Training staff for Alzheimer's disease. (Assisted Living Review).

Recent studies indicate that 52% of all assisted living residents suffer from Alzheimer's disease or some other form of dementia. As many residents "age in place" the percentages increase, putting many providers in the challenging position of providing appropriate and safe care. Providers have been forced to rethink the physical and staffing structure of their residences to accommodate the very special needs of these residents.

While the process of developing a safe and physically secure setting for the resident is high on everyone's list of priorities, the additional requirement of specialized staff training is often overlooked. All too frequently, staff members are transferred into an Alzheimer's/dementia unit with little or no preparation to meet the challenges of care in this environment. One caregiver likened the experience to being sent onto a tennis court without a racquet.

Providers who have successful Alzheimer's units report that staff training is critical to providing the specialized care required by the residents with Alzheimer's. Failure to provide training often results in employee burnout and frustration and reduced quality of care.

What are the components of a good Alzheimer's/dementia training program? In developing the Alzheimer's program for the Assisted Living Federation of America (ALFA), we focused on three critical areas: understanding the disease, skills to manage challenging behaviors, and strategies for helping families and caregivers cope with the emotional challenges of caring for a resident with Alzheimer's disease.

Understanding the Disease

Many caregivers and family members do not fully understand Alzheimer's disease and other related dementias. It is helpful for caregivers to understand that there are different kinds of dementias, some of a temporary nature that are reversible and others, such as Alzheimer's, that are progressive and irreversible.

It is important for caregivers to understand the progression of the disease from its early stage of mild symptoms through the moderate and severe stages. Understanding the progression of the disease allows the caregiver to respond appropriately to residents' symptoms as they occur.

Early-stage symptoms include recent memory loss (residents frequently lose or misplace things), confusion (particularly with numbers), increased need for security and hesitancy to try new things, language problems evidenced by difficulty finding the right word, and mood or personality changes.

As the disease progresses, the caregiver will see increased memory loss, perhaps growing suspicion of others, the need for assistance with activities of daily living (ADLs), "sun-downing" syndrome (more restless and confused in the late afternoon and early evening) and language difficulties in expressing thoughts or feelings.

In the late stage of the disease, residents often experience severe language deterioration and are unable to communicate with words, as well as having severe memory loss to the extent that family might not be recognized, difficulty swallowing, total care for ADLs, and possibly incontinence.

The caregiver who understands this progression is better able to monitor the resident's health status and to assist both the resident and the resident's family.

Skills to Manage Challenging Behaviors

One of the most difficult aspects of caring for a resident with Alzheimer's is coping with challenging behaviors. As the disease progresses, the resident might wander and become highly agitated or aggressive.

Caregivers who understand these behaviors and who receive appropriate training in Alzheimer's care are better able to effectively respond and redirect the resident in a compassionate and respectful manner. Communication skills become increasingly important as the disease progresses and residents resort to physical behaviors rather than words to express themselves.

Basic to training is a clear understanding of the effect of Alzheimer's disease on communication. Imagine living in a strange land where you do not speak the language, people don't understand what you are saying and you don't understand what they are saying. Would you perhaps feel frustrated, sad or lonely? A resident with Alzheimer's disease lives in a land like this. It falls to the caregiver to find ways to improve communication verbally and nonverbally.

When a resident's behavior becomes challenging, it could be a result of declining brain function, or it could be an expression of a need or feeling. The challenge to caregivers is to "enter the resident's world," to try and understand the situation from the resident's point of view and figure out what the resident is attempting to communicate.

Skill-based training for managing these behaviors empowers the caregiver to minimize residents' discomfort and make their challenging behaviors less of a problem. Caregivers should be given strategies that help them cope effectively with such behaviors as wandering, agitation, aggression, paranoia and repetitive actions.

Coping Strategies 

Long-term caregiving, in general, is an emotionally and physically demanding profession. Providing care for a resident with Alzheimer's disease is even more challenging. The caregiver is often faced with limited communication from the resident and what might seem to be hostile or aggressive behaviors. Even with an understanding of the disease and its manifestations, day-to-day encounters with these residents can take a heavy emotional and physical toll.

The caregiver is also one of the consistent interfaces with residents' family members. Families experience a great sense of loss as the disease progresses and often turn to the caregiver for support and reassurance. Sometimes family members vent their frustrations with the disease inappropriately, directing their anger at the caregiver.

It is important that caregivers learn how to care for themselves both physically and emotionally so that they are able to deal with the very real stresses of a demanding position. Burnout is commonplace in this field but can be minimized with appropriate training and support from administration.

Just as no tennis coach would expect a player to go onto the court without a racquet, the assisted living provider is responsible for providing each caregiver with the tools necessary to provide quality care for their residents with Alzheimer's disease. Caregivers who understand the disease, and have the skills to manage behaviors and coping strategies to relieve the inherent stresses, are able to provide the quality care your residents require and deserve. Those who are thrown "into the game without a racquet in hand" are operating at a severe disadvantage. As you assess your own program, take inventory and make sure each caregiver has been given the tools for the job.

David Peete is president of ALFA University, the training initiative of the Assisted Living Federation of America ALFA University offers a comprehensive Alzheimer's training program and certificate of study for caregivers.