Instead of the 12 days of Christmas…Get Ready For 8 Days of Dementia Tips

Rule 1: There is no perfect response. As you have undoubtedly discovered, what worked yesterday may not work today. The person you are caring for may have a positive reaction to your first response, but  might later turn negative. It is important to forgive yourself if you do not answer with the perfect comment. Step back and try to understand why your response did not work. Remain calm.

Rule 2: Listen for the feeling behind the person’s statement. Do not debate the accuracy of what is said. For example, if a person states he or she wants to go home and is already home, explaining, “This is your home” will probably not be effective. Rather, try and imagine what the person might be feeling that made him or her want to go home and then respond, “Did you need something from home?  Tell me what you like best about your home? Can I get you something to drink?  Let me show you where the bathroom is.” Likely when a person is asking to go home or wanting their parents or spouse, there is an unmet need.  It is our job to figure out what they need. By answering in ways similar to the examples, you accomplish three things:

1. You did not debate the statement.
2. You acknowledged a feeling the person might be having.
3. You focused on something positive. When the person asks, “Where is John?” (when John has been dead for 10 years), a possible response might be, “Do you miss John? I miss him when he isn’t here. Remember his wonderful smile? What other things do you remember about John?” Again, the focus of the response is on the feeling and positive memories.  If they state worriedly while trying to exit seek, “I need to get home before the kids get home from school.”  Validate the need to take care of the kids, but tell your best therapeutic fib to reassure them that you picked up the kids, or that the kids went to the neighbors, etc.  Again, the more you know, the more accurate the fib will be and believable.

Rule 3: Distract or focus the person on another activity. If the person repeatedly asks when you are going somewhere, (i.e., the bank) you might say, “Your money is fine, it is safe and you have enough in your pocket to pay for what you need right now.” Then distract the person by saying, “Have I shown you the pictures I found? I’d love for you to see them.” Distract them with “busy” activities, such as folding laundry, sorting a fencing toolkit or nuts and bolts, or looking at pictures from the past focuses the person onto another topic.  The more you know the person you are caring for, the better the distraction will work as you can make it something that they will relate to.

Go back to the first example on day 1 and know that there is no perfect response.  This is the disease, not the person trying to be mean, etc.  Likely they don’t understand what is happening to them.

In the early stages of the disease, people with Alzheimer’s may experience personality changes such as irritability, anxiety, or depression. As the disease progresses, other symptoms may occur, including sleep disturbances, delusions (firmly held belief in things that are not real), hallucinations (seeing, hearing, or feeling things that are not there), pacing, constant movement or restlessness, checking and rechecking door locks or appliances, tearing tissues, general emotional distress, and uncharacteristic cursing or threatening language.

Helpful Hints during an Episode of Agitation:

• Do: back off and ask permission, use calm positive statements, reassure, slow down, use visual or verbal cues, add light, offer guided choices between two options, focus on pleasant events, offer simple exercise options, or limit stimulation.
• Do not: raise voice, take offense, corner, crowd, restrain, rush, criticize, ignore, confront, argue, reason, shame, demand, condescend, force, explain, teach, show alarm, or make sudden movements out of the person’s view.
• Say: May I help you? Do you have time to help me? You’re safe here. Everything is under control. I apologize. I am sorry that you are upset. I know it’s hard. I will stay until you feel better.

Helpful Hints to Prevent Agitation:

• Create a calm environment: remove stressors, triggers, or danger; move person to a safer or quieter place; change expectations; offer security object, rest, or privacy; limit caffeine use; provide opportunity for exercise; develop soothing rituals; and use gentle reminders.
• Avoid environmental triggers: noise, glare, insecure space, and too much background distraction, including television.
• Monitor personal comfort: check for pain, hunger, thirst, constipation, full bladder, fatigue, infections, and skin irritation; ensure a comfortable temperature; be sensitive to fears, misperceived threats, and frustration with expressing what is wanted.

Possible Causes of Agitation Include:

Physiological or Medical Causes

• Fatigue at time of request, activity or event
• Disruption of sleep pattern (day/night reversal) causing sleep deprivation
• Physical discomfort, such as pain, fever, illness, constipation, fecal impaction, expressed as anger
• Loss of control over behaviors due to physical changes in brain
• Adverse side effects of medication such as psychotropic, sedatives or tranquilizers
• Impaired vision or hearing causing person to misinterpret sights and sounds
• Hallucinations

Environmental Causes

• Sensory overload. (Too much noise, activity or clutter or too many people in the environment)
• Unfamiliar people, places or sounds.
• Sudden movements, startling noises.
• Feeling lost, insecure, forgotten. (When familiar people are out of sight, the impaired person may feel abandoned)
• Difficulty adjusting to darkness from well-lighted areas or vice versa.

Other Causes

• Being asked to respond to several questions or statements at once.
• Responding to arguments between other people.
• Response to caregiver’s impatience, stress, irritability.
• Person scolded, confronted, contradicted.
• Surprised by unexpected physical contact.
• Inability to perform what was a simple task, i.e. buttoning clothing.
• Instructions unclear or too complicated.
• Change in schedule or routine.
• Attention span too short for task.
• Task not broken down into manageable steps.
• Activity perceived as too childlike, insulting.

Coping Strategies

• Begin with medical evaluation to rule out physical and/or medication problems.
• Discuss possible adverse side effects of current medications with physician.
• Alternate quiet times with more active periods.
• Plan outings, activities, when person is rested.
• Make sure person is comfortable – clothes are not tight, person is not too hot/cold.
• Simplify environment by reducing noise, number of people and clutter.
• Keep daily routine as consistent as possible. Avoid changes and surprises. For some people with dementia, the slightest change may lead to confusion and disorientation.

Try scheduling meals, bathing and walks for example at the same time every day.

• If a new care partner is to be introduced, or day care is being tried, make the person accustom to the new place or care partner as gradually as possible.
• Keep furniture and objects in the same place at all times.
• Orient person to time by using calendars and large numeral clocks, as the person may lose a sense of time because of the disease.
• Make sure the person is protected from hurting himself. Remove sharp utensils, tools and objects. Give them something to have in their hands so they cannot hit or pinch, scratch etc. like a washcloth in the shower.
• Remove the person from stressful situations, persons or places. Gently guide the person from the environment while speaking in a calm and reassuring voice.
• Distract the person with a favorite food or activity. This may reduce agitated feelings Distraction and avoidance is often useful approaches when handling agitated behaviors.
• Exercise regularly to help reduce stress. Try walking or dancing.
• Try music, massage, quiet reading as a way to calm the person. Try These Communication Techniques:
• Avoid asking questions that rely on memory.
• Try not to reason with the person, as he/she no longer has the ability to think logically.
• Reasoning or rationalizing with the person frequently leads to frustration and anger.
• Try not to express your anger or impatience verbally or with physical movements such as shaking head, pointing fingers, etc. These responses are easily sensed and likely to increase confusion and agitation.
• Speak slowly and clearly. Use short simple sentences.
• Approach the person slowly and from the front. Approaching from behind or side may startle the person.
• Be sure you have the person’s attention before speaking and touching.
• Use repetition. Frequently, clearly stated reminders are needed to reassure the person with dementia.

During Tasks or Activities

• Allow adequate time for person to respond to directions, request or to perform activity. Due to physical changes in the brain, more time is needed to absorb instructions.
• Limit choices in food, activities, and clothing. Decision-making may be overwhelming to the person and result in an angry response.
• Give clearly stated directions for each step. Complete one step at a time. The person no longer has the ability to think of several things at once and may be overwhelmed in trying to keep track of multiple events, statements, questions or directions.
• Offer activities and events that the person is capable of doing.

In Long-Term Care Settings

• Try to maintain consistent staffing. When possible, have a familiar staff person responsible for the person with dementia. If the resident does better with two people bathing him / her, make sure that you can have two people for bath time.
• Try to involve families or volunteers in one-to-one activities, if large group activities are upsetting to the person.
• Identify stressful times of day for the person and try to schedule baths, dressing, or other difficult activities at other times.
• Discuss successful and unsuccessful approaches with other staff
• Be aware that shift changes are often stressful times and provoke anxiety because of increased noise and activity level.

Other Considerations

It is important to recognize that angry or agitated behaviors are often symptoms of dementia and are not deliberate responses. Sometimes, keeping a log or journal can be helpful in identifying why the person becomes angry or agitated. Try writing down everything that happened each time the person becomes agitated. What time of day was it? Who was present? What immediately preceded the outburst? Often a pattern emerges which helps the care partner think about how to alter the situation. The way in which care partners approach people with dementia is a critical part of avoiding angry behaviors. A gentle, supportive, simple approach will almost always be more successful than commands or rationalizing. Persons with dementia will often sense a care partner’s frustrations or anger and become anxious or angry themselves.

Anger and rage are often signs that the person is feeling loss of control in his/her life. Calmly acknowledge feelings even when you do not understand what is being said or why the person is angry. Saying something like “I know you are angry (or upset) about what is happening to you,” can be helpful in reducing agitation.

Remember that all behavior has a purpose; we shouldn’t assume the purpose is sexual. The underlying need could be physical, psychological or social. For example: The person living with dementia could be asserting his/her sexual identity as a way to gain control over their environment. As human beings, we all need to feel acknowledged and connected. Consider that the individual living with dementia may be expressing a desire for touch. Alzheimer’s disease affects people in varying ways. Sexual desire may increase or decrease after the onset of Alzheimer’s disease. Changes in the sexuality of people with Alzheimer’s disease include the following:

Bold Behavior

The person may forget his or her marital status and begin to flirt or make inappropriate advances towards members of the opposite sex. Consider how you might be giving the resident the wrong message or signal. For example, if you are leaning across a resident to help put on a shirt and he/she grabs your breast, you might want to help with the shirt from behind.

Exposure

The person may forget how to dress or take her clothes off at inappropriate times and in unusual settings. For example, a woman or man may remove a blouse or shirt simply because it’s too tight and she/he feels uncomfortable. The person doesn’t realize or understand that clothes shouldn’t be removed in public places.

Paranoia

The person may become unreasonably jealous and suspicious. For example, the person may think that his wife has a boyfriend, and accuse her of going to see him.

Misinterpretations

The person may make sexual advances to a stranger who resembles a former spouse, lover or companion. In addition, the patient may forget that he or she is married and approach a person in a sexual manner.

Physical Illness

Physical illness may cause the person to lose interest in sex or make sexual intercourse difficult or painful. Reactions to medications may also reduce sexual desire.

Depression

Depression can reduce interest in sex, both by the patient and their spouse or loved one. Some care partners report that they experience changes in sexual feeling toward their loved one after providing daily care taking actions. By understanding these factors, and recognizing that they may affect you and the person with Alzheimer’s, you will be able to respond better to the sexual needs of the person with Alzheimer’s disease.

Action Steps

• Look for a reason behind the behavior. Keep in mind that if the person exposes himself, he may simply need to go to the bathroom. If the person begins to take off his clothes, he may want to go to bed.
• React to the person with patience and gentleness. If the person is engaging in unusual sexual behavior, carefully remind her that the behavior is inappropriate. Then, lead the person to a private place or try to distract with another activity. But take care not to get angry with the person or laugh and giggle at the behavior. In most cases, anger and ridicule may cause negative reactions. Make statements, not judgments, to the resident when his or her behavior is not acceptable. Do not scold, argue, tease, or shame. Respond to the behavior, not the person. For example say, “Mrs. Smith, grabbing is not O.K.” or “Please stop, I do not like that,” or, “Keep your hands to yourself, please.” Define your role clearly, e.g., “Mr. Jones, I am your nurse.”
• Respond carefully to threats and accusations. If the person has become paranoid, he or she may accuse you of sexual misbehavior. Simply seeing you with another person may be enough to cause suspicion. Remember that paranoid behavior doesn’t respond to reason or argument. Try to distract the person with another activity or reassure him or her with a hug or touch.
• Adjust the person’s clothing. Or provide the person with pull-on pants with no zipper. Loosely fitting clothing with elastic waist bands is more comfortable and less likely to encourage fidgeting.
• Increase the level of appropriate physical contact. Sometimes the only time a person receives touch is during personal care. Offer touch at other times if cares become a time of difficulty. The sense of touch remains well preserved in many residents, even in advanced stages of the disease. Touch is a special gift we never seem to lose. Spending time in close physical proximity to one another can help fulfill the need for intimacy.
• Give the person plenty of physical contact in the form of stroking, patting, hugging and rubbing. In many cases, the person is anxious and needs reassurance through touch and gentle, loving communication.

Talk to your teammates to determine the best approach for addressing recurring behaviors.  Plan a care consultation with Alzheimer’s Association staff.  There must always be a team approach to problem solving.  Any plan must be carried out consistently by all staff on all shifts.

“Boy, she sure is a big gal.” or “I don’t want him taking care of me because….”

It is not unusual for people with dementia to regress to an earlier time in their lives. For some residents, this can result in reverting to a language that was spoken when they were young. Traumatic events from a resident’s younger years can have a significant impact as their condition progresses, as well. For example, dementia may progress very differently for a Holocaust survivor, a military veteran, a person who has been abused or a former refugee. Dementia may also present very differently for patients who have intellectual disabilities.  A person may be suffering from PTSD along with dementia.

Every person living with dementia is unique and will evolve and change as the condition progresses. Successful caregivers offer person centered care. Person-centered care is essential to good dementia care and the underlying philosophy of the 2018 Alzheimer’s Association Dementia Care Practice Recommendations. Person-centered care is a philosophy of care built around the needs of the individual and contingent upon knowing the person through an interpersonal relationship. It’s spending time engaging with the person living with dementia, as well as with their families and friends if possible, to gain a better understanding of their personal stories in order to provide better care.

Many people worry about inadvertently causing offense or appearing culturally insensitive with regard to diversity. But asking questions, listening and learning does not equate to insensitivity. Successful caregivers treat patients respectfully, maintain an attitude of cultural humility and spend time learning about each resident’s unique needs and wants.

Our workforce is also unique and diverse.  We must also realize that a resident’s memory may be back at a date and time when they didn’t have the opportunity to be around diverse populations, or they may be fearful of any female because they were abused by an adult female when they were young, etc.  Again, if you know the source of their fear, you can work toward alleviating that distress with what you know is a comfort for them.

The first question to ask is, is it hurting the resident or anyone else for him or her to be first?  If not, let it go.  Because of what’s physically happening to a person’s brain who is living with dementia, they don’t have the capacity to understand the concept of time anymore.  When losing the concept of time, is it that days and nights are mixed up?  If so, the joy of a long term care facility is that it is staffed 24 /7 and a qualified staff is ready and willing to care for those needs at night. Naturally during the daytime is when it’s easiest to serve meals, keep a routine, etc., so it’s most convenient for all for a resident to be awake during daytime hours. Consider if the resident is sleeping during the day.  If so, try to keep them more awake and active during the day to make them tired so they can sleep better at night.  Try avoiding too much caffeine during the day.  Ease into a night time routine of a quiet environment and dimming lights.  When losing the concept of time and wanting to go first, does this mean group activities / mealtime is being disruptive?  If so, consider more one on one and small group activities and meal time.  For any of the above scenarios, consider the following tips from the topic sheet with tips that could apply to any type of behavior.

“Redirecting” Difficult Behaviors: Validate, Join and Distract

Have you ever heard of redirection? It’s a common term used in Alzheimer’s care. Is your loved one anxious? Redirect them with a cup of coffee! Is your loved one asking to go home? Redirect with a basket of towels to fold! The problem with redirection is that it often doesn’t work for good reason. When we jump right into a distraction like coffee or folding towels, we are missing some crucial steps.

Imagine yourself in my friend Emily’s shoes. Emily, who is 91 years old, spent much of her life caring for her family – her grandparents, her children, her parents and finally her husband. Her lifelong routine as nurturer didn’t end with the onset of Alzheimer’s disease. Since long-term memory tends to remain intact well into the disease process, Emily has been thinking about her parents, recalling how much she loves them. As her disease progresses, Emily gets confused and forgets that her parents have died. Soon, Emily is convinced that her parents are back in Connecticut waiting for her to come home and take care of them.

How would it feel to be Emily? Today, the innate drive to watch over her family is as real as ever. How would you feel if you were certain that your family needed you, but you couldn’t get to them? Panic-stricken? Frightened? Terrified?

Challenging behavior usually indicates deep emotion. Fear, loneliness, embarrassment and frustration may be expressed through anxiety, aggression, pacing or wanting to go home. An essential piece in “redirection” is recognizing the emotion being expressed. Acknowledging the emotion out loud and validating the emotion as justified are crucial steps to providing reassurance.

The importance of validation is evident throughout our lives. Imagine you come to me and say, “I am having the worst day. My dog died last night. This morning I woke up with a terrible cold. I was in a car accident on my way to the store. I just feel awful.” And what if my response was “Come and play an exciting round of Bingo with me!” What an injustice! I completely failed to acknowledge the depth and breadth of your feelings. And yet, because Alzheimer’s disease can cause childlike behavior, we sometimes forget that people with Alzheimer’s have a lifetime of adult experiences and adult emotions that deserve our utmost respect.

So if you were Emily, what would you do next? I don’t know about you, but my guess is that I would do whatever I had to do to find my family. My friend Emily is doing just that. Everyday she tries to leave home to get to Connecticut where she believes her family is waiting for her. Those of us who care about Emily have tried gentle reminders to orient her back into reality. “Emily, didn’t you tell me that your parents died several years ago? Didn’t you say that your children were grown with children of their own?”

“Oh no,” she says, “If that were the case, someone would have told me. My family is not like that.” Next we tried redirection. As she tried to leave the house we would call to her, “Emily, we’re going to play Bingo. Come join us.” But as you might imagine, when given the choice between home and Bingo, Emily still headed for the door.

What is the dilemma here? Why aren’t these traditional techniques working? We seem to be forgetting that for Emily, the need to find and take care of her parents, as ridiculous as that may seem to those of us who have intact brains, is as real to her as our drives, ambitions, and needs are to us. For Emily, this is real. And who are we to tell her otherwise? When we do, we become “the enemy” – part of the problem standing in the way of her reaching her goal.

So what would happen if, instead of standing in her way, we joined her? What if we said, “Oh, you’re trying to get to Connecticut? Let me see what I can do to help you.” From Emily’s perspective, how would you feel if you heard that? Relief? Trust? Comfort? To join Emily may mean that I have to use approaches that are untrue, but Emily has a disease that prevents her from understanding and recognizing truth as we know it. Isn’t it more humane and ultimately more effective to frame my response in a way she understands?

Finally, we can use an activity to distract Emily from this disturbing train of thought. Using what we know about her life story, we can draw from her interests and strengths to find a task to engage her. How quickly we jump to the distraction depends upon the situation. Some examples follow below:

This scenario with Emily has played out in a number of different ways. What works today might not work tomorrow – and vice versa. Here are some examples of techniques that have worked to calm and reassure Emily when she is headed for the door.

Approach gently with a hand lightly on her back. “Hi Emily. It looks like you’re heading somewhere.” “Yes, I need to reach my parents in Connecticut.”

Validate – “You seem worried about them.” “I am, they are all alone and I need to take care of them.”

Join – “That sounds frightening. Let me see what I can do to help. I’m going to make some phone calls to see what we can do to help you.”

Distract – “In the meantime, here’s a cup of coffee and you can glance through the newspaper while I’m on the phone. I know how much you enjoy reading the paper.”

At this point, leave the room. If Emily is distracted by the paper and the coffee (or folding a basket of towels or looking through an old photo album), back off to see if she stays distracted for a while. If not, and she still has concerns about her parents, join her by giving a reassuring message. “Emily, I got a message from your family. They want you to know that they are all okay and safe. They know where you are and everything is fine. Isn’t that a relief! Boy, I know how worried you are, so I was so relieved for you when I got that message!”

This reassuring message might come from a letter, typed and signed from her parents. It might come from a tape-recorded message though the voice of a familiar loved one; play it to her on the phone or directly from the tape recorder. It might come on a pink telephone message slip where we’ve printed the message. Or perhaps make some phone calls together to a family member, or someone who can provide the reassuring message over the phone. Sometimes, when the message comes from me, Emily doesn’t buy it – but for some reason, talking on the phone increases the validity of the message. Then, try another distraction.

Approach gently with a hand lightly on her back. “Hi Emily. It looks like you’re leaving.” “Yes, I need to reach my parents in Connecticut and you can’t stop me.”

Validate – “You seem worried about them.” “I am, they’re all alone and I need to take care of them, so don’t try and stop me.”

Join – “That sounds frightening. Let me see what I can do to help. I’m going to make some phone calls to see what we can do to help you.”

Distract – “In the meantime, here’s a cup of coffee and you can glance through the newspaper while I’m on the phone. I know how much you enjoy reading the paper.” “I’m not reading any paper, I’m getting out of here.” And out the door she goes.

When this reaction occurs, joining is essential. “Emily, I want to go home too. Let’s get out of here.” Then go for a walk together, eventually trying to steer her home. Sometimes we would walk until we grew tired and called a friend for a ride home. Sometimes we would walk around the block and stop at our house for a drink of water (and a distraction). Sometimes we would walk until we saw a friend who we could flag down for a ride – a friend who might inform us that the bus to Connecticut was cancelled, but we could stay in town tonight – and as long as we needed.

I must constantly ask myself, what message would be most reassuring to her? What’s the easiest and most believable way to present that message? My main goal is to provide reassurance and love. What was once “redirection” becomes gentle guidance to refocus energy from anxiety and loss to comfort and strength

When a person has a diagnosis of dementia, it may be difficult to determine if what you are seeing is from the dementia or mental illness.  Knowing they have dementia, always communicate with the positive techniques you have learned using patience, limiting distractions, validating, joining, redirecting and then distracting.

Mental Illness and Dementia: Similarities and Differences

In many ways, mental illness can manifest the same symptoms of dementia, and vice versa. While there are a lot of similarities between the two, there are also some pretty critical differences.

Mental Illness with AD

It’s common for mental illness, particularly depression, to happen in the early stages of Alzheimer’s disease and other forms of dementia. Accurate diagnosis and treatment have been known to improve cognitive function. It’s difficult enough living with AD, but the symptoms are compounded when it occurs in conjunction with other mental disorders like anxiety, depression, and psychotic conditions.

In fact, the CDC says that serious symptoms of depression occur in up to 50 percent of older adults with Alzheimer’s, and major depression occurs in about 25 percent of cases. Depression is often intermingled with the belief that this is simply an older adult’s reaction and awareness of progressive decline. But there is more to it than that, with some research suggesting there is a biological connection between AD and depression.

Anxiety disorders are also common, happening in about 30 percent of adults who have AD. Anxiety can include anything from generalized nervousness and fear of leaving home to agitation regarding changes of routine and feelings of suspicion or paranoia. Anxiety can also be psychologically and physically linked to AD.

Symptoms for Dementia Sufferers

Alzheimer’s may also co-exist with psychotic conditions. Older adults who have schizophrenia are just as likely to develop AD as those who have no severe mental illness. They are also at a higher risk for depression, translating to a possible trifecta of co-occurring mental disorders. Symptoms of these disorders include:

• Extreme sadness
• Feelings of hopelessness
• Disinterest in people and previously-enjoyed activities
• Irritability
• Anxiety about change, going out of the house, strangers, etc.
• Feelings of suspicion or paranoia
• Sleep disturbances
• Agitation
• Restlessness
• Increased aggression
• Pacing
• Immobility
• Delusions
• Hallucinations
• Verbal or physical abusiveness
• Refusal to cooperate

Such symptoms are also associated with negative consequences for those who are caring for the patient, such as heightened caregiver burden, and increased risk of depression, anxiety disorders, and physical illness in caregivers.

Making the Distinction

When you think of dementia, you may think of it as a mental illness because of the effects on the brain. However, there are some big distinctions between dementia and mental illness which must be considered in order to make an accurate diagnosis. Yes, dementia does affect mental health but it is not a mental illness. Rather, it’s a disorder of the brain that can cause memory loss and communication difficulties.

The correct diagnosis of mental illness or dementia in the elderly is key in making sure they get the appropriate treatment as fast as possible. Misdiagnosis of mental illness in seniors is very easy to make, as symptoms tend to be so similar to dementia, such as confusion and erratic behavior.

It’s important to get a clear look at the symptoms of dementia and the symptoms of mental illness.

Dementia Symptoms

Alzheimer’s disease is the most common cause of dementia. It basically causes cells in the brain responsible for controlling memory to die. This irreversible condition occurs in severe and moderate stages, with the main symptoms of dementia including: Difficulty communicating, increased memory issues, general confusion, personality and emotional changes.

Common Mental Illnesses in the Elderly

If a senior shows signs of mental illness, it’s vital to recognize the symptoms and seek treatment quickly. Some of the common mental illnesses among the elderly include:

• Depression: This is the most common mental disorder in seniors. Social isolation plays a big part in emotional well-being, so when a senior is left alone for long periods of time away from loved ones, depression can set in quick. Depression is also a symptom of dementia which is where things get tricky.
• Late-onset bipolar: This can be tough to diagnose in late stages due to its similarities to dementia symptoms such as manic behavior, agitation, and delusions.
• Late-onset schizophrenia: This manifests in adults after age 45, and also has symptoms similar to dementia, such as hallucinations and paranoia.

Is there history with the other resident/residents they are acting aggressively toward? Do they look like someone from their past? It’s important to try to understand what may be triggering the aggression.

Never assume that a behavioral or cognitive symptom is inevitable or irreversible. Always search first for a treatable cause of the symptom. Daily possibilities to watch for include pain, hunger, thirst, and drug side effects.

Reward desired behaviors every time. This means simply a touch, a smile, a thank you. To great extent possible, ignore undesired or inappropriate behaviors. This means showing no emotion, nor making eye contact, and not speaking of the unwanted action.

Provide daily activities involving movement to music (dancing, marching, exercising, signing and swaying, etc.) An electronic Echo, portable CD/tape player or radio will prove very handy.

Foster any and all remaining skills that are appropriately independent. Let the person help with tasks, however small, that he or she can still do. Avoid routinely doing things that the person can do. Give no more help than is needed.

Foster routines by maintaining a consistent schedule and consistent way of doing things.

Choose some desired behaviors that are too infrequent, and work on increasing them. This is more likely to prove helpful than if you focus on decreasing some frequent, undesirable ones. Prompt, invite, and encourage the person to participate in appropriate activities.

Simplify complex behavioral sequences into small segments. Eating a meal, for example consists of sitting down at the table, picking up a fork, spearing the food, raising it to the mouth, and so forth.

Avoid confrontation with the dementia sufferer over any factual issues. If he or she holds firmly to an inaccurate belief or dislikes some facts that can be grasped accurately, don’t be drawn into argument. Instead, be non-committal about facts, (“My goodness! I just don’t know!” or “We’ll have to check on that”), and show empathy for the person’s feelings, (“That must be awful! I hear you!”).

Decide based on your observation of the person, what his optimal level of stimulation is, then try to provide it. Pay attention to lighting, noise, and the number of people around.

Provide multiple, redundant sensory cues. For example, help the person locate bedroom items, and drawers may be labeled with pictures and names of the contents.

Modify the environment to improve their access to appropriate places and materials, and to reduce his/her access to inappropriate activities, behavior, other residents. If the resident has their room in close proximity to the other resident or residents they are aggressive to, try to change rooms a further distance and where it may be easier to supervise what they are doing.

If you cannot figure out why a certain behavior problem continues, keep a behavioral journal or log. Look for patterns that will identify causes and connections between triggers, behavior and rewards.

Care partners, both family and professional must take good care of themselves. They should fully use the skills of knowledgeable professionals who are available to them.

Hallucinations, delusions and paranoia

Due to changes in the brain, people living with dementia may sometimes experience hallucinations, delusions and/or paranoia. Understanding the difference between these can be helpful.

A hallucination is a false perception of objects or events and is sensory in nature. When individuals with Alzheimer’s have a hallucination, they see, hear, smell, taste or even feel something that isn’t really there. They may see insects crawling on their hand or hear people talking to them and respond to those voices.

In contrast, a delusion is defined as a false idea, sometimes originating in a misinterpretation of a situation. For example, when individuals living with dementia have a delusion, they may think that family members are stealing from them or that the police are following them. This kind of suspicious delusion is sometimes referred to as paranoia.

It’s important to remember that hallucinations and delusions may or may not be upsetting to the person with dementia. Not all hallucinations are frightening, and not all delusions are paranoid in nature.

See the doctor. When helping someone who is experiencing hallucinations or delusions, the best way to start is by arranging a consultation with the person’s doctor. The physician can look for physical causes, such as kidney or bladder infections, dehydration, pain or alcohol/drug abuse, all of which can cause hallucinations or delusions. It is also possible that treatments being prescribed for pain are the cause. If the physician prescribes a medication, watch for and report any side effects that you may notice, including over-sedation, increased confusion, tremors or tics.

While non-drug interventions are often effective, medications can be helpful when the person is persistently upset by the symptoms and non-drug approaches (described below) have already been tried. You may also want to ask the doctor to evaluate the person to determine if medication needs to be added or adjusted to reduce hallucinations or delusions. If the person has a history of serious mental illness, such as schizophrenia, the hallucinations and/or delusions may be related to that illness. It’s important to work closely with the person’s doctor to help determine an appropriate course of action.

It may also help to have the person’s eyesight or hearing checked. This should be done regularly. Make sure the person wears any prescribed glasses or hearing aids as needed.

Non-medical interventions. Interventions that are not medical in nature are often the best ways to help someone experiencing hallucinations or delusions. Assess the situation and determine whether or not the symptom is a problem for you or for the individual. Is the hallucination/delusion upsetting to the person? Is it leading him or her to do something dangerous? Does the sight of an unfamiliar face cause him or her to become frightened? If so, react calmly and quickly with reassuring words and a comforting touch.

Respond with caution. Be cautious when responding to the person’s hallucinations and/or delusions. If they don’t cause problems for you, the person or other family members, it’s typically best to ignore them. Avoid arguing with the person about what he or she sees, hears or believes. Unless the behavior becomes dangerous, you might not need to intervene.

Offer reassurance. Reassure the person with kind words and a gentle touch. For example, you might want to say, “Don’t worry. I’m here. I’ll protect you. I’ll take care of you,” or “I know you’re worried. Would you like me to hold your hand and walk with you for a while?” Gentle patting may turn the person’s attention toward you and reduce the symptom. Also look for reasons or feelings behind the hallucination or delusion and try to find out what it means to the individual. For example, you might want to respond with: “It sounds as if you’re worried” or “I know this is frightening for you.”

Use distraction. Suggest that the person comes with you on a walk or sits next to you in another room. Frightening hallucinations and delusions often subside in well-lit areas where other people are present. You might also try to turn the person’s attention to a favorite activity, such as listening to music, drawing, looking at a photo album or counting coins.

Respond honestly. Keep in mind that the person may sometimes ask you about the hallucination or delusion. For example, if he or she asks, “Do you see him?” you may want to answer with, “I know that you see something, but I don’t see it.” This way, you’re not denying what the person sees or hears, but you avoid getting involved in an argument.

Assess the reality of the situation. If the person is having a hallucination, ask the person to point to the area where he or she sees or hears something. Glare from a window may look like snow to the person, and dark squares on a tiled floor may look like dangerous holes.

Modify the environment. If the person looks at the kitchen curtains and sees a face, you may be able to remove, change or close the curtains. Turn on more lights to reduce shadows that could look frightening. If the person insists that he or she sees a strange person in the mirror, it’s possible that the person doesn’t recognize his or her own reflection. If the person has delusions about people stealing from him or her, have some duplicates of those items on hand so you can provide the person with a replacement if it becomes lost.

Use all of the positive ways you’ve learned to communicate and respond to all behaviors in the previous 7 days of Christmas. Validate (I’m sorry your purse is missing), join (I’ll let everyone know to keep an eye out for your red purse), distract (while we’re looking for your purse, let’s grab a cup of hot chocolate)!