Caregiving Tips for Care of the Alzheimer's Patient.

A distillation of advice from the recent literature

Ten years ago my mother, at the age of 50, was diagnosed with probable Alzheimer's disease. I was sure that this diagnosis was a mistake. She was young, active, newly married, and an accounting technician in a large corporation. However, as time passed, I realized that my family was dealing with a chronic illness. My stepfather took an early retirement to care for my mother. She functioned well in her routine environment. However, when she was hospitalized for an acute episode, she had personality changes. These changes were, in part, caused by the fact that not every hospital or long-term care facility had a special Alzheimer's unit. Instead, providers--who might have had little or no education in caring for a patient with dementia--gave the healthcare. In addition, many facilities were short-staffed and nurses floated to different areas.

There are areas of care that cause conflict between people with Alzheimer's disease and healthcare providers. Many individuals with Alzheimer's become agitated and even aggressive in response to stress. Negative behaviors include incontinence, insomnia, loss of communication skills, aggressive episodes and wandering. Areas in acute and long-term care that increase stress for those with dementing illness include (a) communication, (b) hygiene, (c) nutrition, (d) elimination and (e) pain. Additionally, special concerns related to comfort and safety must be addressed.

Research indicates that staff can often defuse these situations with simple techniques. Following are practical guidelines, organized within specific problematic areas with specific interventions aimed at two outcomes: (a) to facilitate independence and (b) to encourage the highest level of physical, emotional and cognitive functioning.

Communication

(Derived from Bartol, 1980; Beck and Heacock, 1988; Gwyther, 1985; Sheldon, 1994; Wilson, 1990; White, Kaas and Richie, 1996)

1. Modify question-asking.

2. Avoid open-ended questions (the resident's ability to generate ideas and think of possibilities diminishes).

3. Ask questions that include limited choices (e.g., would you like to go for a ride or stay home?).

4. Minimize the use of pronouns. Repeat the name of the person each time.

5. Breakdown tasks into simple steps (give only one step at a time).

6. Repeat yourself. Be redundant and restate critical facts several times to help relay messages.

7. Be explicit and direct. Residents have difficulty processing implied information. Be literal. Say what you mean.

8. Provide additional cues.

9. Use eye contact.

10. Avoid noisy and busy surroundings.

11. Do not pretend to understand vague and nonsense words.

12. Use hand gestures. Show residents what you want them to do.

Hygiene

(Derived from Hall, 1991; Wilson, 1990)

1. Bathe resident at his/her best, most rested, least confused time.

2. When possible, avoid using the shower.

3. Soft music, low singing or talking, snacks, massage or colored bath towels might distract the resident and make bathing less fearful.

4. Have the resident's hair washed at the beauty salon, if available.

5. Bathe resident at the time he/she was used to bathing at home.

6. A resident might refuse to have someone of the opposite sex bathe him/her.

7. Prepare in advance (i.e., have soap and shampoo available, towels and clean cloths on hand, water drawn, temperature tested).

8. Keep bathing area warm.

9. Gently direct the resident at bath time.

10. If the resident refuses a bath, try distracting him/her for a few moments and then try again.

11. Avoid bath oils that make tub or shower slippery.

12. Because showers often are more frightening to people with Alzheimer's disease than baths, install grab bars and use a tub seat and rubber mats.

13. Never leave the resident alone in a bath or shower.

14. Coach the resident during each step of the bath.

15. Castile soap rinses well and might be gentler than deodorant soaps.

16. Make sure the genital area is washed.

17. Check for reddened areas of skin, rashes and sores. Pressure areas could develop undetected.

Nutrition

(Derived from Beck and Heacock, 1988; Durkee, 1996; Hall, 1991; Miziniak, 1994; Wilson, 1990)

1. Eliminating caffeine from the diet might help calm the resident.

2. Narrow food choices on the tray to one or two at a time.

3. Serve several small dishes, frequent meals and snacks.

4. Sometimes a resident refuses to eat because he/she "can't pay." Reassure him/her that the meal has been paid for.

5. Remind the resident to eat, and touch him/her lightly on the arm. This has been shown to increase food intake.

6. As the disease progresses, the resident loses the dexterity needed to maneuver utensils and cups. Use finger foods, covered toddler cups and broad-handled utensils.

7. Eventually a blended diet will be needed when the resident forgets how to chew.

8. Cut food carefully into small bite-sized pieces. Remove all bones from plate. Avoid using Styrofoam or paper cups and napkins, which might be mistakenly eaten.

9. Remind the resident to chew and swallow properly.

10. Use only a spoon for feeding.

11. Place a damp washcloth under the plate to prevent it from sliding.

12. If necessary, place the spoon in the resident's hand, put your hand over his/hers and guide the food to the mouth. The patient might be able to continue independently after a few assists or with encouragement.

13. Weigh the resident weekly. If there is weight loss, double food portions. (Breakfast is usually the besteaten meal of the day.)

14. If resident "wanders" or won't sit down, make sandwiches that can be carried.

15. Freeze liquids into popsicles.

16. Make sandwiches Out of mashed potatoes, meat and vegetables (potatoes are the "glue" that holds meat and vegetables together).

17. Allow resident time to eat.

18. Provide four to six small meals a day.

19. Pureed food can be put in milk, ice cream, high-protein or instant breakfast type drinks.

20. Residents might eat more if they are in small groups rather than large ones.

Elimination

(Derived from Hall, 1991; White, Kaas, Richie, 1996; Wilson, 1990)

1. Clear a path to the toilet or commode. Place commode at bedside.

2. Record the resident's bowel habits and observe closely for constipation.

3. Put resident on a q2 voiding schedule to avoid unnecessary embarrassment or accidents.

4. Put the word "toilet" on the door to the bathroom as a gentle reminder.

5. Leave light on during evening hours to help the resident find the way to the bathroom.

6. Praise appropriate behavior and ignore inappropriate behavior.

7. Make sure the resident is dressed in clothing that can be easily removed (limited zippers, buttons, belts or snaps).

8. Provide the overactive resident who gets up and down while on the toilet with a distraction (e.g., a magazine or photo album).

9. Offer fluids every 1 to 2 hours to prevent dehydration or urinary tract infections.

10. Recognize signs such as lethargy, reduced appetite and abdominal distention as indications of constipation.

11. Encourage a high-fiber diet. Discourage laxatives.

Pain Control

(Derived from Hall, 1991; White, Kaas, Richie, 1996; Wilson, 1990)

1. Many Alzheimer's residents have good reasons for pain, yet are undertreated because they can't express themselves. Look for cues (e.g., irritability, yelling, change in vital signs).

2. Postoperatively, give the resident a regularly scheduled analgesic.

3. Avoid Demerol; restlessness is a common side effect.

4. When residents present with agitation, yelling and/or acting out, evaluate for pain or discomfort.

Comfort

(Derived from Hall, 1991; White, Kaas, Richie, 1996; Wilson, 1990)

1. Assess the area around the resident for potentially overwhelming or misleading stimuli (e.g., ice machines, fire bells, public address systems, places where people congregate).

2. Keep the television off until the resident turns it on or request it.

3. Remove artwork that represents people or animals if it is possible that the resident might view them as real-life intruders.

4. In early stages of Alzheimer's, presence of a clock might be a reassuring reminder of the present.

5. Provide a consistent, predictable structure in routine.

6. Try to schedule at least two rest periods (after morning care and an hour in the early afternoon) to prevent late-day confusion and agitation.

7. If possible, post rest period hours on the door. A dark, quiet room cues the patient to sleep.

8. Maintain a calm, quiet, gentle demeanor.

9. Simplify phrases to one thought or message per statement.

10. Make sure glasses, dentures and hearing aids are in place.

Cindy Stinson, MSN, RNC, CNS, is an instructor in the Department of Nursing, Lamar University College of Arts & Sciences, Beaumont, Texas.

Bibliography

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