WHEN YOUR CLIENT HAS ALZHEIMER`S DISEASE
This inservice has been designed to provide an overview of Alzheimer’s disease (AD) and to increase your understanding of how to provide quality care to clients with the condition. If you work with older clients, then it is likely that you have already cared for clients with AD. If not, you may soon be assigned to care for a client with this disease as it is becoming very common in our society.
AD occurs most often in older persons. As the percentage of older persons in society increases, more and more people are getting the disease. Some famous people who have been diagnosed with AD are Ronald Reagan (former President of the United States), Rita Hayworth (actress), and Sugar Ray Robinson (middleweight world champion boxer). It has been estimated that over 4.5 million Americans have AD. There are currently about half a million Canadians living with Alzheimer`s disease or a related dementia. Estimates for Canada are that one in 11 persons in the 65+ age category has the disease. As well, the incidence in persons 85 years and more is 25%.
WHAT IS ALZHEIMER’S DISEASE?
Alzheimer’s disease is not a new disorder. In 1906, a physician, Dr. Alois Alzheimer, found changes in the brain of a 51-year-old woman who had died of a strange mental illness. The condition was found to be a new disease and was later named “Alzheimer’s disease” after its discoverer.
AD is the most common form of dementia. Dementia describes a group of symptoms caused by a variety of disorders. The disorders cause a decline in mental and cognitive function over time. AD results in the death of certain types of nerve cells in the brain. It affects thought, memory, and language. Changes occur in the way a person behaves, as well as in mood and personality. Judgment and reasoning are affected as well as the ability to communicate and to carry out daily activities.
When a person presents with symptoms of AD, tests are usually done to detect other possible causes of dementia. Once other problems have been ruled out, diagnosis depends heavily upon the client’s history. The only certain way to diagnose the disease requires an examination of the brain tissue at autopsy. Research is ongoing into the cause and treatment of AD. There is no cure for the disease, although medication can prevent or reduce some of the symptoms, at least for some time. These medications work best when used along with behavior management. The basis of care for clients with AD remains behavior management.
WHAT CAUSES ALZHEIMER`S DISEASE?
The exact cause of AD is not known. Researchers are exploring possible causes, contributing factors and treatments for the disease. A number of risk factors seem to make it more likely that someone will get the disease. Some of these factors are:
- Age. This is the greatest known risk factor for AD. The disease is uncommon before the age of 65. After the age of 65, however, the incidence doubles every 5 years.
- Family history and genetics. Having someone in the immediate family (i.e. parent or sibling) with AD increases a person’s chances of getting the disease. The more individuals with AD in a family, the higher the risk for remaining family members. Certain types of genes cause forms of AD that may occur even before the age of 65. A rare form of inherited AD can occur as early as the age of 30.
The risk factors of age, family history and genetics cannot be controlled. Scientists are also exploring risk factors that can possibly be controlled to prevent AD. Some of these risk factors include):
- Environment. Studies indicate that AD may develop partly as a result of environmental influences. For example, having a twin with AD puts the other twin at increased risk but it does not mean that the disease will definitely occur.
- Serious head injury. There seems to be a link between serious head injury and later onset of AD.
- Lifestyle choices, such as a balanced diet, active social life, avoidance of tobacco and alcohol, and regular physical and mental exercise, promote a healthy brain and may protect against AD.
- Factors related to blood circulation, such as high blood pressure or high cholesterol, heart disease, stroke, and diabetes appear to increase the risk of AD.
AD is more common in women but that may be because women tend to live longer than men in our society. It is likely that the disease is caused by a number of factors that are present at the same time, rather than just one.
SYMPTOMS OF ALZHEIMER`S DISEASE
Memory changes with aging happen to everyone. People with AD, however, have severe problems with reasoning, memory and language. These changes seriously affect the person’s ability to work, to communicate with others and to care for himself. The Alzheimer’s Association has developed a list of ten warning signs that help to show the difference between changes due to aging and those due to AD. These warning signs are:
- Memory loss. The person with AD forgets recently obtained information.
- Difficulty performing familiar tasks. Even simple everyday tasks are hard for the person with AD to complete.
- Problems with language. The person with AD often has trouble finding the correct word for even common items such as a toothbrush.
- Disorientation to time and place (e.g. forgetting what day it is, getting lost) happens often.
- Poor or decreased judgment. The person with AD may show poor judgment in many aspects of everyday life (e.g. dresses oddly, gives away valuable belongings).
- Problems with abstract thinking. Handling personal finances (e.g. not paying the bills, paying too much for purchases) becomes a struggle.
- Misplaced belongings. Items may be often lost or placed in odd places.
- Changes in mood or behavior. Rapid mood swings (e.g. crying, aggression) with no obvious reason may be common.
- Changes in personality. Confusion, suspicion, withdrawal may be evident.
- Loss of initiative. Some AD clients may sleep for long periods of time and not want to do much of anything when awake.
AD starts out slowly and worsens over time. Different methods of staging have been used to show how the disease progresses. One staging system divides the disease process into seven stages. Another system uses three stages – early, middle, and late – to describe the common changes that occur as the disease progresses over time. Keep in mind that the symptoms occur at different times for persons with AD. As well, symptoms from one stage often overlap with symptoms from another stage of the disease. The three-stage system is described below:
Symptoms in the early stage coincide with the warning signs outlined by the Alzheimer’s Association. Mild forgetfulness is one of the first signs of AD. Although this happens to all of us at some time, it happens more often to someone with AD. The person may forget names, appointments, and telephone numbers.
Someone with AD will have difficulty with new learning and the memory problems will worsen over time. The person may forget the correct names of simple everyday objects. Items may be forgotten or misplaced. For example, the newspaper may be placed in the refrigerator or the butter in the laundry basket. At first, the person with AD will be concerned about the memory lapses and decreasing ability to perform tasks that were once easily completed. This knowledge may cause a great deal of stress.
Judgment may be impaired. The ability to do well in demanding job situations will decrease. Help may be needed with handling money and performing tasks that require abstract thinking. Some of the other symptoms common at this stage include trouble concentrating, getting lost easily, and forgetting the date and time. Shifts in mood, restlessness, anxiety, and mild coordination problems may also occur.
At this stage, the person with AD will have great trouble organizing their thoughts. The person forgets where they are and do not remember what day or month it is. Sleep may be disturbed and the person may mix up day and night. Wandering behavior is common. Sexual behavior may be inappropriate. Memory worsens to the point that the AD individual may no longer know their family members. Help with simple tasks like dressing, bathing, and toileting will be needed.
Marked personality changes become apparent over time. Rapid changes in mood, such as aggression or severe anxiety, can happen for no obvious reason. The person may be suspicious and experience delusions. The personality changes and challenging behaviors may cause a great deal of anxiety for family members and healthcare workers.
As the disease advances, the person with AD may become unable to walk or to speak, except for possibly a few simple words. There may be difficulties with eating. The ability to remember will be lost and the person will require help with all aspects of personal care. Loss of bowel and bladder control occurs.
Even though physical and mental abilities have decreased greatly at this stage, there may be a reaction to music and touch. There may also be some response to emotion.
People with AD generally live for eight to 12 years following diagnosis. However, this time frame can vary greatly with some people living 20 years or more with the disease.
CARING FOR THE CLIENT WITH ALZHEIMER’S DISEASE
About 70% of persons with AD in the U.S. are cared for at home. Typically, the client is diagnosed with AD while living at home and remains there during the earliest stages of the disease. Family members are often heavily involved in the care of their relative at this point. A home health aide may visit and assist with care and the family may use respite services as available. Other health providers besides the physician may be involved in the care of the client. These include the nurse, social worker, physical therapist, occupational therapist, nutritionist, clergy, and others as appropriate to the client’s situation.
As the disease progresses, challenging behaviors associated with the disease become more pronounced and the family may no longer be able to provide the care that is needed. At this point, the family may explore placement into a care facility. Possible options include assisted living facilities, personal care homes, centers that specialize in the care of clients with dementia, and nursing homes.
The type of support and care you give to a client with AD depends on how far the disease has advanced and also on your client’s individual needs. Over time, the client will require greater assistance with all aspects of daily living. Check the care plan to find out more about the care of your particular client. Consult with your supervisor if you have concerns about the client’s behavior or if you do not understand any aspect of the care plan. This section discusses general approaches to care that have been found to be helpful in the care of clients with AD.
The client with AD will display many challenging behaviors such as wandering, agitation, and aggression. When your client displays challenging behaviors, consider the situation. Examine the behavior. What is happening? Try and see the behavior from the client’s point of view. For example, repeatedly calling a relative on the phone may seem logical to the person who cannot remember any of the calls recently made. Consider if the behavior is harmful to the client or to others. If not, it may be okay to ignore the behavior.
Consider what factors (e.g. fatigue, noise) may have led up to the behavior. Is your client scared, hungry, tired, or uncomfortable? Is the environment noisy and crowded? Where possible, take steps to remove the source of anxiety. Sometimes resolving the problem is as easy as taking the person to the bathroom. At other times, you may have to try different approaches to find one that works.
Despite the progressive loss of memory, judgment, and other abilities, many persons with AD retain some interest and ability in old hobbies and skills for a period of time. The math teacher who cannot remember his own name may be able to recall the numbers to open the doors to a locked unit. The woman who loved the piano may be able to play simple tunes despite obvious progression of the disease in other areas. The devoutly religious person may be able to take part in church services or may find it comforting just to watch.
Several basic factors to keep in mind when caring for a client with AD are to:
- Always treat the client with respect and dignity. Treat clients with AD the same way that you would like to be treated or as you would like someone to treat one of your loved ones.
- Be flexible in the care that you give. Things will often go more smoothly if you adjust your schedule to meet the needs of the client with AD.
- Do not argue, correct or confront the client. Instead, try and redirect problem behaviors into more positive forms. Clients with AD are generally easily distracted. Imagine your client is creating a lot of noise by banging a spoon on the table at mealtime. You may be able to get him to pay attention to something else. Several possible options are:
- – Remind him to use the spoon to eat the dessert.
- – Replace the spoon with another item.
- – Take him for a short walk.
- Keep things simple. Break complex tasks into simple steps. For example, if you want the client to sit at the kitchen table to eat, tell him/her to “Sit on the chair,” “Pick up the spoon,” and so on.
- Establish routines. Where possible, have these routines similar to what is familiar to the client.
- Establish reminders. It may be useful to put a picture of a toilet on the door to the bathroom as a reminder to the client with AD.
- Limit choices to two possible answers (e.g. the red dress or the blue one). Both answers should be acceptable.
- Encourage independence as long as possible. Encourage hair combing, washing, and going to the bathroom. Over time, the amount of help the client needs to do these simple tasks will increase and the time will come when the client will be unable to do them at all.
- Promote hobbies and skills of interest.
- Ensure that your client gets adequate rest each day.
Don’t force care on clients who are resistive. Remember, your supervisor and the care plan are resources to you. As well, check with co-workers who are familiar with the client. Medications can be used to control some of the challenging behaviors common with AD. They will work better, however, when used with other strategies such as a flexible approach.
Some challenging behaviors may occur because of poor communications between the healthcare worker and the client with AD. Below are tips that you may find helpful when communicating with the client who has AD.
- Ensure that the surroundings are quiet.
- Approach the client from the front so that you will be easily seen and the client will not be startled.
- Stay at eye level with the client. Sit down if the client is seated. Stand up if the client is standing.
- Before you begin speaking, look directly at the client and smile. Clients with AD are often able to detect tension and stress in others. Make sure that the nonverbal cues (smiles, body language) that you send are reassuring. Use a calm and friendly tone of voice.
- Speak in a normal tone of voice.
- Slow down. Speak clearly and slowly so as not to confuse the client with AD. It may be necessary to repeat what you have said.
- Use words that are simple and familiar in everyday language.
- Use your hands to point or demonstrate as you are talking.
- Ask close-ended rather than open-ended questions. Close-ended questions can be answered simply (e.g. “yes” or “no”). An example of a close-ended question is “Do you want a drink of water now?” Open-ended questions can be very confusing to clients with AD. An example of an open-ended question is “How are you?” Attempting to answer open-ended questions can be very frustrating for some clients. As the disease progresses, AD clients are unable to organize their thoughts to be able to answer open-ended questions.
- Give your client lots of time to answer any questions.
- Avoid the word “don’t.” Whenever possible, state things in a positive way. Imagine that your client is not chewing his food well at mealtime. Rather than say “Don’t eat so fast”, you could remind your client to eat slowly. Follow up with smiles and encouragement when he does so.
- Repeat important information as needed.
- Touch can be very calming when you are talking to the client with AD. Place your hand on the client’s arm or your arm around the client’s shoulders as you communicate in a calm and unhurried manner.
Several challenges can occur with respect to eating and clients with AD. Clients may forget to eat or be unable to let you know when they are hungry or thirsty. Frequent small meals or snacks may work better than three big meals a day. Encourage clients to eat and drink throughout the day.
Clients will forget how to eat in a socially acceptable way at mealtime. They may not be able to understand the purpose of food or how to use knives, forks, and spoons. A noisy room may make the client too anxious to eat. Finger foods such as fruit, sandwiches, or vegetables allow the client to stay independent with feeding as long as possible. Provide a mug or cup with a wide handle that the client can use for drinking. Serve one food at a time. Give simple directions and praise:
“Open your mouth.”
“You’re doing very well.”
Check the client’s teeth and mouth when you provide morning care each day. The client with AD will not always be able to tell you when decayed teeth or inflamed gums are causing a problem. Ensure your client has dentures in and is wearing glasses if used.
Below are suggestions to follow to prevent injuries from occurring at mealtime:
- Ensure that the table is not cluttered.
- Use nonbreakable dishes if necessary.
- Remove harmful items from the table.
- Ensure sure that food is cut into small pieces (to prevent choking).
- Check the temperature of the food before you serve it.
Report any concerns you may have about swallowing or possible choking.
As AD advances, clients will need help with all aspects of personal hygiene. They will need your help to wash their hands, to bathe, to brush their teeth, to toilet and so on. Without good personal hygiene, clients are at risk for skin breakdown and infection. Bathing clients with AD often poses particular challenges for healthcare workers. Try and make bath time a relaxing experience. Play soft music, ensure the room is warm, and make sure that you have plenty of time so that you are not rushed. Being organized in your work will help the procedure to go more smoothly. Check that:
- You have closed the door to ensure privacy.
- You have another person available to assist as needed.
- The temperature of the water and room is comfortable.
- You have everything you need, such as soap, washcloth, and towel, laid out ahead of time.
Other tips that may help with bathing include:
- Give one direction at a time.
- Allow the client to get into the bath slowly.
- Explain what you are going to do before you do it.
- Give the client a washcloth to hold onto during the bath.
- Allow the client to wash without help as much as possible.
- Use a calm and encouraging approach. Smile. Praise the client.
- Demonstrate what you wish the client to do; for example, wash his face.
Many clients with AD dislike bathing. The client may be afraid of water or may not understand what is happening. Perhaps the client is not feeling well or the room is chilly. Some clients will strongly resist bathing. They may strike out, scream and try in every way to stop the process. Don’t force your client to get in the tub or shower. Be flexible. Remember that each situation and person is unique. Give some thought to what is happening and why. Consider the options that are available to you. For example, is the client refusing to undress due to modesty? If so, can you bathe the client with underwear on or with a towel wrapped around him/her? Clients with AD are often fearful of getting water around their face and head. Can you schedule bathing and hair washing at different times? Consider bathing the person later in the day or giving a sponge bath.
A towel bath has also been found to be helpful for some confused clients who resist personal care. The process involves placing washcloths and towels in a plastic bag and then adding warm water with no-rinse body shampoo to the bag. Using the towels and washcloths, the healthcare worker begins the cleansing procedure at the client’s feet moving upwards. The upper body and the hands are washed last.
This bathing process provides warmth, comfort, and relaxation while cleansing in a manner that is not too invasive. If the client will tolerate the presence of two healthcare workers, one can talk to the client and help distract him/her while the other healthcare worker performs the bathing.
One aspect of personal hygiene that is often overlooked for clients with AD is mouth care. Good mouth care can prevent cavities and gum disease. Clients should see a dentist on a regular basis and teeth need to be brushed twice a day. If dentures are used, ensure they are cleaned each night. Speak to your supervisor if your client resists mouth care. A variety of products and strategies are available for mouth care for confused and debilitated clients. A dentist or dental hygienist may need to be consulted.
As the disease progresses, AD will affect bladder and bowel control. As with most other aspects of care for the client with AD, it is important to be flexible with toileting. The following tips may help you to care for the client’s toileting needs:
- Ensure that the bathroom is easy to find. Keep the path to the bathroom well lit. It may be necessary to post a sign to help the client remember where the bathroom is located.
- Remind the client regularly to go to the bathroom.
- Monitor the toileting pattern and develop a schedule.
- Watch for cues (e.g. grimacing or agitation) that the client needs to go to the bathroom.
- Make sure that clothing is easy to remove.
- If the client needs help with starting to void (urinate), try running the water for a while.
- Observe how well the client gets on and off the toilet. Is it necessary to have handrails put on?
- Be patient when accidents occur. If accidents do continue, protective pads, liners or briefs may be needed.
- Assist the client with handwashing following toileting
You can help make the environment safer for a client with AD. Some general suggestions are outlined below.
- Use grab-bars for the bathtub.
- Keep medications out of reach.
- Use a non-slip mat for the bathtub.
- Ensure that proper lighting is in place.
- To prevent falls, ensure that clients wear proper footwear.
- Remove items that can injure the client such as sharp objects.
- Check scatter rugs and remove if necessary to prevent tripping.
- Supervise when the client is smoking or lock away the cigarettes and lighter.
- Remove cleaning solutions and personal care items (e.g. soap, shampoo) that could be harmful if ingested. Many people do not realize that common household plants can also be poisonous.
For the client living at home, it may be necessary to lock away guns, power tools, and electrical appliances. Alcohol must be kept out of reach and unused outlets covered with safety plugs.
Another important safety issue for clients with AD is wandering. Confused clients who wander away from home or a care facility are at extreme risk of injury. If you are caring for a wandering client at home, supervise the person closely and keep exterior doors locked. Alarms may have to be installed. Ask the family about using a bracelet with the client’s name, address, and telephone number on it. They may also wish to check with their local chapter/office of the national Alzheimer’s Association (US) or the Alzheimer Society of Canada to find out about available resources, including a registry/enrolment program for wandering persons.
Most facilities caring for clients with AD have secured units for residents who wander. The units are locked and an alarm sounds when at risk clients leave the unit. Follow agency policies with respect to supervision and locking of doors.
As a direct healthcare provider, you are in an excellent position to identify potential safety issues before they become major problems. If you think that your client’s safety may be at risk, and you are not sure what to do about it, tell your supervisor.
AD is a form of dementia that is becoming much more common as the population ages. The exact cause of the condition is unknown although a variety of factors make it more likely that someone will contract the disease. AD progresses slowly and has been described through a three-stage process. Research is ongoing into the cause and treatment of AD. There is cure for the disease, although medication is available to prevent or reduce some of the symptoms, at least for awhile. Management still relies heavily upon behavior management. Various approaches and strategies have been found helpful in the care of clients with AD.
CHECK YOUR KNOWLEDGE
- Name two risk factors for AD
- Identify three common symptoms in the early stages of AD
- Identify three basic factors to keep in mind when caring for someone with AD
- Give three strategies that you could use to communicate with someone with AD
- Identify two strategies you could use to make bath time more pleasant
- Identify three strategies you could use to make the environment safer for someone with AD
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