Module #5 
Dementia & Alzheimer’s Disease

Module #5 focuses on care for patients with dementia or Alzheimer’s disease. Dementia is a general term for a decline in mental ability severe enough to interfere with daily life, while Alzheimer’s is a specific disease. Alzheimer’s is the most common cause of dementia.

Read carefully because at the end of this module is a quiz required for successful completion of this module.

There are 10 questions and 5 minutes to complete. A passing grade is 70%; you must get 7 or more answers correct.  You have 8 chances to pass this module. 

Remember that you must successfully pass 12 in-service modules/year to meet the requirements for home health.

In-Service Exams provided by Essential In-Services for Home Health, 2021

Upon completion this module, you should be able to:

Know the definition and symptoms of dementia.

Understand the relationship between Alzheimer’s disease and dementia.

Know the importance of trying to understand what a patient with dementia is thinking and feeling.

Know some good ways to respond to difficult behavior.

Understand the difficulties faced by someone with dementia.

Dementia is an organic mental disorder involving a general loss of intellectual abilities and changes in personality (organic in the sense means the disorder is caused by physical changes in the brain).

Dementia is a brain disorder that seriously affects a person’s ability to carry out daily activities. It involves the parts of the brain that control thought, memory and language. Healthy brain tissues die or deteriorate, causing a steady decline in memory and mental abilities.

Alzheimer’s disease is the most common form of dementia with 60-80% of dementia being diagnosed as Alzheimer’s. Approximately 5.7 million Americans have Alzheimer’s. It is the 6th leading cause of death in the United States. Late onset Alzheimer’s occurs after age 65 and is the most common type.

Early-onset is an inherited genetic disorder where there is agene mutation of the chromosomes. A child whose biological parent carries the genetic mutation has a very strong probability of developing early-onset Alzheimer’s. Researchers have found that patients with certain variations of a gene known as APOE can increase the risk of Alzheimer’s disease by up to 12 times that of a normal APOE gene.

Many other different disorders can cause dementia. Vascular dementia which often occurs after a stroke is the second most common type of dementia. Other diseases may cause symptoms of dementia, which may be reversible. This includes thyroid crisis, vitamin deficiencies, Parkinson’s disease, brain tumor, head injury, and alcoholism.

Researchers have found that people with Alzheimer’s have lower levels of the chemicals that carry these important messages from one brain cell to another. In addition, people with Alzheimer’s have many damaged or dead nerve cells in areas of the brain that are vital to memory and other mental abilities.

Although the person’s mind still contains memories and knowledge, it may be impossible to find and use the information in the brain because of Alzheimer’s.

Abnormal structures called plaques and tangles are other characteristics of Alzheimer’s:

  • Plaques. It is believed that plaque deposits form between brain cells early in the disease process.
  • Tangles. This refers to the way that brain cells become twisted, causing damage and nerve cell death.

These structures block the movement of messages through the brain, causing memory loss, confusion and personality changes.

Symptoms can vary greatly, but at least two of the core mental functions below must be significantly impaired to be considered dementia.

  • Memory
  • Communications and language
  • Ability to focus and pay attention
  • Reasoning and judgment
  • Visual perception

You will recognize the following signs in many patients with dementia.

Memory loss:

  • Increasing and persistent forgetfulness
  • Affects recent memories the most
  • Makes it difficult to learn anything new or to follow instructions

Attention loss:

  • Unable to start or stop a task. 
  • Pacing and agitation. 
  • Easily distracted.

Loss of perception or senses:

  • Unable to recognize things or people. 
  • Misinterpretation of what is seen, heard or felt.

Language loss:

  • Makes it difficult to recognize words and understand complex sentences.
  • Makes it difficult to express ideas.
  • May use inappropriate words or curse words.

Judgment loss:

  • Cannot accurately assess circumstances that may be dangerous. 
  • Unable to see the consequences of actions.
  • Difficulties with abstract thinking or complex tasks.

Loss of muscle organization:

  • Unable to perform multi-step tasks. 
  • Requires prompts or cues for routine tasks.
  • Difficulty performing familiar activities such as brushing teeth or bathing.

Communication Tips

  • Be open, friendly and gentle at all times.
  • Always address the person by name to get his or her attention at the beginning of an interaction.
  • Give your full attention to the conversation or task. This helps the patient stay focused.
  • Briefly introduce yourself and offer some cues when you approach, stating your name and relationship and the purpose of your visit.
  • Speak slowly, but do not speak down.
  • Use gentle touching or hand-holding, but get permission first.
  • Avoid arguing and attempts to reason with a person who is upset. Acknowledge the patient’s feelings and gently distract him or her with something calming, pleasant and friendly.

Caring For Dementia Patients

Structure. Serenity and stability reduce behavior problems. When a person with Alzheimer’s becomes up the ability to think clearly declines even more. Follow a regular daily routine. Plan the schedule to match the person’s normal, preferred routine and find the best time of day to do things, when the person is most capable. lie sure to keep familiar objects and pictures around.

Bathing. Some people with Alzheimer’s won’t mind bathing. For others, it is a confusing, frightening experience. Plan the bath close to the same time every day. Be patient and calm. Allow the patient to do as much of the bath as possible. Never leave the patient alone in the bath or shower. A shower or hath may not be necessary every day. Try a sponge or partial bath some days.

Dressing. Allow extra time so the patient won’t feel rushed. Encourage the patient to do as much of the dressing as possible.

Eating. Some patients will need encouragement to eat, while others will eat all the time. A quiet, calm atmosphere may help the patient focus on the meal. Finger foods will help those who struggle with utensils.

Incontinence. Set a routine for taking the patient to the bathroom, such as every three hours during the day. Don’t wait for the patient to ask. Many people with Alzheimer’s experience incontinence as the disease progresses. Be understanding when accidents happen.

Environment. Make the environment familiar and safe. Set the water heater no higher than 120°. Keep medicines and any potentially dangerous items out of reach.

Exercise. This helps patients improve their motor skills, functional abilities, energy, circulation, stamina, mood, sleep and elimination. Avoid pushing the patient to exercise, but provide encouragement. Give simple instructions. Mild stretching exercises are good. Demonstrate how to tense and release muscle groups in sequence, keeping the order the same each time. Exercise or walk at the same time each day. A daily walk may reduce wandering.

Night ritual. Behavior is often worse at night. Create a ritual that is calming. Soothing music is helpful for some. Leave a night light on to reduce confusion and restlessness.

Ideas for Dealing with Difficult Behavior

Hiding, hoarding and rummaging. These common problems can be disturbing to caregivers and to others the Alzheimer’s patient lives with. Try the following strategies:

  • Lock doors and closets.
  • Put a sign that says ” No” on places you want to keep the person out of, such as certain rooms, closets or drawers.
  • Watch for patterns. If a patient keeps taking the same thing, give him one of his own.
  • Don’t leave things lying around in the open. Put things away neatly.
  • Make duplicates of important items like keys and eyeglasses.
  • Keep the person’s closet open so she can see her things in plain view. When the patient can see at all times that she still has her everyday items, she may not feel the need to go looking for them.
  • Designate an easily-reached drawer as a rummage drawer. Fill it with interesting, harmless items like old keys on chains, trinkets or kitchen implements. Allow the patient to rummage freely in this drawer.
  • Look through waste can when something is lost and before emptying them.
  • Patients with Alzheimer’s tend to have favorite hiding places for things. Look for patterns.

Repetition. A person with Alzheimer’s can become fixated on a task and repeat it over and over without stopping. Pacing, turning lights on and off, or washing hands repeatedly are examples of this. As long as the activity isn’t dangerous, there is nothing wrong with letting the person continue doing it. When the time comes that the patient must be asked to stop, try these tips:

  • Say “stop” firmly but quietly.
  • Touch the person gently.
  • Lead the person by the arm away from the activity.
  • Point out something distracting.
  • Say, “Thank you for folding all those towels. Now let’s go to dinner.” 

Wandering. First, find out if the patient needs something. Look for patterns in the wandering and possible reasons, such as time of day, hunger, thirst, boredom, restlessness, need to go to the bathroom, medication side effects, overstimulation or looking for a lost item. Perhaps the patient is lost or has forgotten how to get somewhere. Help meet the patient’s needs and keep her or him safe by trying the following things:

  • Remind the patient to use the bathroom every two hours.
  • Have healthy snacks and a pitcher of water readily available.
  • Provide a quiet environment away from noise, distraction, and glaring light.
  • Provide a purposeful activity such as folding clothes or dusting.
  • Provide an outlet such as a walk, a social activity, a memory book or classical music played through headphones.
  • Give the patient a stuffed animal to cuddle.
  • Keep lights on at night.
  • Try using different shoes on the person. Some people wander when they are wearing shoes but not when they are wearing slippers.
  • Use alarms, bells, or motion sensors. Bed alarms are flat strips laid under the sheets that sound when the person gets up. Outside doors should have bells or alarms that sound when opened.
  • Motion sensors can be used in hallways.
  • If the patient is in a home or agency with stairs, porches or decks, child safety gates should be used to block these. Two gates can be used for height.
  • Use child-resistant locks on doors and windows.
  • Put a black mat on the ground in front of the outside doors, or paint the porch black. Patients with Alzheimer’s often will not step into or over a black area.
  • If possible, the person should carry or wear some form of identification, such as an ID bracelet that looks like jewelry but is engraved with the person’s name, address, and phone number.
  • Educate neighbors on what to do if they find a wandering patient.

Confusion. Don’t try to enter the person’s world by pretending to see or hear the things that he or she seems to see or hear. Help the person stay grounded in reality by patiently using some of the following techniques:

  • Ask questions with yes/no answers.
  • Make a positive statement that lets the person know what you want. For example, say “stand still” in­stead of “don’t move.”
  • Give the person a limited number of choices.
  • Lay out clothes in advance. Keep the wardrobe simple, and try the following things:
    • Avoid buttons and zippers if possible.
    • Use Velcro fastenings and elastic waistbands.
    • Limit the number of colors in the wardrobe.
    • Eliminate accessories.
    • Use memory aids, such as posting a list of the daily routine or putting up a large calendar and clock. Other aids include:
      • Put name tags on important objects.
      • Use pictures to communicate if the person doesn’t understand words.
      • Make memory books with pictures of important people and places.
      • Post reminders about chores or safety measures.
      • Put a sign that says ” No” on things the person shouldn’t touch.
      • Paint the bathroom door a bright color and put a brightly colored seat cover on the toilet. These will remind the person where to go.
    • Give simple, precise instructions. Reduce distractions during a task. Give only as much guidance as necessary.

Sundown syndrome. Many patients with Alzheimer’s are more agitated, confused or restless in the late afternoon or early evening. Research shows the following things help: 

  • Leave lights on and shut out the darkness by closing blinds and shades.
  • Provide more activity earlier in the day. This will use up energy, reducing stress.
  • Schedule essential activities and appointments early in the day.
  • Encourage an afternoon nap every day. This reduces fatigue and agitation.
  • Play classical music on a portable radio or music player through headphones or earpieces. Shut out disturbing noises to soothe the patient.
  • Warm, relaxing baths, foot soaks or massages may help.
  • Reduce activity and distractions toward the end of the day.
  • Discourage evening visits and outings.
  • Avoid overstimulation. Turn off the television or radio before speaking to a patient.
  • Keep the patient well hydrated by offering plenty of water throughout the day.

Aggression and agitation. First be sure that the person is not ill or in physical pain, such as from an infection or injury. Then try the following suggestions:

  • Maintain a calm environment.
  • Reduce triggers such as noise, glare, television or too many tasks.
  • Check for hunger, thirst or a full bladder.
  • Make calm, positive, reassuring statements. Use soothing words.
  • Change the subject or redirect the person’s attention.
  • Give the person a choice between two options.
  • Don’t argue, raise your voice, restrain, criticize, demand or make sudden movements.
  • Don’t take it personally if the person accuses or insults you.
  • Say, “I’m sorry you are upset; I will stay until you feel better.” Don’t say, “I’m not trying to hurt you.”
  • Encourage calming activities that have a purpose. Sorting and folding laundry, dusting, polishing, vacuuming, watering plants and other quiet, repetitive tasks can be soothing.

Case Studies: What Would You Do?

Mr. Blair is not normally incontinent. Recently, however, he has begun walking outside to relieve himself. Occasionally he wets himself. He has started to wander, and he often seems anxious and agitated. 

What caregivers may assume: Mr. Blair has lost the ability to control his bladder and should be placed in adult incontinent briefs. 

What is really happening: Mr. Blair cannot find the toilet. In his home, the white toilet blends in with the cream-colored tiles and walls, and his visual loss is causing him to be unable to see it. He spends much of the day looking for a place to urinate, but when he can’t find one he relieves himself outside, where there are more bright colors that are easy to see.

Try this: Place a sign on the bathroom door or a brightly-colored toilet seat or toilet cover on. Mr. Blair’s commode to help him locate it. When you see Mr. Blair pacing or acting agitated, ask whether you can help him find the bathroom and then guide him to it.

Mrs. Mead is a retired nurse who lives with her elderly husband. Mrs. Mead has always enjoyed cooking for her husband. Mr. Mead reports that over the past few weeks Mrs. Mead has left the stove on after cooking dinner and last night placed a cake on top of the stove instead of in the oven.

What caregivers may assume: Mrs. Mead will have to be placed in a nursing home because she is not safe to be home.

What really is happening: Mrs. Mead has become more forgetful and confused as her disease progresses. She forgets the steps involved in meal preparation.

Try this: Make a list of steps to follow when fixing a meal. Place a large sign next to stove that reminds her to turn stove off. If this behavior continues, Mr. Mead may want to consider disabling the stove so that it can’t be used.