do family visitors a great
service by introducing them to each other. Many family visitors appreciate
shared visits with other non-verbal or apathetic clients. Some begin to
check on each other's relatives while the family is vacationing. Just the
companionship at the facility is helpful, and many of these one-to-one
supportive relationships lead to friendships outside the confines of the
facility. Encourage families to attend Alzheimers Disease meetings or sup-
port group meetings together. The meetings offer more opportunities to get
uncomfortable feelings off their chests and to share experiences in a
supportive atmosphere.

Activity 50.
Why is communication so necessary with each of the stakeholders in
the care of a dementia person.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Staff Communication and Coordination of Care
Consistency is critical to quality care of dementia victims. This means that
each member of the treatment team (including the housekeeper, dietary
aide, and maintenance person) should be taught how to communicate with
and respond to the Alzheimers Disease client. This is not a breach of
confidentiality. Clients' family members appreciate consistent care based
on thorough understanding of the disease and its impact on this particular
individual.
Care plans must be re-evaluated regularly because this is a progressive
disease. Expectations of the client and family must be changed with
changes in either client or family conditions. Each facility must develop a
quick, efficient method of communicating changes to all shifts. If problems
persist, think about a care conference with family members, physician and
nursing staff present. People may see problems differently, depending on
their role with the client, and on when or how often they see her. This
conference need not take a lot of time, but pulling everyone together may
save time and effort in the long run.
An Alzheimers Disease client's care, goals, and methods of attaining the
goals should be time-limited, specific and related to her observed
behaviour. It's helpful to document changes in self-care and thinking ability
over time. There are many short behaviour scales which measure changes
in self-care and memory over time. It is helpful to repeat the same tests at
regular intervals to encourage re-evaluation of care plans and goals.
Sudden changes should always be evaluated thoroughly and the causes
treated promptly. Many families of terminal clients go to great lengths to
discuss or plan for potential decisions that are usually made in a crisis.
Many families become angry when pneumonia in their terminally ill relative
is vigorously treated or ignored. Many families have strong feelings about
transfers to a hospital for tests or intensive care. If a family has strong
feelings and these feelings are explicit, they should be recorded and on file
for all staff to check. Most large families appoint a family manager-the
primary next-of-kin for staff to call. Make sure all communications and
decisions about care are reported to this person.
Observations by staff mean a great deal to our understanding of creative
approaches that work with specific clients. Be sure to include these
observations in charting care activities and goals. Give staff members
special responsibility for clients who interest or challenge them. Many of
the ideas submitted for this manual were taught to family members by
personal care attendants who "figured them out by trial and error."
Experience with an individual client over time is invaluable, and it should
be part of the record.
Staff communication also means recognizing and rewarding each other for
a job well done. Clients and their families are often too caught up in their
personal tragedies to notice special efforts on their behalf. A chance to talk
things out or "rap" with other staff can be a real morale booster and
inspiration. Encourage staff to use each other's expertise and to call on
each other for support. Many facilities improve team performance by
encouraging support groups for staff. People who are working together,
and become friends or peer-helpers, improve their communication around
work issues too. Support groups build the trust necessary for good team
cooperation.


Communication with Outside Providers
Many people unfamiliar with nursing homes see them as "holding actions"
or places where little is going on to make people well. When a family is
forced to look at facilities for a dementia victim, they uniformly express
interest in places "where something is being done" and staff "don't give up
on terminal clients."
All communications with outside agencies or professionals should convey
this image. That doesn't mean you don't have realistic expectations about
the downhill course of Alzheimer's. It just means, as care professionals,
you're interested in improving care. There are techniques and
management strategies that make a difference in your effectiveness and
the quality of life for Alzheimers Disease clients and their families. Your
expressed and demonstrated interest in improving care makes your facility
competitive and appealing to families as consumers. Families are your
consumers when Alzheimers Disease clients can no longer make
decisions. Alzheimers Disease clients don't voluntarily select and enter
facilities. Most Alzheimers Disease clients aren't asked about satisfaction
with the facility, but families are often asked, and they share their eval-
uation with other potential consumers.
You have an opportunity to teach other agencies and professionals what
nursing homes can and should do for Alzheimers Disease clients. You can
make your interest known to community providers by opening the facility to
support group meetings, to educational presentations, and as a teaching
site for future health care providers. Quality of care improves when
teaching is going on.
Learn the potential contributions of good medical management, and share
information and articles with physicians managing the Alzheimers Disease
clients in your facility. Let them know what they can expect of your staff
and when your staff will look to them for assistance. Families will
appreciate your efforts to make their relatives more "interesting clients" for
the physician. This increases physician involvement with the facility, and
most facilities report better care and higher morale with increased
physician interest and availability.

Contribute to team discussion on care planning and care plan review to
minimise behaviours

Principles
The Alzheimers Disease client gradually loses the ability to interpret and
express what is happening to her body or her mind. Staff must read the
nonverbal cues to pain, discomfort, urgency or worry, in her eyes, her
behaviour and her appearance. Sudden changes in self-care ability,
continence, confusion or disorientation may all mean a treatable illness.
Most older people have atypical symptoms of common illnesses. The usual
signs of fever or pain may not be there. Symptoms of infection or heart
ailments may be no more than increased confusion, incontinence, or falls.
Alzheimers Disease clients often forget to drink and become more
confused due to dehydration. They may forget to eat, lose interest in food,


or develop preferences for sweets only. Nurses must be creative in
providing clients with adequate nutrition and hydration. Reminding the
client that "it's good for you" is simply not adequate. Some clients have
trouble chewing and swallowing, and may choke, even on clear liquids.
Nursing care plans often fail because they are overly optimistic or
pessimistic with Alzheimers Disease clients. Demanding too much of the
client aggravates her symptoms, may make her withdraw, or may hold out
false hope to family and friends. Expecting too little of an Alzheimers
Disease client may lead to helpless or hopeless behaviour on the part of
the staff that affects both client and family. Keep an open mind, and
celebrate with client and family all small victories or moments of clarity.
The key, according to one nurse, is "hope and flexibility." Families also say
they learn to "take one day at a time and go with the flow."

Take a look at a form Forms Care Plan Peter Dafonseca to see how a
person with slight Dementia would be written up on a care plan. Number
for the form is on the side panel.

Immobility induces a host of related problems: muscle weakness,
constipation, trouble with sleeping at night, rigidity, bed sores, etc.
Alzheimers Disease clients should be kept mobile as long as possible, and
moved frequently once they are unable to walk. Teaching the family to help
with range-of-motion exercise can be helpful to you, the client and the
family.
Grooming is especially important in the care of Alzheimers Disease
clients.
All nursing efforts to make the client presentable to family, visitors and
other residents will be appreciated.
Adult clothing may be a gentle reminder of "self" to the patient. It also
provides more opportunities for touch and affection and physical or
nonverbal reassurances that are so important to Alzheimers Disease
clients.
The keys to good nursing care of Alzheimers Disease clients are in provid-
ing security, reasonable stimulation, and reassurance in maintaining their
self-esteem.

Developing Care Plans

Developing, monitoring and evaluating care plans for Alzheimer's clients
demand creativity, patience, and judgement from all levels of staff, as well
as from the family. These plans must be constantly revised with changes in
the client's self care capacity or as other illnesses develop. Family
caregivers should participate in care planning, to the extent they are
interested and capable, with written suggestions or actual participation in
team conferences.
Once a care plan is developed for an Alzheimers Disease client, it must be
well understood and strictly followed by all levels of staff, family and
visitors. Care plans should not be finalized on the day of admission. Staff,


client, and family all need time to get to know each other's strengths.
Alzheimers Disease clients function best with a total milieu, or facility-
wide, approach. To encourage these consistent approaches, each staff
person and family caregiver should be encouraged to contribute
suggestions and observations on the client's response to the plan. A good
care plan recognizes the family as a client and includes an assessment of
the family's needs and capacities, as well as the client's.
Care plans should be specific-more specific than "encourage independent
functioning." The plan should begin with a specific listing of what the client
can do herself, what she can do with some assistance, and which of her
activities require total assistance. There are some excellent scales for
instrumental and physical activities of daily living. Using these scales can
help document any real changes in the progress of the disease.
Care plans also should set individual priorities, encouraging all staff to
tolerate any especially meaningful client or family routines or preferences
that don't interfere with the rights of others. For example, note special
security objects preferred by the client, even if that means letting her wear
her special hat to bed. Teach staff how to prevent, divert or distract a client
from potential difficulty rather than arguing, convincing or explaining
something to her. Document your efforts to routinely orient new clients to
all staff and routines and to escort new clients to all activities. Document
your efforts to "model" or demonstrate helpful strategies to family or new
staff. Permit clients who prefer to sit and fantasize the opportunity to do
this without undue embarrassment, interruptions, or obvious neglect of
their physical care needs.
Document care procedures to be done, and by whom. Some families
prefer to participate in physical care or feeding when and if they are able to
be there. Your support and encouragement in helping families do this will
be appreciated. Other families find physical care offensive and want to be
assured that the client will be dressed and presentable for visits. Families
shouldn't be expected to relieve staff, but they can often take more time
with tasks like feeding and walking than staff can. Helping each family
member to find or preserve his/her special role with the client will
encourage family members to work with staff rather than against staff.
The care plan also should include suggested helpful answers to questions
the client is most likely to ask. Some families prefer that the client believe
she is in a "hospital" or "hotel," and some families prefer that the client
never be told she has Alzheimers disease. These decisions must be
worked out with the family, with the physician, and with the best interests
of the client in mind.
Preferred activities should be considered with the client's past, as well as
with her present condition in mind. Some clients become frustrated trying
to do something which was once a fine skill. She may recognize that her
performance or skill has changed, and she won't want to be reminded of
this. Others may want to look like they are doing something "dignified" like
reading the paper, even if the paper is upside down.
It's best to take nothing for granted in developing care plans for
Alzheimers Disease clients. Some are able to continue many self-care
activities far longer than one would expect, just judging from symptoms or
testing. Staff shouldn't take over too early-it's better to do "with" than "for"
as long as possible, even if it takes longer or it isn't done perfectly.


Protection from frustration, embarrassment, or risk must be based on
observations over time with a specific client.
Our approach to all phases of care planning should be to personalize or
individualize each client's routine, security objects, and stimulation while
offering as much reassurance as possible to the family. Care plans should
suggest consistent approaches to the client by both family and staff, using
recommendations from both family and staff. These approaches generally
include:
DO
Keep everything as simple as possible.
Expect her to ask the same questions repeatedly. Give her only simple
tasks to perform.
Get some relief for yourself in your caretaking duties. Hug her.
Remember she will follow you and want to know where you are always.
Hold her hand. Be gentle.
Give instructions one step at a time. Ignore things she does which
annoy you. Remain calm and pleasant. Get ample rest.
Keep her occupied (if possible) with simple chores. Maintain your
sense of humour.
DON'T
Expect answers to your questions to be accurate.
Get irritated when she asks the same questions over and over. Give
her instructions and then expect them to be carried out perfectly.
Fuss at her.
Give her too much responsibility.
Expect her to identify certain words, names, things, etc. Take her
behaviour personally. Scold her or argue with her. Try to do it all
yourself.
Give her a choice-it is too confusing. Get upset.
Raise your voice.
A Word About Activity Programming

Alzheimers Disease clients respond to a variety of activities which might
be planned for the entire facility or just for them. Entertainment, visitors,
exhibits or demonstrations where little is expected from the audience are
usually a success. It is necessary to watch the length of time, the
crowding, confusion, or noise level when including easily upset Alzheimers
Disease clients. It's always a bonus if a family member or visitor can
accompany the client to any program, thereby offering individual
reassurance and a chance to leave early if the client is overstimulated.
Alzheimers Disease clients who walk usually love to "be on the go." They
enjoy field trips, outings, and picnics in small groups, especially with food
as the centre of the activity. The chance to watch children playing or


athletic events is appealing to some, while others only enjoy the chance to
play along.
By far the most successful activities are those which include music or
rituals from long ago. In the South, singing gospels, hymns or patriotic
songs has great appeal. Listening to children's choirs, musical ensembles,
or staff members with musical talents is a big hit. If movement, dance or
exercise is incorporated with the music, the opportunity to touch (hold
hands, shake hands, or hold on) serves many more purposes. The
movement to music sometimes triggers old, pleasant memories.
Expressive art projects, using a minimum of materials at one time, also can
be effective. Talking quietly while painting, colouring, or working with
brightly coloured designs, shapes or beads can encourage reminiscing.
Social groups also help break down loneliness and isolation. Small groups
of confused residents, meeting daily with the same staff, may come to
greet each other and even miss those not present. They may work, walk,
sing, dance and exercise together, or staff may trigger memories and
conversation with pictures of familiar objects like cars, animals, factories,
farms, etc. The activities of these groups are less important than the
consistency of meeting with the same people. Alzheimers Disease clients
are able to form new friendships and offer real support to each other,
sometimes even without words.

Activity 51

Using a blank proforma from your Care plans you are to develop a Care
plan for the following resident. After you have completed this Care Plan
discuss it with your facilitator
Mrs. Jenkins, an 84-year-old Alzheimers Disease client (with the energy
level of a 5-year-old), became impossible to manage from about 5 p.m.
until after midnight. She screamed if confined in a Geri chair, or she'd pace
up and down the same hallway near the front door, pulling at her clothes,
and mumbling, "Help me-I wanna die!" Sometimes, she'd even pull long
and hard enough on her clothes that her clothes would tear or come off.
She scared the after-work visitors away with her strange, hysterical
appearance or her constant begging of each visitor to "take me home!"
After dark, she'd get worse. She would empty clothes out of her drawers,
packing them in any available container for her "trip home." The nurses
requested extra sedation, but her children wouldn't allow the doctor to
"drug" their mother. At the same time, her children were so embarrassed
by her behaviour that they visited only briefly after church on Sunday
mornings. The nurses resented Mrs. Jenkins' children's "tying their hands"
in their efforts to restrain her, and they resented Mrs. Jenkins' hanging
around the nursing station during each shift's report, making them all
nervous with her constant fidgeting.


Implement strategies to minimise the likelihood of and reduce the impact of
behaviours on the person and others then regularly review strategies that
are implemented to ensure maximum effectiveness and reflect changes in
the care plan

From an ADRDA Newsletter - Anderson
Upon admission you should be given.. answers to help acquaint you with
your client. I believe no Alzheimer's client should ever just be left in any
new environment without his primary caregiver until he has formed some
feelings of belonging and begins to feel "at home." We all know CHANGE
is particularly upsetting to these clients.
When client habits and preferences are known, a planning session should
take place among the team of personnel. . I believe the family caregiver's
presence at this meeting would be most helpful to staff, and at the same
time serve to bolster the caregiver in having to make the decision to
institutionalize his/her loved one.
Be flexible-the best laid plans should be reviewed, and often a minor
change can work wonders. A structured environment with pre-planned
daily activities and rest periods is a must. Not doing this with an
ALZHEIMERS DISEASE victim may cause fear, hopelessness, or serious
depression. They are unusually active, and their activity must be
channelled. Some suggestions follow;
I have stumbled onto activities here that my husband has come to look
forward to and enjoys tremendously. About once a week, we walk to
the retail store. He enjoys looking and being in an atmosphere once
familiar to him. I try to interest him in items such as birthday cards for a
relative or friend, which he then enthusiastically helps to choose. I
always praise his choice, whether I purchase it or not. I have never
tried to teach him about the coupon books used here; it was not a
familiar way to purchase, and he won't be able to learn it now. If I were
not here, he would need an attendant or volunteer to take him (to the
snack/gift shop).
The library is a happy experience for my husband, because books are
familiar friends. Though he still reads skilfully, backwards or forwards,
his comprehension is poor. So we choose the big pictorial books and
just turn the pages. Often we have spent close to two hours a couple of
times a week at the library. Music therapy is wonderful. It is uplifting, a
happy experience, and an entertainment. We follow the schedule
posted on the bulletin board and try to go where the music is playing.
Gym activities such as basketball games are great time passers and
happen late in the day when he is tired, so he is content to sit and
watch the kids play. I find, too, that the families are very social and try
to include us, and my husband likes that. He actually enjoys the
games, just as I do, and many times we will laugh out loud when some
players, scrambling for the ball, end up in a heap on the floor.
Outdoor walks: This is such a beautiful place in all seasons, and the
seasonal decorations are too good to miss . . . flags for Veterans Day,
the Christmas decorations, etc. Walking is such good exercise and
therapy. Nature is uplifting and fresh air is good for everyone as well as
exhilarating. We sit on the benches and feed the squirrels, or simply


watch their antics. Often we sit quietly together, holding hands, just
content to be together and at peace.
The cafeteria: Often I look at my too-thin husband and wish I could
help him gain weight. I began to bring him a goodie bag several times
a week. He loved it, and he remembered to look for it. Other days I
would take him downstairs and let him choose his own snack from the
machines, or we go to the cafeteria.
It is so nice to have this opportunity to thank all of you for all that you are
doing for my husband, and I thank God, too, that Langley is in such a
wonderful place. I try always to remember that my husband has only lost
his memory-he has not lost his human dignity, his sense of humour, or his
love for me and his family. These are the last days I will ever spend with
my dearest loved one in all the world to me, so it is important to me to
remain with him as long as he is cognizant that I am there. After that, I will
have to give him up to God's plan, but for now . I am part of God's plan for
him, just as I have been by his side for the past 41 years-"until death do us
part."

THANK YOU!!!

From an ADRDA Newsletter-Guise
Activities for A.D. Clients

At this Durham meeting, support group members became initially
"reluctant" clients, who gradually acknowledged they were having fun!
Inez, with her silver hair and sweet-16 figure, reminded us that "most of us
will rust out long before we wear out!" For frail, confused people, access,
interest, and acceptance of activity decline even further. Regular exercise
will strengthen bone and muscle tissue and lower blood pressure, reducing
the risk of heart and lung disease. (Too bad it is not a deterrent to
Alzheimers Disease.) Regular exercise may help clients feel more
energetic and confident. Exercise need not be strenuous. People "out of
shape," over 60, and disabled should consult a physician before starting
any regular exercise program. Good exercise is more than repetitive body
movement. A good exercise group experience should promote social
interaction, body self-awareness and relaxation. Building self-esteem,
increasing physical mobility and simply having fun are major objectives of
exercise therapy. Our work with confused older people convinces us that
exercise helps achieve these goals.

Techniques
Older, confused or disoriented persons resist structured exercise, although
their restlessness requires "channelling." For some, it is simply an attitude
("Old ladies have no business running around acting like teenagers-it's not
respectable!") For others, there is real fear of falling, injuring oneself, and
demonstrating to others that one's health is failing. Confused persons often
forget how to move or how to coordinate their movements in relation to
objects. Motivating them is not easy, but the rewards of increased stamina,


self-esteem, and coordination make it worthwhile. Exercise should be light
and enjoyable. Feel free to pause during intervals to allow rest, filling time
with small talk, sharing jokes, anecdotes, or games. This builds group
cohesion. It's a good idea to use soft, repetitive or familiar music during an
exercise program. Loud, rapid music interferes with a confused person's
ability to hear and process directions.
Durham group members tried some creative exercises such as voice
exercise, chair waltz, scarf dance, Swedish massage, a volleyball party,
and a "Hawaiian luau." Sound interesting? You really should have been
there. Instructions were simplified: i.e., no directions mentioned the use of
right vs. left arm. This consumes too much time and energy for clients
trying to distinguish lefts from rights, when it really doesn't matter. It's
better to just keep moving. Small talk, old-time tunes, and humour make
exercise a popular activity with confused older people.-By Vera Guise

Staffing

Consistent staffing is extremely important in the care of Alzheimers
Disease clients-sometimes more important than the educational qual-
ifications of the staff. All staff must be trained to work with confused
residents, but it requires even more patience and energy to run between
intact and confused residents. Families appreciate the opportunity to get to
know the special staff over time, and to share observations and tricks with
the hands-on staff. Alzheimers Disease clients require more direct nursing
care than most other clients, but that care is personal care id not highly
technical procedures. It's best to have more aides per client and one
skilled supervisor to care for a wing of Alzheimers Disease clients.
Training in handling behavioural problems and communication skills is
critical to all staff working with Alzheimers Disease clients. Routine
observation and skills relating to care of the terminal, immobile client
become important in the later stages of the disease.

Stress Management for Staff

Caring for Alzheimers Disease clients is very stressful-just ask their fami-
lies. It's difficult caring for people who don't recognize their need for care or
appreciate your efforts. It's also upsetting to become attached to people
who deteriorate despite your best efforts. Watching sad, painful visits with
relatives who mourn the loss of "the mother I once knew" also hurts.
Casual conversation becomes more one-sided with staff doing all the giv-
ing and very few flickers of understanding or response from the
Alzheimers Disease client. Their families may have little energy for you
either, in their consuming need to assist the client. All these things make
caring for Alzheimers Disease clients stressful.
Good facilities seem to have staff that develop a tolerance for confusion or
strange behaviour as well as a sense of humour. Some individuals bring
this to their work, and others develop it in response to work of this kind. But
it's hard to give all the time if someone isn't "giving back" to you. Support
groups for staff, parties and contests that involve staff with healthier


members of the community, or providing staff with its own system of
rewards and recognition helps boost morale. Your ALZHEIMERS
DISEASE clients won't notice your weight loss, your new hairdo, or your
engagement ring, but your co-workers will.
Informal support groups for staff sometimes develop during team
meetings, parties, or in the middle of other events. Support groups
shouldn't be an added burden but a bonus-a place to get things off your
chest, share successes, and support each other through difficult times.
Family caregivers are always urged to pay attention to their own needs,
and staff would do well to follow the same advice. Breaks should be
encouraged. While routine, predictable environments are best for
Alzheimers Disease clients, they can be deadly for staff.
Create your own breaks, diversions, and social life without depending on
the clients and their families to provide these things. It will make working
together more pleasant, as well.

Activity 52.

You are looking after the following dementia patient. Looking at her
reactions how would you deal with it or how would you approach the
situation with the help of the rest of the staff

It was time for Ms. Haswell's bath, and none of the personal care
attendants wanted to do it. Ms. Haswell was stubborn about bathing-she
would get real uppity and insist she had taken one herself earlier. As
Denise walked into the room, Ms. Haswell was standing with her back to
the door rocking a doll and singing. Denise approached and reached out to
put the doll down. Ms. Haswell whirled around, striking Denise in the face
with her free hand and screaming, "You bitch, get out of here before I call
the police!" The day before Ms. Haswell told Denise that she was "the best
nurse on the floor."
Two days earlier, Ms. Haswell attended a baking activity group in which
she stirred the flour and liquid. Some of the flour was brushed out of the
bowl into her skirt. She suddenly became hysterical, shouting, "It didn't
work again. I made a mess again. I'm no good to anybody-I'm gonna kill
myself." She couldn't be consoled for the rest of the afternoon.
What Are Catastrophic Reactions?
This is a term describing the behaviour of a dementia client when a
situation overwhelms her ability to think and react. The behaviour may be
any of the following:

1. suddenly changing mood (also called emotional liability)
2. crying inconsolably for a long time (even over nothing sad)
3. anger-increasing suspiciousness
4. increasing restlessness, pacing, wandering off
5. combativeness (striking out)


6. stubbornness
7. worry or tension
The client appears stubborn, overly critical or overly emotional, all out of
proportion to the incident. These reactions can be set off by any number of
things:
1. being asked several questions at once, especially "why" questions
2. feeling lost, insecure or "left"
3. small accidents (spilled milk)
4. too many strange people in a new place with new sounds and
sights
5. TV shows that the client has trouble separating from her reality.
She may think she is the character who is arrested, killed, or has
just murdered her child.
6. being scolded or contradicted, having an argument
7. noisy, crowded, or unpredictable environment that is misjudged or
misinterpreted by the client
8. if staff members are tense, irritated, rushed, or impatient
9. if the client tries and fails to complete a task she once regarded as
simple, i.e., washing dishes, tying a shoe lace
What Causes Catastrophic Reactions?
Like clients with other organ system illnesses, the dementia client's most
vulnerable organ is her brain. No matter what the triggering situation-
environmental or acute illness - a demented client will usually respond with
symptoms of increasing agitation, behavioural problems or increasing
confusion. It's like blowing a fuse in an overloaded thinking system.
Alzheimers Disease clients also experience a loss of impulse control. The
part of the brain that controls most childish impulses like lashing out is
damaged in Alzheimers Disease. This means that women who never
cursed may curse, and peaceful, timid women may lash out at those
closest and dearest to them. Even macho men may become inconsolably
weepy or upset over minor incidents.
Finally, an Alzheimers Disease client loses adult judgement. She can't
evaluate the seriousness of a single incident or predict the effects of her
behaviour on others. She may actually lose her capacity to think of "the
other" at all-a source of great frustration to spouses. One husband who
had tenderly cared for his wife's cancer before his dementia was evident,
forgot even to ask her how she felt as his own disease progressed.
Sometimes an Alzheimers Disease client misperceives a cue in the
environment and acts on that misperception. Ms. Haswell perceived
Denise as someone "stealing her baby." A female aide trying to bathe a
male client may be perceived as making sexual advances. When impulse
control is lost, a male client doesn't stop to consider, are there other
people in this room? Do we have privacy? He may just grab her and
respond as if she were his sexual partner from many years before.


Discuss these thoughts and actions below and the discuss with your
facilitator.
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


5. Implement self care strategies

5.1
Monitor own stress level in relation to working with people with
dementia
5.2
Use appropriate self care strategies and seek support if
required

Monitoring own stress level in relation to working with people with
dementia and then use appropriate self care strategies and seek support if
required

Alzheimer's disease exacts a heavy toll on the emotional, physical, and
financial resources of the family, especially the primary caregiver, usually a
spouse or a daughter. Even though the family member willingly assumes
the role of caregiver, the physical and emotional energy required can
exhaust the most devoted individual. In a recent survey of 400 caregivers,
two common themes emerged: anticipatory grief and ambiguous loss.
Anticipatory grief is the pain and sadness of losing a loved one before
death actually occurs. Ambiguous loss is the unsettling feeling of
interacting with someone who is physically alive but seems no longer
socially or emotionally present (Frank, 2008).
Caregivers also face loss of their previous role in the relationship while
dealing with responsibilities formerly shouldered by or shared with the
patient. If an adult daughter or son is the caregiver, he or she joins the
"sandwich generation," caught between the parent's needs and the
demands of career and family at home.
The time commitment required to care for a person with AD is daunting. An
Alzheimer's Association survey showed that caregivers who live with a
relative with AD spend about one hundred hours weekly providing care.
Caregivers who are employed outside the home devote an average of 40
hours weekly to providing careequivalent to a second full-time job. Half
of all caregivers reported not having enough time for themselves. The
caregiver is always on call; theirs is a 36-hour day (Mace & Rabins, 2006).
As AD progresses, the physical energy required to care for the increasingly
dependent patient may deplete the caregiver's capacity. By mid-stage AD,
the patient needs help with bathing, dressing, and a host of other activities.
According to the Alzheimer's Association, 45 percent of caregivers report
not getting enough sleep. Hospitalization rates are high for caregivers.
The lives of the caregiver and the patient are inextricably linked in a long,
painful dance toward death. When the caregiver's quality of life suffers, it
affects the quality of care for the person with AD. Without help and support
from family, friends, health professionals, and community resources,
caregivers are at great risk for:


Emotional distress, such as depression and anxiety
Fatigue and sleep deprivation
Social isolation, when relatives and friends stop calling or visiting
Family conflict
Substance abuse

Just as education and training for staff can improve care and quality of life
for patients, educational interventions for family members can make a
positive difference in the caregivers' ability to cope with their difficult task.
A long-term study in New York city found that caregivers receiving
enhanced counselling and support, including support group participation,
and continuous access to ad-hoc telephone counselling reported
significantly better self-rated health than the control group. The benefits of
the intervention lasted for two years (Mittelman et al., 2007).

Caregiver support and counselling may also help delay nursing home
placement by as much as 18 months (Mittelman et al., 2006). Caregivers'
guides also are available from many hospitals and government agencies
including the National Institute on Aging:
http://www.nia.nih.gov/Alzheimers/Publications/caregiverguide.htm.

Better understanding of the dementia and techniques to cope with it can
reduce caregivers' burdens and the negative reactions to disruptive
behaviours common to AD. Reducing the burdens of caregiving can delay
the need for nursing home care.

Caregivers may benefit from the following suggestions from the National
Family Caregivers Association:

* Believe in Yourself.
* Protect Your Health.
* Reach Out for Help.
* Speak Up for Your Rights.

Activity 53,
What would be do you feel the best way to alleviate your stress in a
dementia nursing situation?
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Use appropriate self care strategies and seek support if required

Stress Management for Staff

Caring for Alzheimers Disease clients is very stressful-just ask their fami-
lies. It's difficult caring for people who don't recognize their need for care or
appreciate your efforts. It's also upsetting to become attached to people
who deteriorate despite your best efforts. Watching sad, painful visits with
relatives who mourn the loss of "the mother I once knew" also hurts.
Casual conversation becomes more one-sided with staff doing all the giv-
ing and very few flickers of understanding or response from the
Alzheimers Disease client. Their families may have little energy for you
either, in their consuming need to assist the client. All these things make
caring for Alzheimers Disease clients stressful.
Good facilities seem to have staff that develop a tolerance for confusion or
strange behaviour as well as a sense of humour. Some individuals bring
this to their work, and others develop it in response to work of this kind. But
it's hard to give all the time if someone isn't "giving back" to you. Support
groups for staff, parties and contests that involve staff with healthier
members of the community, or providing staff with its own system of
rewards and recognition helps boost morale. Your ALZHEIMERS
DISEASE clients won't notice your weight loss, your new hairdo, or your
engagement ring, but your co-workers will.
Informal support groups for staff sometimes develop during team
meetings, parties, or in the middle of other events. Support groups
shouldn't be an added burden but a bonus-a place to get things off your
chest, share successes, and support each other through difficult times.
Family caregivers are always urged to pay attention to their own needs,
and staff would do well to follow the same advice. Breaks should be
encouraged. While routine, predictable environments are best for
Alzheimers Disease clients, they can be deadly for staff.
Create your own breaks, diversions, and social life without depending on
the clients and their families to provide these things. It will make working
together more pleasant, as well.

Taking Care of Yourself

1. Be gentle with yourself. You didn't create all the problems you face
daily.
2. You're not a fixer. You can't change the clients/families, but you can
change your reaction to them.
3. Find a quiet hideout to use when you need it.
4. Pat other staff on the back for success. Let them return the favor.
5. Even when you feel helpless, hang in there. Being there is sometimes
more important than doing something.
6. Change your home routine often if work routine is dull.


7. On the way home, focus on one good thing that happened that day.
8. Get creative-try something new on an old hassle.
9. Use your supervisor or buddy system to reassure yourself and build
morale. Two heads are better than one.
10. Sometimes you must say, "No, I won't." People will value your "Yes, I
will" even more. People appreciate a definite answer more than a
"maybe" or being ignored.
11. Laugh, play, and stop "to smell the roses along the way."
* adapted from Olivia Escobosa, BSN, and Barbara McBride, RN

Activity 54.

Go onto the web and research and find self help facilities for you as a
care-giver list below and make a note of what they offer
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________
___________________________________________________________


Creative Solutions to Nursing Care Problems

Caregiver Tips

Many of the following solutions were suggested by families, as well as staff
of specialized units for Alzheimers Disease clients. The following is a start
- add your own to make this manual more useful to you.
(Note: A physician's order may be required for some of these strategies)

1. Give the client a washcloth to hold while you are washing the parts she
forgets. Don't use showers on ALZHEIMERS DISEASE clients who
seem fearful. Wrap the client in a towel in the water if she is frightened
to be undressed all at once.
2. Whirlpools, which clients can be lowered into from a seat (with harness
to hold sitting position), improve circulation in immobile clients and
relax muscles for range of motion.
3. Tomato juice added to bath water removes persistent body odour.
Odours from incontinent clients that often permeate an entire unit can
be removed by adding fabric softener to humidifiers and coolers.
4. Milk of magnesia paste applied to sore skin around feeding tube
stomas cuts the acidity that causes skin to break down.
5. Some bed clients develop very dry skin that lead to bedsores. Mineral
oil added to the bath water is cheap and improves this condition.
6. Avoid laxatives for potentially incontinent clients-try a high fiber diet.
Observe subtle signs of constipation/impaction: low energy, decreased
appetite, bloating, increased confusion.
7. Incontinence should be handled with routine, consistent toileting first,
then diapers, then catheters. Some facilities report success by giving
instant rewards like M & M's after "catching the client" at the right time.
8. Sheets of bed-bound clients should be kept from wrinkles. The use of
disposable draw sheets helps absorb perspiration and urine, and keeps
the client drier and more comfortable. (See Excerpts from Dealing with
Incontinence following this list.)
9. Bed-bound clients should be turned every two hours and skin should
be massaged with lubricants.
10. Soft music in the background on ALZHEIMERS DISEASE units is
calming. Activities should be social, in small groups, and featuring
favourite foods-ice cream socials are always a big hit.
11. One family member found that drooling was causing her husband's
chin to be red and sore. Eliminating orange juice and milk from his diet
reduced the drooling.
12. One nurse found she could get a disinterested client to eat
by singing to her, just as her mother probably had done.
13. Clients who bruise easily from hitting the bed rails should have padding
put around the rails. Temperature-controlled water mattresses or
alternating pressure mattresses work well for some.


14. Alzheimers Disease clients lose the capacity to judge temperature
early in the disease. Bath water temperature should be adjusted for
them so it's never too hot or cold. Hand-held shower nozzles are better
than showers. Never fill a tub too deep.
15. Many clients are confused or upset by mirrors-they don't recognize
themselves or feel they are being watched or followed. One man
looked into a mirror and said, "Oh no, there's two of me!" Some clients,
however, enjoy mirrors. Some enjoy the "companionship" of the image
and talk into the mirror about everything.
16. Dressing: lay out clothes and hand her each item in order as it should
be put on. Jogging suits are comfortable and don't require buttons.
Outfits which fasten in the back with velcro may be easier for
incontinent bed clients. Tennis shoes for mobile incontinent clients are
easier to keep clean. Always keep toilet articles in the same place if the
client is to participate in self-care. Don't leave razors, scissors or
potentially dangerous items in clients' rooms.
17. A high protein, high carbohydrate finger food diet may be best for
restless, hyperactive Alzheimers Disease clients. Some clients forget
to swallow, and others lose the ability to swallow. It helps to remind the
client to swallow. Use thicker liquids and semi-soft foods if swallowing
difficulty persists. Suction cups and plates, and non-skid materials
placed under plates, help clients with motor problems to eat. Flexible
drinking straws are also helpful.
18. Be discreet about providing personal care in front of visiting family or
children. Don't undress or expose a client without asking visitors to
leave. Some younger visitors find catheters and feeding tube stomas
very traumatic.
19. Seizures occur in many clients with Alzheimers Disease. Stay with the
client and let it run its course. Stay calm-don't restrain or revive her. If
she's seated, ease her to the floor until the movement stops. Don't
force open her mouth if her jaw is clenched, but make sure she has an
airway. Loosen clothing. Let her sleep after it's over. Reassure her if
she's confused afterwards.


Cognitive Disorders Book Resources

Perspectives from Individuals with Dementia

Alzheimer's from the Inside Out by Richard Taylor (2006) - Written by a
psychologist who was diagnosed with Alzheimer's disease at the age of
58.

Living in the Labyrinth: A Personal Journey Through the Maze of
Alzheimer's by Diana McGowin (1994) - Written by a woman diagnosed
with Alzheimer's disease who tracks her decline in a journal format.

My Journey Into Alzheimer's Disease by Robert Davis (1989) - Written by
a minister diagnosed with Alzheimer's, this book explores the disease from
a religious perspective.

Speaking Our Minds: Personal Reflections from Individuals with
Alzheimer's by Lisa Snyder (2000) - A collection of narratives based on
interviews and conversations with people who have Alzheimer's disease.

About Caregiving

Learning to Speak Alzheimer's: A Groundbreaking Approach for Everyone
Dealing with the Disease by Joanne Koenig Coste (2004) - Offers a
practical approach to enhancing the well-being of both individuals with
dementia and their caregivers.

The 36-Hour Day: A Family Guide to Caring for People with Alzheimer
Disease, Other Dementias, and Memory Loss in Later Life (4th Edition) by
Nancy L. Mace, MA, and Peter V. Rabins, MD, MPH (2006) - Considered
one of the best and most comprehensive books for family members caring
for a relative with Alzheimer's disease or a related dementia.

There's Still a Person in There: The Complete Guide to Treating and
Coping with Alzheimer's by Michael Castleman, Matthew Naythons, and
Dolores Gallagher-Thompson (2000) - Uses case studies to explain how
Alzheimer's disease affects thinking and behaviour, and how different
strategies can help caregivers and individuals with Alzheimer's cope with
the disease.


Appendix 1: Excerpts from Dealing
with Incontinence
Speaker: Carol A. Brink, R.N., M.P.H., Assistant Professor, University of
Michigan School of Nursing and member of the Continence Clinic Team.
When incontinence develops, in either normal adults or Alzheimer's clients,
urinary problems generally occur prior to bowel problems. Of course a
doctor should be consulted to be sure that any disease is diagnosed and
treated. But more persistent problems must be managed. This involves
looking at the pattern of urination or bowel movements and then antici-
pating when the next urination or bowel movement will occur. The
incontinent person is put on the toilet shortly before the anticipated
incontinent release and left there until he produces. Such a practice results
in a greatly reduced number of incontinent episodes. This process is called
habit training.
Because of normal changes in the kidney due to aging, all of us urinate
more frequently as we get older. In fact, one of the causes of wandering
during the night by Alzheimer/dementia clients may be a need to get to the
bathroom.
There are several common impediments to urine control which are found in
normal people as well as in Alzheimer's clients:
1) Urinary Tract Infections
These are more common in women than in men until the 70s, when the
incidence becomes equal. Infections frequently result in a loss of control. If
a client starts to lose urinary control, particularly in the early stages of
Alzheimers Disease, he or she should be checked by a doctor for such an
infection.
2) Faecal Impaction (Constipation)
Here loss of control occurs because of pinching off of the urinary outlet by
the constipation. As a safeguard to keep the bladder from bursting, the
body releases urine in trickles and spurts.
3) Dehydration
Insufficient intake of fluids results in urine that is too concentrated, causing
irritation of the bladder and resulting in control problems. It is helpful to
keep track of both the fluid intake and urinary output of the client for 24
hours, recording times and volumes of fluid consumed. Fluid should be
distributed throughout the morning, afternoon, and early evening until two
hours before bedtime. Everyone needs a minimum of (6 cups) of liquid
over a 24-hour period. As much as 2 litres of liquid daily is recommended.
Fluids should always be given when a client is thirsty. In fact, his request-
ing fluids is a good sign because the thirst mechanism does not always
function very well in older people. It is very important to be sure that
Alzheimer's clients consume enough liquids. Do not reduce overall liquid
consumption in an attempt to increase bladder control. You will only be
irritating the bladder. One aspect of Alzheimers Disease is that the client
puts out as much urine during the night as during the day. This problem
increases as the disease progresses.


4) Diurising Fluids (fluids having a diuretic effect)
Such fluids include coffee, tea, colas, cocoa, beer, etc. Caffeine is a
natural diuretic. Switch to herbal teas and decaffeinated coffee. Volume of
liquid, of course, is also relevant.
5) Drugs
Any drug can affect control of urine, especially tranquilizers, hypnotics, and
sedatives. These are often given to facilitate sleep or calm behaviour, but
also reduce a person's sensitivity to his body's sensations.
6) Acute Illness
Incontinence is often a symptom of acute infection.
7) Chronic Illness that Is Out of Control
Diabetes and heart failure that are out of control result in incontinence. The
client needs to see a doctor immediately.
8) Prostate Problems in Men
These are a source of incontinence in men. Consult a doctor.
Established incontinence, as found in Alzheimers Disease clients, requires
a thorough evaluation by a health professional. Dementia clients can't plan
ahead and so can't empty their bladders preventively without assistance.
They also forget where the toilet is or have too little warning before their
bladders empty and so can't make it to a bathroom that is too far away. (In
this case, a commode kept close to the client may help.) The restraints or
padding used with clients in nursing homes may also give clients the
message to not control themselves. Alzheimers Disease also results in
degenerative neurological changes that result in the voiding of urine.
Moreover, these clients have an increased vulnerability to urinary tract
infections, which should be treated medically.
In managing incontinence, it is important to first become aware of the
bladder pattern of the individual by writing down the time and amount of
voidings and all liquid consumption over a several-day period. A metal
measuring hat with a scale on it may be put under a toilet seat to collect
urine. If the client is wearing diapers or incontinence pants, the time of
pad/diaper changes and the gross saturation of them should be recorded
(e.g., fully saturated, leaking, damp, outer pants wet, running down leg,
pooling on floor, etc.)
A habit retraining technique used by some facilities involve three phases:
1) Drink adequate amounts of fluids.
Be sure the dementia client is drinking at least six cups of fluid daily. He
cannot be counted on to do this of his own accord, because the thirst
mechanism may be affected by the disease. Both clients and care takers
may cut down on fluids in the mistaken belief that this will reduce
incontinence. It won't. In fact, because the urine is more concentrated, it
irritates the bladder, resulting in increased incontinence. Degenerative
neurological changes in advanced Alzheimers Disease cause the client to
urinate as much during the night as during the day. The result is small
irritable bladder demands, and urination occurs with little warning.


2) Observe the pattern of liquid consumption and urination, as
suggested above.
3) Adjust your behaviour to fit the voiding pattern of the client.
Preventative toileting is the method. Toilet the person just before their
expected time, and make sure they go before they get off the toilet. A
special raised toilet seat and an arm rest for the toilet can help. So can a
chair-style commode with the top left off so that the client can see clearly
that it is a toilet. It should be placed as close to the bed as possible to cut
down on the distance to the toilet.
When using a public rest room, you might ask a person of the same sex to
go in with the client. Another option is to get someone else to stand at the
door of the rest room while you assist the client. Early Alzheimer's clients
can manage for themselves. In fact, the factors contributing to
incontinence in early-stage clients should be examined carefully, because
incontinence generally is not a problem until later in the disease process.
In picking a nursing home, notice how incontinence is managed. Ask
specific questions: What is their rate of incontinence? (Half the people in
nursing homes have urinary incontinence.) What percentage of clients are
on catheters? (Should be minimal.) What percentage have bed sores?
(Not a good sign.) What percentage are on air mattresses? (These help
prevent bed sores.) How does the home look and smell? (A strong urine
smell isn't good.) Also notice the clients' skin. Moist skin and mouths
indicate clients are getting enough liquids.

Aids for Managing Incontinence:

1) Urinals
These are available for both men and women. For men there is a spill-
proof urinal which a man can keep in bed with him.
2) Bed Pads
The Kylie bed pad, manufactured in Douglasville, Penn., and designed in
Australia, is washable. It has a wicking action so that the top stays dry, as
long as it has to hold less than 300cc. (The average adult bladder holds
about 1800cc.) Must be ordered from manufacturer. Disposable bed pads
are widely available locally.
3) Diapers
Sold by hip and/or waist size. Must be changed with every major excretion.
Washable diapers with snapping plastic outer layer. Disposable diapers-
Expensive! Depend-Kimberly Clark. Widely available. Copy cats also avail-
able. Urinary incontinence or drip problems only. Attends Proctor and
Gamble. Have gathered fitted elastic leg. These are best for clients in bed
and for the doubly incontinent (both urinary and faecal). Sold individually or
in lots. Very expensive.
4) Washable Pants and Disposable Pads
Pants are about $14 each, plus pads. Before you go shopping, measure
the client's hips and waist. Good for urinary incontinence only. Pads must


be changed with each major excretion. Dignity pant-Can be ordered. Have
internal pouch for pad. Male and female styles. Kanga pant-Male and
female styles. Men's has side fly. Men are often willing to use women's
style pants, but women buyers often prefer the side fly, as do some men
who are in the early stages of Alzheimers Disease. The pad goes in a
pouch that is on the outside of the wicking pant, making the pad easier to
change. Tranquillity Brief-Velcro holds inner pad in place. The tranquillity
pad is the only flushable pad available. You must remove the sleeve from
the pad and wait three minutes for the pad to dissolve before you can flush
it. These are OK even for septic systems, but too complicated for dementia
clients to handle themselves. Kotex maxi-thins and other pad designed for
menstrual flow -These may be used with drip incontinence clients and are
much cheaper than any of the other pant and pad systems. Pin pad to
pants.
5) External Collecting Devices for Urine
None are available for women who have urinary incontinence. Texas
catheter (Slips over the penis like a condom and connects to a bag
strapped to the leg.) Most men don't like them and prefer a pad-pant
combination instead. Hollister Faecal Bag-Glues to cleanly shaven anus.
Looks like a plastic baggie.
6) Diaper Rash Products
There are special products, often creams which act as both soaps and skin
conditioners. Many companies make them. Ask the pharmacist for a cream
for adult diaper rash. Wicking pad and pants cut down on the need for
these creams, which are expensive.
HINT: It's possible to shop for these products by phone at medical supply
houses and drug stores. The disposable products are all quite expensive,
but so are the washable ones. Prices vary considerably from store to store.
In most cases you will want to try out a product before spending a fortune
on it. Product lines may vary over time. Request these products from your
local druggist and tell him your experience with them. User comments:
With severe incontinence, no products are as adequate as consumers
would like, in part because adults excrete such large volumes. Still, many
improvements have been made in the last couple of years, and more are
likely as the market for such products increases.

CHCAC319A Provide Support To People Living With Dementia WBK

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

CHCAC319A Provide Support To People Living With Dementia WBK

Uploaded by

Copyright:

Available Formats

C

You might also like