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Dementia Caregiving Advice

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					Copyright © Dementia Caregiving Advice 2007

Copyright © 2007 Dementia Caregiving Advice All rights reserved worldwide. No part of this e-book may be copied or sold. Please note – this is not a free book. If you have received the e-book for free, please let me know!

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Introduction
If you’ve recently had a loved one diagnosed with dementia then you’ll probably be wondering just what to expect. The FAQ section addresses many of the most common questions that caregivers of dementia sufferers ask. Others of you will have been struggling to care for a dementia sufferer for some time and will have experienced many of the problems addressed in this book, but without knowing how to effectively deal with them. The main purpose of this book is to help show you ways to cope with your loved one when they’re being particularly challenging in their behaviour. By showing you how to use these coping strategies and techniques – life will become much easier for you and your loved one. As you read this book, it’s important to remember that dementia will affect people differently. Some things are common to most dementia sufferers (such as the forgetfulness!) but other symptoms will vary from one person to the next. A dementia sufferer may become very difficult to live with or they may become more sweet-natured and agreeable – a lot depends on their original disposition! Remember, that not every method will work in your situation – that’s why you need to try out all the methods and find out what works best for you. Each chapter is summarised with a check-list of the methods discussed to make it easier for you to see them at a glance. I hope that this book will provide answers to your questions, and prove to be an essential guide to you as you care for your loved one. If there’s anything

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that hasn’t been covered but you think would be useful – please let me know. Caring for a loved one with dementia can be very difficult – but it can also be incredibly rewarding. Make sure you read the additional e-books that explain how to take care of yourself (and why you must!) and how to plan enjoyable activities for your loved one, so that you can both enjoy the time you spend together.

Best wishes

Anna Taylor (MSc) P.S If you have any suggestions or comments to make please I’d love to hear from you – please email me.

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INTRODUCTION .............................................................................................2 (1) FREQUENTLY ASKED QUESTIONS........................................................6
1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 What is dementia?...............................................................................................................6 What are the different types of dementia? .........................................................................6 What causes dementia?.......................................................................................................7 Who is at risk? ....................................................................................................................9 Is dementia preventable? .................................................................................................. 10 How is dementia diagnosed?............................................................................................. 11 What are the stages of dementia? ..................................................................................... 11 How is dementia treated?.................................................................................................. 13 Are alternative treatments available?............................................................................... 14 Do mental exercises help? ................................................................................................. 15 Is it safe to drive with Dementia? ..................................................................................... 16 My aunt refuses to take showers - what should I do?....................................................... 17 What are the care options? ............................................................................................... 18 How do we find out about taking part in Dementia Trials?............................................. 19

(2) COPING WITH FORGETFULNESS/CONFUSION ..................................20
2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 Getting Support ................................................................................................................ 21 What to do in the early stages of dementia............................................................... 22 Useful Organizational Tips ........................................................................................... 23 Keeping their long-term memory ................................................................................ 24 Repetitive Stories and Questions ...................................................................................... 25 Reality and Validation Therapy ....................................................................................... 26 Providing Reassurance...................................................................................................... 27 Coping with Forgetfulness/Confusion Check-List............................................................ 28

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(3)
3.1 3.2 3.3 3.4 3.5

COPING WITH WANDERING ............................................................29
Keeping Track of Wanderers ........................................................................................... 29 Have a Plan ....................................................................................................................... 30 Why are they wandering?................................................................................................. 31 Preventing Wandering...................................................................................................... 31 Coping with Wandering Checklist.................................................................................... 33

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COPING WITH ANGER AND AGGRESSION ....................................34

4.1 What causes anger and aggression? ......................................................................... 35 4.1.1 People ............................................................................................................................ 35 4.1.2 Physical problems .......................................................................................................... 37 4.1.3 Environment................................................................................................................... 38 4.2 4.3 Additional Tips for Dealing with Anger and Aggression ........................................ 38 Coping with Anger/Aggression Checklist ................................................................. 40

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5.1 5.2 5.3 5.4 5.5

COPING WITH HALLUCINATIONS ...................................................41
Provide Reassurance .................................................................................................... 42 Causes of Hallucinations................................................................................................... 42 Preventing Hallucinations ............................................................................................ 43 Delusional Behavior .......................................................................................................... 43 Coping with Hallucinations Checklist ........................................................................ 44

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6.1 6.2 6.3

COPING WITH ANXIETY ...................................................................45
Keep a Journal .................................................................................................................. 45 Reducing Anxiety.............................................................................................................. 46 Coping with Anxiety Checklist ......................................................................................... 49

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7.1 7.2

COPING WITH INCONTINENCE AND SEXUALITY ..........................50
Incontinence and how to deal with it ................................................................................ 50 Sexuality and how to deal with it ...................................................................................... 51

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USEFUL LINKS ..................................................................................52

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(1) Frequently Asked Questions

1.1

What is dementia?

Dementia is caused by the destruction of brain cells from ageing, illness or injury. It is commonly associated with aging, although it can affect adults of all ages. The first sign is usually memory loss, although not all memory loss is an indication of dementia. A person with dementia might forget where he lives or how to put away the groceries. Over time, dementia affects a person’s ability to reason, communicate and focus. It can cause their personality to change.

1.2

What are the different types of dementia?

Alzheimer’s is the best-known and most common type of dementia – it accounts for about half of all cases. Over time, people with Alzheimer’s lose their memory and their ability to speak or understand language. They cannot make decisions or solve problems. They don’t recognize friends or family. They don’t know their own name or know where they are. Vascular dementia is the result of small strokes that cause bleeding in the brain. The bleeding damages that area of the brain. If the bleeding occurs in the language area of the brain, for instance, the speech will be affected. The damage is not always reversible but if the cause of the strokes is treated, then further bleeding can be stopped. This type of dementia is the second most common type (around 20% of dementia patients suffer from vascular dementia).

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Dementia with Lewy bodies is similar to Alzheimer’s. It gets its name from abnormal collections of protein (Lewy bodies) which occur in the nerve cells of the brain. But unlike Alzheimer’s, it includes elements of Parkinson’s disease such as muscle rigor, trembling, shuffling gait and slurred speech. Hallucinations may also be experienced.

Pick’s Disease is the rarest form of dementia and causes personality and behavior changes. It is caused by degeneration in the front temporal lobe of the brain that controls judgment and social behavior. This type of dementia can occur in people in their 40s.

1.3

What causes dementia?

All dementia is caused by damage in the brain. Sometimes the damage is reversible, sometimes not. It is important not to jump to conclusions. Memory loss or some other symptom of dementia could be caused by something minor and treatable. You should always consult a knowledgeable physician. Alzheimer’s and Lewy body dementias are caused by areas of protein that develop in the brain. The clumps of protein – called plaques and tangles -scramble the messages sent in the brain. Researchers aren’t sure what causes the proteins to develop, but they suspect inflammation is partly responsible. Vascular dementia is caused by strokes that produce bleeding in the brain. Treating the underlying cause can stop further damage.

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Certain lifestyle choices can cause dementia, too. Poor diet, smoking, excessive drinking, not exercising, can all adversely affect brain health. Recent studies have found that being a smoker increases your risk of dementia by 50% - another great reason to give it up! Something as simple as dehydration can affect mental function. Severe head trauma such as is seen in boxers can also result in dementia. Researchers are now seeing a link between head trauma and the onset of dementia years later. Reactions to medications, especially in older people with slower liver function, can also cause dementia. Dementia from these causes can usually be reversed by lifestyle changes. Several research studies have suggested a possible link between aluminium and Alzheimer’s disease and some research suggest that people living in an area where there is a high concentration of aluminium in the water supply may be more likely to develop Alzheimer’s – but this evidence is not conclusive. Using deodorants or drinking tea, where there is low exposure to aluminium has not been linked to an increased risk of Alzheimer’s disease. Exposure to mercury (e.g. in dental fillings) is also unproven to cause Alzheimer’s although mercury can be toxic to the central nervous system.

A variety of diseases can be accompanied by dementia: 1 Sexually transmitted diseases like syphilis and AIDS 2 Pellagra, a lack of niacin or B-3 3 Pernicious anaemia, a lack of B-12 4 Hypoglycaemia, caused by lack of sugar in the bloodstream 5 Hypothyroidism, decreased thyroid function 6 Severe brain infections like meningitis and encephalitis

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7 Creutzfeldt-Jakob disease, a brain infection 8 Huntington’s, a hereditary brain disease 9 Parkinson’s 10 Down’s syndrome It’s interesting that in countries like India and China, people are less than half as likely as people in western countries to suffer from Alzheimer’s. This is a clear sign that the difference is to do with diet, lifestyle or other environmental factors. It’s unlikely to be due to the difference in genetics, as people emigrating from these countries to western regions, soon catch up in terms of a greater risk of dementia. In other words – there’s a lot that you can do to reduce the likelihood of developing dementia!

1.4

Who is at risk?

Dementia can occur at any age, although it is typically a disease of old age. Almost half of people over 85 suffer from Alzheimer’s, but only about 5% of people between 65 and 74 are diagnosed with it. A person with a parent or sibling with Alzheimer’s has a higher risk of developing it. Early onset dementia that occurs at midlife is believed to be hereditary. Women are more likely than men to have Alzheimer’s, possibly because they live longer. Researchers also think women who take hormone replacement therapy after age 65 increase their risk for dementia.

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Researchers are finding that people who chronically use antacids such as Tagamet, Pepcid and Zantac have 2 ½ times the normal risk for Alzheimer’s. In addition to acting on stomach acid, the drugs also inhibit the brain’s cholinergic system, which is involved in memory and cognition. Education levels also seem to be an indicator. Research has found that people with lower levels of education are at greater risk. The theory is that mental stimulation may be a preventive. Relationships have also been found between the development of Alzheimer’s and disturbances in insulin and glucose metabolism. This may explain why people with diabetes have a much higher risk of developing Alzheimer’s disease.

1.5

Is dementia preventable?

There’s is no proven way to prevent dementia such as Alzheimer’s but keeping to a healthy diet and staying physically and mentally active seems to reduce the risk. Mental fitness is particularly important. Solving puzzles and engaging in hobbies are recommended as ways to exercise the brain. Studies show that the use of anti-inflammatory drugs such as ibuprofen (Motrin and Advil), naproxen sodium (Aleve) and indomethacin (Indocin) may reduce the risk. But they should be used with caution because they can cause gastrointestinal bleeding. Statin drugs like atorvastatin (Lipitor), rosuvastatin (Crestor) and simvastatin (Zocor) that are used to treat high cholesterol may also reduce the risk, but researchers are not sure how.

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Another drug, raloxifene (Evista), that is used to treat osteoporosis seems also to reduce mild cognitive impairment, a memory disorder that precedes Alzheimer’s.

1.6

How is dementia diagnosed?

There is no simple test for dementia. A physician will make the diagnosis by a process of elimination. The doctor will take a thorough medical history and do a physical exam that includes testing the blood and urine. He/she is looking for other conditions or possibly drug interactions that could be causing the problems. The doctor will interview the patient, asking them to solve problems and make simple calculations. The patient also will be tested for vision-motor coordination. The doctor may order a brain scan to rule out tumors or blood clots.

1.7

What are the stages of dementia?

Dementia is a progressive disease in all of its forms. How quickly it progresses, however, depends on the overall health of the patient. Symptoms may fluctuate. Patients often are more alert early in the day and fade later in the day, something called “sundowning”. It begins with mild cognitive impairment that may only be noticeable to the patient such as forgetting names or misplacing items such as glasses or keys. But the patient will then have difficulty in conversations often repeating themselves or forgetting something they’ve just heard. They may

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have trouble with organization and planning. These problems will be evident to family and friends. With moderate cognitive impairment, the patient has trouble remembering recent events, paying bills or remembering personal history. They may seem subdued or withdrawn. In the later part of this phase, the patient may be unable to remember their address or phone number, or be confused about the date. It’s usually at this stage, when the patient may need to stop driving. With severe cognitive impairment, personality changes may occur. They may become suspicious, combative or delusional. The patient may need help with routine daily activities, including personal hygiene. They may forget the name of their caregiver and dress inappropriately. And they may wander. In the final stage, the patient loses touch with their environment. They no longer answer to their name or converse. They need help with eating, dressing and personal hygiene. Eventually they will lose their ability to control their movements such as walking and swallowing. They may experience muscle rigidity. On average, someone with dementia will live between 7 and 14 years from when the symptoms start showing, although this can vary quite considerably depending on the person involved. Dementia, although a life-shortening disease, is not usually the cause of death itself.

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1.8

How is dementia treated?

Dementia is not curable but more and more drugs are coming on the market that can delay cognitive impairment. Two types of drugs are commonly prescribed. Cholinesterase inhibitors (Aricept, Exelon and Razadyne) prevent the breakdown of acetylcholine, a neurotransmitter that is essential to memory and thought processes. These drugs are used to treat mild and moderate Alzheimer’s and can delay the progression of the disease up to a year. Only about half the people who have tried the drug have benefited. The other drug, memantine (Namenda), regulates glutamate, a different neurotransmitter. It is prescribed for patients with moderate to severe Alzheimer’s. It also delays the disease’s progression in some patients. Other symptoms such as restlessness, combativeness, hallucinations and delusions can be treated with behavior modification as well as medication. Caregivers need to be alert to things that trigger behavioral problems, such as a change in environment. The patient may be responding to an awareness of their diminishing abilities, or attempting to communicate some need. Patients should be checked for injuries, illness, drug interactions or side effects. Dementia also can change sleep patterns, which can affect mood. A variety of anti-depressant, anti-anxiety and anti-psychotic drugs are available.

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1.9

Are alternative treatments available?

A number of nutritional supplements are sometimes used to reduce dementia symptoms. Research on their effectiveness is limited and claims are mostly anecdotal. Some may have side effects or interfere with prescription medications. The manufacturing of these products is not regulated and so their quality and purity can vary widely. Before trying any of these products, research the product and manufacturers. You should also consult a Physician as some vitamins/herbal medication may interfere with prescribed drugs. Vitamin E is sometimes prescribed because it is an antioxidant. It may help delay mental decline. However, in high doses, Vitamin E can interfere with medications including blood-clotting drugs. Another antioxidant, Coenzyme Q10, or ubiquinone, sometimes is used to treat dementia. It occurs naturally in the body, but little is known about effective dosages or side effects. Turmeric, the bright yellow seasoning in curries, also has shown to have antioxidant properties. Studies in rats have found that turmeric stimulates an enzyme called hemeoxygenase to act as a defense mechanism against free radicals, which are believed to be a factor in dementia. The herb ginkgo biloba has been used for centuries by the Chinese to treat memory problems. It has antioxidant and anti-inflammatory properties. Research has found that it can help with cognition and behavior, but it also can reduce the blood’s ability to clot. There is a lot of evidence that suggests ginkgo can help to reverse some of the memory difficulties of

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people with dementia – check with your Doctor before taking to make sure it doesn’t interfere with any other medication. Another Chinese herb huperzine A has properties similar to cholinesterase inhibitors and is being tested in clinical trials. It has shown to be effective in small studies, but it is not known how it reacts with medications. Omega-3 fatty acids are believed to reduce the risk of heart attack and stroke. Omega-3 also is shown to protect nerves and elevate mood. These fatty acids are found in fish and plants such as flax. The U.S. Food and Drug Administration recommends that no more than 3 grams be consumed. Since fish often are contaminated with mercury and other toxins, it is important to use pharmaceutical grade oil. Phosphatidylserine is a type of lipid that makes up the membranes around nerve cells. Since these membranes deteriorate in dementia, it is believed that phosphatidylserine may help slow the progression of the disease. However, little official research has been done. B vitamins are vital for mental health and a deficiency in any of these will rapidly affect how someone thinks and feels. Because B vitamins are water soluble you need to make sure you get a daily intake, either from food or taking vitamin supplements.

1.10 Do mental exercises help?
All kinds of exercise help the brain – physical, mental and social. It’s a case of use it or lose it. Several studies have found that physically exercising at least twice a week can reduce the risk of developing dementia by between 40 and 60 percent.

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Researchers recommend a 20-minute walk twice a day as a way to increase blood flow to the brain. Mental exercises such as solving puzzles or pursuing hobbies help stimulate the brain. It’s probably best to stick to familiar activities like crosswords and jigsaw puzzles. People with dementia find it harder to learn new things and if they’re not used to puzzles like Sudoku, may find it difficult to master! Cognitive Stimulation Therapy (CST) has been shown to have a positive effect on dementia sufferers. CST consists of activities like word games, reality orientation and other information processing activities. It's been shown to improve cognitive ability and quality of life for participants. Contact your local support group or speak to your physician about whether this is available in your area. Social interaction also is valuable. It stimulates the brain and improves emotional health. Having friends and family visit or phone on a regular basis is a good way of ensuring the dementia patient gets adequate social contact. And, finally, good nutrition is important. A diet with lots of fresh fruits and vegetables is good for the whole body.

1.11 Is it safe to drive with Dementia?
Because Alzheimer’s and other dementias affect judgment and memory, patients should not drive after the symptoms become persistent. Memory-impaired patients often get lost in familiar territory, forget traffic rules and drive erratically. This may be one of the early indicators of a

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cognition problem. An undiagnosed dementia patient may realize they are having problems when they are unable to find their way home. This might only happen occasionally at first, and the patient may try to hide it from family. Surrendering driving privileges may be difficult for some, as it represents a loss of independence. It should be handled with sensitivity.

1.12 My aunt refuses to take showers - what should I do?
As dementia progresses, it's not unusual for sufferers to lose interest in keeping clean and tidy - personal hygiene becomes less important to them. Using showers rather than baths is likely to be much easier for you as the caregiver - because there’s less manual lifting involved. Provided you have a non-slip mat and ideally safety rails to hold on - then this should be the easiest way to keep your loved one clean. Alternatively a sponge bath may be adequate. Unfortunately, shower times can become something of a battle of wills. If you find yourself constantly getting into arguments then try doing things differently. Experiment with different times, it could be that having the shower in the early morning, works better than at night, or vice-versa. Avoid having your loved one stand round for ages while you get the shower to the right temperature and make sure you have a bath robe or similar for them to wear right up until they get in the shower to prevent them getting cold or feeling uncomfortable.

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Finally, if they are becoming anxious, try distracting them by talking about other things so that their focus changes and they become calmer and more amenable. Using humor and staying cheerful may also help.

1.13 What are the care options?
Dementia is a progressive disease and the types of care required will change as the disease changes. Many families try to care for their loved one at home, which can be very challenging. In the early stage of the disease, the patient will have lucid times and confused times. A familiar face often is reassuring. But homecare requires a support network of family and friends to provide respite for the caregiver. Some visiting nurse agencies now provide nursing and personal care services for dementia patients. Assisted living facilities are becoming a popular choice. Many of these facilities offer several levels of care so the patient’s needs can be addressed in one place. Often the spouse can live at the facility with the patient and can participate in their care without bearing the full brunt of it. These facilities provide food, laundry, maid, personal hygiene and nursing services. Many of them cater to Alzheimer’s patients and offer recreation and other stimulating activities. Nursing homes often become necessary in the late stage of the disease as the patient loses the ability to care for themselves or communicate with others.

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1.14 How do we find out about taking part in Dementia Trials?
New drugs are constantly being developed but before they can be released they have to undergo clinical trials. Unfortunately, there’s no guarantee that the drug will improve the patient’s condition, they may be given a placebo or the drug may not work. However, volunteering to take part in one of these trials can be beneficial for the patient as well as the company. The dementia sufferer will receive a high level of care throughout and it can be very educational. You also have the added benefit of knowing that you’re contributing to this important area of research. To find out about dementia trials in your area, if you're in the US, visit the Alzheimer’s Association website (www.alz.org), where you can check the Clinical Trials index to see what’s available. Also, visit www.clinicaltrials.gov for information on relevant trials. Alternatively, you can speak to your Physician for more information about any local trials. In countries other than the US, you should contact your local Alzheimer's Association or ask your Doctor about taking part in trials.

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(2) Coping with Forgetfulness/Confusion
Everyone over 40 has had a “senior moment.” That little bit of information that just won’t come when called. It’s aggravating, and when it happens often enough, it can be unnerving. Hiding our weaknesses is part of our instinct for survival. And the patient often hides the earliest stage of dementia from family and friends. It’s as if admitting something is wrong means a loss of independence. The advantage of an early diagnosis of dementia is that the patient and caregiver can talk about the changes ahead and make plans.

Wayne was a healthy, active 80-year-old. He lived alone in an apartment complex of active elderly residents. He bowled twice a week and dabbled in real estate. He was divorced and none of his three children lived within 1,000 miles of him. They talked by phone but rarely visited. He was able to hide the problems he was experiencing with his memory. No one noticed that he couldn’t remember how to put away the groceries: the frozen foods in the cabinets, the canned goods in the freezer, the beer under the bathroom sink.

Only the telephone operator knew about the calls he tried to place to his sister in Canada. He couldn’t figure out which of the jumble of numbers in the address book was her phone number. He tried repeatedly to call her and finally gave up. When he began acting out, the neighbors noticed. They found him wandering around complaining that he was locked out of his apartment. He was holding his keys but he wasn’t sure what to do with them. He asked them for money, saying he didn’t have

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any. But when a neighbor searched his pockets they found thousands of dollars.

A neighbor called the children. When they arrived, they found their father’s apartment in shambles. And a huge box by the front door was filled with financial documents, many of them torn into little pieces. It took months to piece together the details of their father’s finances, track down insurance policies, his will and property records. In the meantime, their father had been admitted to a hospital where he had been diagnosed with late-stage Alzheimer’s.

Wayne had needlessly gone through the first phases of Alzheimer’s alone, without the support of family, physicians or community services.

2.1

Getting Support

The early phases when forgetfulness and confusion are the primary issues can be managed in a partnership with the patient and caregiver. This is when valuable bonds of trust can be established with family, physicians and friends.

Many of the anxieties that occur when the patient is aware that something awful is happening can be allayed when they realize they are surrounded by people who will take care of them when they can no longer care for themselves.

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It is important that while the patient still has good days that there is candid conversation among the patient, family and caregivers. This is uncharted territory for everyone and it’s important to share feelings and fears. Try keeping a journal, joining a support group or seeking counseling. The Internet can be a good source of message boards and chat rooms with others who are going through the same thing.

Al had been a Presbyterian minister for 40 years. After he retired from his church, he stayed on as pastor emeritus with an active role in the church. When he was diagnosed with Alzheimer’s, Al announced it from the pulpit. Al was an outgoing man who loved to talk with people.

As his memory faded, he explained his situation by saying, “I no longer remember your name. Tell me how we know each other.” He relied on his wife, who he now called his “memory of 50 years.” During the next few years as Al declined, the congregation rallied, providing the couple with home repairs, respite for Al’s wife and companionship for them both.

2.2

What to do in the early stages of dementia

Candid conversations on a variety of subjects are important in the early phases. Sit down with family, close friends and a trusted financial adviser to talk about the financial situation.

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Set up direct deposit of checks and direct payment of bills, and make sure someone is double-checking that nothing falls through the cracks. Consider establishing a joint bank account. Check insurance policies so that everyone knows what medical and longterm care options are available. Consult with a lawyer about power of attorney, guardianships and other legal avenues for caregivers. This also is a good time to update wills and living wills to make wishes known about end of life care. Let people around you know what is happening. A neighbor, the mailman or the gardener can be alert to problems. And get acquainted with services available in your community such as respite care and adult day care. Write it down - in the early phases of dementia, it can be helpful to post a daily schedule, including meals and medication times, to help the patient keep track of their day. You could use an erasable white board placed somewhere prominent, such as the kitchen.

Be aware that early on the patient wants to stay as independent as possible and may become hostile or sullen if they feel people are trying to take over their life. Make sure you allow them to be as independent as possible.

2.3

Useful Organizational Tips

Frequent reminders about upcoming doctor appointments or family visits may be needed. A pill organizer that includes a medication schedule can help the patient feel independent. But the caregiver should stay alert and ready for the time that

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they take over administering medication. At the point all medication in the house should be locked away to avoid overdoses or inappropriate use.

If your loved one frequently forgets telephone numbers, you may want to purchase a phone with large buttons. Set up each of the numbers for speeddials and then on each of the buttons you could fix a sticker with a name or photo of the person it dials. The number for a doctor could be an ambulance for example. Make sure that when you give a task, you make it easy to understand and remember, by breaking the task down into small concrete steps. For example, simply asking your loved one to do the laundry is unlikely to meet with much luck. A better way would be to ask them to put the laundry in the wash, followed by asking them to hang it out when it was dry (or put in the dryer), followed by a request for it to be ironed, and finally folded.

Another thing that can help is having visits and phone calls from friends and relatives scheduled at a particular time, rather than on a sporadic basis. Remember also that overly long conversations may end up becoming confusing – if possible ask callers to talk over past events that your loved one is more likely to remember. If it’s a phone call from a relative, you could show your loved one a photograph of them so that they can put a face to the name.

2.4

Keeping their long-term memory

Being surrounded by familiar possessions can be a comforting thing early on but later as cognition begins to decline, too many objects can be confusing. There will come a time when the patient’s environment needs to be simplified. A few family photos, labelled with names, can help stimulate the memory. But a treasured collection of porcelain figurines should probably be

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put out of harm’s way. Throw rugs and electrical wires should be eliminated from frequently travelled areas. Use what’s known as “Reminiscence therapy”. This is where you help to stimulate your loved one’s long term memory by showing them pictures, or objects from the past. Or talk to them about past events. Additionally, you could use music, videotapes etc. You’ll find when it comes to talking about their younger days; most dementia patients’ memories are as good as ours! Rather than starting your loved one on new hobbies or tasks, try to stick to familiar tasks that they can do almost automatically – without having to think about it. This could be things like; folding laundry, making beds, setting out cutlery, gardening, washing and drying plates and the like. This makes it more likely that they’ll be able to remember what to do and in carrying out the task successfully, they’ll feel satisfied that they’re being useful.

2.5

Repetitive Stories and Questions

Allow the person to re-tell stories even if he repeats the same story over and over again – so that you feel like screaming after hearing it for what feels like the 100th time! Unfortunately, there’s no way round this – If you say anything you risk hurting your loved one’s feelings – just smile and nod.

In the case of repetitive questions, ensure that you answer the question initially. Then if possible, ignore the questions and try to redirect the conversation to something new. Obviously, if your loved one gets upset, then reassure him and answer his question, but you should then continue trying to redirect his attention through conversation or by giving him a task to do. Realize that they are usually repeating the question because they

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aren’t able to process the information, or possibly because they need reassurance.

2.6

Reality and Validation Therapy

Reality Therapy can be used when your loved one is in the early stages of dementia. This basically means frequently referring to the date, time or other things likely to be forgotten by your loved one throughout the day. Saying something like “It’s Friday, so we go the cinema today” would be an example. However, as the dementia progresses and your loved one increasingly loses all sense of time and memory, you should replace reality therapy with what’s known as “validation therapy”. This techniques consists of “validating” your loved ones feelings, beliefs etc, even though they may be inaccurate or completely wrong. So, for example, if your loved one tells you that they are going to see their sister that afternoon (even though they don’t have a sister!) don’t argue with them. Instead, simply agree, and then try to redirect the conversation towards something else. You could say “You’re going to see your sister? That’s nice, now how about we go for a walk first?” You’ll probably find that they will quickly forget all about it. Of course, it won’t always work, but a lot of the time it will and it’s a great technique as it helps prevent confrontation!

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2.7

Providing Reassurance

It’s also useful to try and reassure your loved one when they do forget an appointment. If they forget a doctor’s appointment, for example, you could say something like “It doesn’t matter, the doctor was running late anyway”. If they’ve forgotten a past event such as a wedding or party, then before they start to worry about it, you could either change the subject or start talking about the event from your own experience (assuming you were there!)

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2.8

Coping with Forgetfulness/Confusion Check-List Deal with the financial and legal situation Ensure neighbors and friends know what’s happening Write it down – use an erasable board to write up the daily schedule Give frequent reminders about appointments and visits Use a pill organizer for medication Keep familiar objects and possessions out Reminiscence therapy – talk (and more importantly listen!) about past events and life history Reality therapy – frequently refer to the date, season, events etc in your conversation, and write it up Stick to familiar tasks and hobbies Break down tasks into simple concrete steps Have visits and phone calls from friends and family scheduled for a regular time

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(3) Coping with Wandering

Anna was busy preparing dinner and didn’t realize anything was wrong until the neighbor’s dog wandered in the open front door. Her father, who had Alzheimer’s, usually was content to watch the evening news. But tonight he had walked out the front door.

Frantic, Anna ran out after him. It was dusk and growing chilly. Her father was wearing a shirt, pants and socks. She called the police and then started alerting the neighbors. Within a matter of minutes, her father was found sitting on a front porch of a house down the block. He was confused and cold, but otherwise fine. It would be hours before Anna calmed down.

Wandering is a common problem with dementia patients. It is estimated that as many as 60 percent of patients will wander from home. Since wandering can be potentially life threatening, it is important to be prepared.

3.1

Keeping Track of Wanderers

In the U.S., the Alzheimer’s Safe Return Program is a national information and photo database that is available 24 hours a day. It has a crisis hot line. The program costs $40 and provides caregivers with inexpensive identification bracelets and necklaces, wallet cards, clothing labels with the toll-free hot line number.

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Someone who finds a wandering dementia patient can call the number and the caregiver is alerted. Safe Return also faxes the missing person’s photo and information to law enforcement agencies. For information or to register called the Alzheimer’s Association at 1-800-272-3900, or go to www.alz.org/safereturn. In these days of high-tech gadgets, Medical Intelligence Technologies of Canada has developed a GPS bracelet for Alzheimer’s patients. It costs $300 with a $60 monthly subscriber fee.

3.2

Have a Plan

It’s important for the caregiver to have a plan, in the event of a wandering incident. Make sure that you; • • • • • •

Make a list of emergency numbers Alert police that you have a patient who wanders Ask neighbors if they would be willing to help you search and add their numbers to the emergency list Keep a wallet card with your loved one’s photo and information with you Make up a missing flyer with photo and contact information to have ready just in case Survey the area within a mile or so of your home for potentially dangerous places like busy highways and lakes. Look for familiar places where the patient might try to go such as a corner store, café, bar or park. Looks for places they might seek shelter or hide. Check out wooded areas where they might get lost.

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3.3

Why are they wandering?

Try to determine why the patient is wandering and find other ways to meet that need. If the wandering takes place mainly at night, you should ensure that they are getting adequate exercise during the day, and not taking naps. If the wandering happens mainly in the late afternoons or evenings, then it could be due to a symptom of dementia called “sundowning”. Later in the day, it’s common for people with dementia to become agitated, anxious and confused. This often occurs between 3 in the afternoon and eight in the evening. With sundowning, the patient may suddenly decide it’s time to go home, even though they are home. Many patients are working on old patterns. During the day they are at work and then they go home.

3.4

Preventing Wandering

Dementia patients often have erratic sleep patterns and this can make night wandering more likely. It may be necessary to install new locks on doors and windows and change doorknobs to styles that a dementia patient would find difficult to open. Putting the locks either high up or low down makes it less likely the patient will see them and be able to open them. Alternatively, you could lock the door from the inside and keep the key with you. Placing black mats by doors has been shown to make it less likely that a dementia sufferer will wander. The black acts as a “mental barrier” so that when the patient sees the mat they often turn back rather than trying to get

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through. Or you could try placing an obstruction in front of the doors to make them less obvious – something like a coat rack would be suitable. Motion detectors also can be installed on doors and windows to set off a light or an alarm. Wandering may occur because the patient doesn’t have enough to do – try and ensure that they have enough activities and tasks to be kept busy. Particularly for people with sundowning syndrome, making sure that they have things to do later on in the day may help reduce their anxiety and wandering. In addition, turning up the lights and closing the blinds as the sun starts to go down may be of benefit. Also, try fixing a mid-afternoon snack. Being hungry increases the likelihood of anxiety and in turn sundowning. Making sure that your loved one has had plenty to eat will help avoid this. Confronting a confused patient is usually counter productive. Instead, play along and agree that it’s time to go home. Then take a short walk or drive around the block, and arrive home.

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3.5

Coping with Wandering Checklist Get a simple Identity Bracelet from the National Alzheimer’s Association or go high-tech with a GPS tracking bracelet! Develop a plan so that you know exactly what to do if it does happen. Use black door mats - they act as a "mental barrier" to dementia sufferers

Locks on doors should be either high up or low down to make them harder to reach, or you can change doorknob styles to make them harder for the patient to open Find activities that keeps the patient busy at the time they’re most likely to wander (For sufferers with sundown syndrome – usually late afternoon/mid evening) If wandering is mainly at night – ensure your loved one gets adequate exercise and doesn’t nap during the day Use technology like Motion Detectors to make you aware when your loved one has left the house. Don’t be confrontational in your approach

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(4) Coping with anger and aggression

Twice a month Patsy came to Dot’s house to do her hair. Patsy had been doing Dot’s hair for years and when Dot’s Alzheimer’s grew worse, Patsy offered to make house calls. The special attention did wonders for Dot’s mood.

But one afternoon, Patsy arrived later than usual and Dot was agitated. She pulled away as Patsy tried to wash her hair and fought her as she tried to finish. When Patsy tried to towel dry her hair, Dot punched and kicked he and accused Patsy of trying to hurt her.

Patsy was stunned and then she realized that Dot didn’t recognize her. Patsy left the room to try to figure out what to do. When she returned she stood in the doorway until Dot saw her and then introduced herself and asked Dot if she could help her fix her hair.

Anger and aggression are the most difficult aspects of caring for a dementia patient. A person you’ve known for decades is suddenly transformed into a stranger. A person who had always been mild-mannered is cursing and throwing things. Aggression tends to be worse once the patient is in the severe stages of dementia – but it can happen before then.

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4.1

What causes anger and aggression?

As a caregiver, it’s difficult not to take these outbursts personally. But try to remember this is the disease, not the person. Above all, never argue with someone who has dementia – this can cause them to become anxious and possibly increase their anger.

Such aggression can be a red flag that something is wrong. One of the most important skills to develop when caring for a dementia patient is paying attention to what’s going on around the patient. As dementia progresses, a patient’s language skills decline and they can misunderstand and misinterpret. Keeping a log of when the patient becomes angry or aggressive will help you to find why the problem is occurring and how you can help eliminate the cause. The following factors can all be causes or triggers for angry outbursts or aggression.

4.1.1 People
Family and friends may be triggering an outburst. The patient may feel overwhelmed by too many people. Someone may be speaking sarcastically or in demeaning way to the patient. Family members often feel angry themselves and uncertain about how to behave around the patient. Family may need to be coached on how to talk with the patient.

Effie’s situation was less than ideal. She was a widow who had a number of health problems, including Alzheimer’s. She was living with her daughter Linda who had recently remarried. Linda and her new husband had several teenage children from their first marriages. And to make matters worse, Linda was

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caring for her 4-year-old granddaughter. The teenage children weren’t happy with the new living arrangements. The house was chaotic with arguments and loud music.

Effie often just sat at the kitchen table and stared. But sometimes she would start yelling for help. She obviously was feeling stressed by her surroundings but no one could tell whether something else was wrong. After one especially bad shouting match, Effie began screaming. The kids screamed back, telling her to shut up.

Finally the 4-year-old intervened. She took her grandmother’s hand and pulled her out of the room. She led her down the hall to her grandmother’s bedroom. She told Effie to sit in the rocking chair and then climbed into her lap and rocked. The 4year-old knew the need for a time out.

It is extremely upsetting to spouses and children the first time their loved one doesn’t recognize them. The patient may feel threatened by these “strangers” in their home. At some point it may be necessary to introduce yourself and assure the patient that you mean them no harm.

Your loved one might lash out during dressing or bathing because they feel embarrassed by being touched or have sexual feelings that they no longer understand.

They may be feeling overwhelmed if confronted with too many activities, choices or decisions. In the beginning, giving patient choices helps them retain a sense of control, but at some point the choices will be too much.

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Probably the most difficult part of dementia from the patient’s standpoint is no longer being able to communicate. They can’t come up with the words to express themselves and then they cannot understand what people are telling them. It’s infuriating. Learn to ask simple yes or no questions.

4.1.2 Physical problems
When they can no longer communicate, a patient may become angry because they are in pain or feel ill. Sometimes it’s as simple as a full bladder. But also check for constipation, dental problems or earaches. Sleep deprivation also can cause angry outbursts.

Bill was in the late stages of Alzheimer’s and no longer could communicate. But he was still active and walked most of the day. He often became overheated.

In the middle of the night, Bill woke up sweating profusely and in obvious distress. Bill’s son was afraid his father was having a heart attack. He called an ambulance. It was several hours before Bill’s son could talk with the doctor. His father was not having a heart attack. He was severely dehydrated and had a bad kidney infection.

Outbursts sometimes occur at a certain time of day. Patients often fade in late afternoon. Sometimes a nap or a quiet time can help.

Medication prescribed for Alzheimer’s can have side effects and the patient may be reacting to them.

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4.1.3 Environment
Keep track of what soothes the patient. The drone of the television can have both calming and stimulating effects. Soft music, a darkened room, or cuddling with a pet can be soothing. Telling the patient what is happening as it happens can also reduce agitation.

Patients eventually will have trouble completing simple tasks such as brushing their teeth. You can simplify these tasks by putting paste on the brush for them.

Also be aware that changes in the environment can be disorienting. Rearranging furniture or having guests over can be difficult for the patient to process.

4.2

Additional Tips for Dealing with Anger and Aggression

Whatever happens don’t yell at or punish the patient, or try to force them to do something. If a patient doesn’t want to eat or bathe, for instance, wait a few minutes and try again. And remember they are sensitive to your mood. So if you are feeling angry or frustrated, take a break. Try to distract your loved one when they became angry, rather than trying to reason with them or argue back. A simple diversionary tactic could be to drop something.

Keep your physician informed about violent episodes. Tranquilizing medication may be necessary. Use “Behavior Modification” techniques. Try to ignore negative behavior (provided that it is not harmful) and encourage good behavior by rewards,

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encouraging comments and the like. If necessary, when negative behavior takes place, you may want to withdraw rewards. Rewards can be something as simple as watching a favorite programme - it really depends on the individual and their preferences.

As a caregiver it is important to protect yourself. If your loved one is violently out of control, get help. Don’t put yourself in a position of being injured.

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4.3

Coping with Anger/Aggression Checklist Keep a log to try and work out the cause of anger so it can be avoided Make sure friends and family speak respectfully and don’t ignore your loved one Give limited choices. Use closed questions that require a yes/no answer or give a list of options rather than an open ended question Check for physical problems that might be causing the anger Speak to your physician if you think it might be caused by new medication Find ways to sooth the patient. This might be by playing soft music, having them stroke a pet etc Avoid having too many distractions at once e.g. TV and radio Use distraction methods to divert your loved one’s attention – whatever you do DON’T get involved in an argument Use Behavior Modification techniques – rewarding positive behavior and ignoring negative actions

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(5) Coping with hallucinations

Roger was determined to care for his wife Julia at home. She was a wanderer, roaming from room to room at all hours. Roger had replaced the hardware and locks on the doors and windows, removed obstacles such as small rugs and electrical cords and let Julia roam.

But one night he was jarred awake by the sound of Julia screaming in another part of the house. He found her on the floor of the spare bedroom shrieking that she was being attacked by wild animals. The only wild animals in the room were their granddaughter’s stuffed animals that covered a bed. In the dark they seemed sinister and threatening to Julia. Roger put away the toys and kept the door to the room closed. One afternoon a few days later, Roger found Julia naked and cowering in the floor in their closet. There was a man trying to assault her. Roger looked around, checked the doors and windows and assured Julia that no one was there. But she insisted that a strange man was after her. So Roger changed tactics. He left the room and began yelling at someone to get out and slammed a door. Then he returned to Julia and told her he had chased the man away.

In the later stages of dementia, areas of the brain can deteriorate that cause hallucinations. They aren’t necessarily scary hallucinations, but the patient perceives things that aren’t there. Depending on the area of the brain that is affected, the patient may smell or taste something that isn’t there. Often they can see someone who isn’t there. It might be a long-dead friend or relative, or it may be a stranger who is threatening.

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The extent to which patients suffer from hallucinations will vary from day to day and over time. The tendency to hallucinate tends to reduce over time as the disease progresses.

5.1

Provide Reassurance

The first thing you should do reassure your loved one that the hallucination is not real. However, if your loved one continues to argue that they are right, then you should agree with them but explain that the problem has been dealt with (like Roger did with Julia in the case study).

5.2

Causes of Hallucinations

Both patients with Lewy bodies and Alzheimer’s can have intense and persistent hallucinations that can be either visual or auditory. Sometimes the patient appears to be carrying on a conversation with someone who isn’t there or to hear noises that no one else hears.

Hallucinations also can accompany a high fever, or may be a reaction to medicine. You may want to speak to your physician if the hallucinations seem to be a reaction to a new medication.

Sometimes hallucinations can be a reaction to being alone. Reassuring the patient and making sure they have someone in the room with them can reduce the problem.

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5.3

Preventing Hallucinations

One way to reduce the likelihood of visual hallucinations is to ensure that the house has good lighting throughout. This type of hallucination is more likely to occur at night or when the lighting is inadequate, causing shadows – this can make it more likely that the patient will misinterpret what they see. Covering up mirrors with sheets and making sure that blinds or curtains are closed as soon as it begins getting dark can also reduce the chance of the patient seeing something out of the corner of their eye leading to a hallucination.

.If the person wears a hearing aid, check the batteries. Check to see if the person is having trouble seeing without their glasses, or may be developing cataracts or other vision problems.

5.4

Delusional Behavior

More troubling is when delusions accompany the hallucination. Someone with delusions may fear that someone is trying to harm them. These situations are difficult to deal with. You should constantly assure the patient that they are safe. The patient may not recognize the people around them and need to be frequently introduced and reassured they are friends.

If the problem persists, talk with the doctor about medication. There are medications available that can help with hallucinations.

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5.5

Coping with Hallucinations Checklist

Reassure your loved one – telling them that the hallucination is not real may work but agreeing with them and explaining that you’ve dealt with the problem may be a better solution

Ensure that you have good lighting throughout the house

Cover or remove mirrors if necessary

Ensure blinds or curtains are drawn as it begins getting darker

Check hearing aid works if it’s an auditory hallucinations

For visual hallucinations – check glasses are correct prescriptions and that there are no other eye problems

Talk to your physician if you think the hallucinations might be caused by a reaction to new medication

Try to have someone in the room with the patient at the time they typically have hallucinations

May need to frequently reintroduce people to the patient

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(6) Coping with Anxiety
Anxiety is a common problem experienced by dementia patients. This can range from fairly mild anxiety, e.g. repeating questions in order to gain reassurance, to the patient becoming more needy and possibly following you around because they worry that they might become lost. Although, in the past it was believed that younger people were more likely to be prone to anxiety and older people had less to worry about, that just isn't true. By and large, if a person suffered from an anxiety disorder when they were young, they're just as likely to suffer in their later years. The cause of anxiety for a person with dementia is wide-ranging. Becoming anxious over health problems or the loss of loved ones could trigger an anxiety attack.

6.1

Keep a Journal

What you'll probably find with frequent signs of anxiety, is that they're being triggered by a particular event, time or person. In order to try and find the cause, keep a journal or diary of each anxiety attack. You need to record the following information; where the attack took place, when it happened and the environment (what was happening at the time). Before long, you'll begin to see a pattern.

Brenda had been becoming increasingly concerned about her husband Jim's anxiety attacks. They seemed to be happening more and more often. She was beginning to worry about Jim's health - it seemed like every other afternoon he would become increasingly frustrated and restless, without any cause that she

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could see.

After keeping a journal for several weeks, she finally realized that Jim’s anxiety was linked to their neighbor’s kids arriving home from school. Although their playing in the back yard wasn’t overly noisy, it was still enough to disturb Jim’s peaceful afternoons. With this in mind, Brenda started putting on some of Jim’s favourite music mid-afternoon – this meant that Jim could no longer hear the disturbance from next door.

6.2

Reducing Anxiety

Singing well-loved and familiar songs has been shown by studies to help make people with dementia more cooperative, as well as being a good way to reduce anxiety. Think about it, hearing a familiar song will instantly take your loved one back in time and will help to change their thoughts to calmer ones - it can also be incredibly uplifting to hear your favorite songs (old ones are probably best, as they're more likely to be remembered than modern songs). And don't worry if your voice isn't the greatest, it’s still sure to be appreciated by the patient! But, if you really can't face it, then why not create a compilation CD of your loved one's favorite songs. These might be pop-songs from a particular era, or it might be old-fashioned songs they sang as a child, or perhaps favorite hymns. Have a selection readily available, so at the first sign of trouble, you can switch it on! Try not to have it going at the same time as the TV or while

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people are talking, it will simply become another background noise which could be distracting to your loved one - remember to avoid noise overload. Cognitive Behavior Therapy (CBT) may also help with anxiety. It involves using techniques such as relaxation training, and replacing anxiety causing thoughts with calming ones. It may take some time to see improvement but is an option worth considering, particularly if medication is not working. Again, speak to your physician about this. Invest in a Rocking Chair! It may sound unlikely, but the rocking motion produced by a rocking chair has been shown to have a soothing effect on dementia patients suffering from anxiety. A study found that it also helped to improve balance and reduce depression and in some cases reduce the need for pain medication! The dementia sufferers in the survey, rocked for around 70 minutes a day. The belief is that prolonged rocking can produce pain relieving endorphins. However, make sure you use a platform-based rocking chair which has a sturdy base, to prevent accidents. Just as massage helps alleviate stress and worry from healthy people, it can have the same effect on those with dementia. Anecdotal evidence suggests that it can have a calming effect. Even something as simple as giving a hand massage using aromatherapy oils can be very soothing and inexpensive. If you're not used to using aromatherapy oils then you can buy massage oils online or from your pharmacy. If you only have a few minutes spare, a hug or even just touching your loved one on the arm can reduce their anxiety levels. Avoid drinks with caffeine in where possible, particularly later in the day. Don’t let your loved one watch violent television programmes. It can be hard for people with dementia to distinguish between what’s real and what

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isn’t. Even just watching the news may cause them upset. Stick to well loved classic TV programmes or films. Keeping your loved one busy throughout the day with activities and tasks can also make it less likely they’ll have time to worry or become anxious. Don’t forget that they will need regular breaks, but they shouldn’t be sitting for hours at a time with nothing to do. Making sure that they get sufficient physical exercise can help too. Don’t forget to give instructions in simple, easy to understand language and to break tasks down to prevent your loved one feeling overloaded with information which can lead to anxiety. See your physician, anti-depression tablets rather than anti-anxiety tablets tend to be the preferred choice, particularly because depression and anxiety usually exist side by side.

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6.3

Coping with Anxiety Checklist Keep a Journal of when anxiety attacks happen

See your physician – they may prescribe anti-depressants

Write answers to common questions and pin on a notice board or similar to give reassurance

Sing familiar songs when your loved one becomes anxious

Ask your physician about any Cognitive Behavior Therapy schemes in your area

Buy a rocking chair – regular rocking will decrease anxiety levels

Use massage and touch to reduce anxiety and have a calming effect

Avoid drinks with caffeine

Don’t let your loved one watch violent TV shows

Keep your loved one busy throughout the day by giving them tasks and organizing activities

Make instructions and tasks simple and break them down

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(7)

Coping with Incontinence and Sexuality

7.1

Incontinence and how to deal with it

Incontinence, the inability to control bowel and bladder, eventually becomes an issue for almost every dementia patient. It is a source of frustration and embarrassment, and it can be at the heart of behavioural problems.

Incontinence can be a sign of other health problems such as urinary tract infection, prostate problems, or diabetes. Consult a doctor to rule out other health issues.

When dealing with incontinence, the best plan is to be prepared and stay calm.

Have a schedule for taking the patient to the bathroom, usually every two or three hours. Asking the patient if they have “to go” at some point will no longer work. They will no longer understand the natural urge or be unable to communicate it. Agitation or pulling at clothes can be a signal.

Limiting fluid intake at night can reduce accidents. And avoid caffeinated drinks as they can have a diuretic effect. Some medications can have that effect, too.

If you are going out with the person, know where the restrooms are and take a change of clothes.

When accidents happen, especially away from home, be calm and reassuring. Help the person keep their dignity while tending to their needs.

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As the baby boom generation ages, a number of incontinence products, such as pads and panties, have come on the market. Prime-time commercial campaigns may have removed some of the stigma of incontinence.

7.2

Sexuality and how to deal with it

One of the most perplexing issues that can arise with dementia patients is inappropriate sexual behavior. A dementia patient may undress, fondle themselves, use vulgar language or act sexually aggressive toward a spouse or others. It is important to remember that this is the disease talking. Consult a physician as your first step.

Then consider some of the reasons for the behavior. The patient may be trying to express his natural sexual needs. Loss of inhibition can accompany the deterioration of the brain. They may be in a situation that arouses them sexually and they no longer know an appropriate way to deal with the feelings.

A person who undresses may be overheated or need to use the bathroom. If a person is masturbating, gently redirect their attention.

If you are the spouse, find someone to talk to about your feelings. You may be feeling rejected, angry and embarrassed. Recognize that you both have needs for affection. A traditional sexual relationship may no longer be possible, but there are other ways of expressing affection such as cuddling.

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(8) Useful Links
www.alz.org www.alzheimers.org.uk www.dementia.com www.caregiver.org Dementia Quiz www.carersonline.org.uk Medical Intelligence Alzheimer's Assoc Safe Return National Alzheimer’s Association Alzheimer’s Society (UK) Advice for dementia caregivers Family Caregiving Alliance Find out if you’re at risk of dementia Information and advice for carers (UK) For information on their GPS Bracelet Find out more about the programme

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Patricia Johnson Patricia Johnson Management Consultant
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