Reasoning with Early Dementia

People with early dementia do not have the capability to understand reasoning from you.  The bottom line is he/she is fine and YOU are the problem :)  This level of dementia no longer has his/her "filter" on what is approriate to say to others and what is not.  They will spout with statements that will make the hair on the back of you're arm stand on end.  I remember my grandmother at a church service with me... we were watching a baby dedication ceremony.  All of the sudden when it was completely quiet my grandma said (very loudly):  "That's one ugly baby;  isn't that an ugly baby?  I don't think I've ever seen such an ugly baby, what a shame".  Awkward!!  Ever feel like you want to sink into whatever you're sitting on and become part of the chair (I did at that moment :).  But I always have to remember that it's the disease talking and not the other parts of her that are my grandma.  Sometimes you have to have a sense of humor, because they will surely test it.. FREQUENTLY.  Similarly when the patient with early dementia accuses his/her loved ones of being against him/her and that he/she are the victim and it's all the family member's fault. That is also the disease talking - which helps us deal with those types of statements instead of allowing it to make us feel guilty; a failure.  Chin up - it's a nasty disease that makes people say things they don't really mean. 

Environmental Engagement

It was so fun today to see a patient sitting outside greeting visitors.. waving and smiling... eating in the diningroom etc.  The same patient that used to stay in her room and scream at people when they entered the room and tried to help her with anything.  It's called environmental engagement and it's like turning on someone's life light switch.    You do this by spoiling the patient and very slowly helping them interact with his/her environment.  It usually involves a lot of sensory approaches.  Finding out which sensory things attract the patient and which things the patient avoids.  Helping him or her be able to tolerate those sensory items that cause him/her anxiety... and giving him/her the sensory stimuli that they crave...that's a skilled intervention and an art.  We'll be exploring more sensory interventions in future blog entries.  

Watch for Symptoms of Apnea

Apnea - a common problem for patients with dementia.  Apnea is defined as a sleep disorder involving abnormal pauses in the breathing pattern.  This causes a drop in oxygen levels and can damage critical organs such as the heart and brain.  Symptoms include sleepiness during the day, complaints of a dry mouth/throat, morning headache, difficulty staying asleep at night (insomnia), loud snoring, shortness of breath that wakes you from sleep, and general pain throughout body.  Putting a patient who has apnea on nighttime oxygen can make sleep apnea even worse.  Apnea can also progress dementia very quickly and also cause something of a temporary "delirium" on top of the dementia that can clear if the apnea is treated.  Ask your physician about testing for sleep apnea if you/loved one/patient have some or all of the above symptoms.  Also some behaviors may disappear once the apnea is treated - such as aggression, withdrawal, and/or lack of appetite.

"I'm not hungry"

This is a common statement among people with dementia.  They stop eating gradually until they reach a point where their body just isn't hungry anymore and just the sight/smell of food makes them sick.  This is a sensory problem and must be approached as such.  The last "taste" group that an individual eats prior to stopping eating completely are sweets.  So to stimulate the appetite - use sweets frequently throughout the day in small doses.  Sometimes I have to start with a little bit of soda in a tiny plastic med cup.  Encourage them to drink this little bit every hour or so.  Sometimes they eat a 1/2 tsp of ice cream frequently through the day.. sometimes it's graham crackers...sometimes it's chocolate...sometimes it's fruit or yogurt.  Start small and gradually build up the amount they eat/drink at a time and/or the frequency of their intake.  These items will "drive" the patient's appetite.  I use essential oil placed on cotton balls placed in the patient's pocket or near them...oils that stimulate appetite such as peppermint or citrus smells.  Also great is boiling apple cider in a small saucepan nearby.  Bake bread in a breadmaker..anything to use smell as an appetite stim.  Sometimes it's a visual processing problem - so I put a tablespoon of food in the center of an over-sized bright colored plate.  That's their meal.  The next meal (if they ate everything for the prior meal) I increase the amount in the center of the plate...gradually.  Until their mind's eye accepts a full plate as a meal.  Appetite re-stim is so easy and sooo rewarding to watch your patient become stronger and able to participate in his/her other therapies or activities of daily living.

Sleeping Beauty

I love it when I hear a nurse wake up a patient to give him/her their sleeping pill :)  Ironic isn't it?  Why do so many people have difficulty sleeping not only in the hospital, but especially in nursing homes, relative homes, and rehab centers.  How many of us like to sleep with a little bit of light?  How many have to have it completely dark?  Who likes to sleep under heavy blankets and who can't handle anything more than a sheet?  How many can't stand any "pilling" on their sheets?  How many need a certain material in their sheets?  Who among us must sleep with a TV, radio, or a fan?  So many variations not only with textures and sounds, but also with smells and the right kind of mattress.  And then we wonder why patients in our facilities are so tired and have difficulty sleeping.  Pay attention to these things from their home and try to re-create as many as possible in his/her new room.  This is a skilled therapy service and a necessary one.  Without sleep - risks involve everything from falls to malnutrition and skin breakdown.

Alert Systems

There are many times that we send patients home alone and we don't feel confident that they'll be safe.  There are alert systems on the market for instance from Life Alert that automatic alert devices.  The patient/person doesn't even have to push the alert button... the system senses when he/she falls and then a representative asks through the monitor if the patient is ok.  If the patient doesn't answer then assistance is sent to his/her home automatically.  The best support system is family/friends or hired caregivers to help supervise a person with dementia at home.  But when this support system is not available - these alert systems are very helpful to assist with a person's independence and safety.

"They Keep Taking My Things"

This is a common accusation from people with dementia - even though most of the time it stems from forgetfulness about where he/she put the item.  I like to help the patient establish a procedural ritual with those items.  That means that I want the habit of putting the item in it's "home" to become automatic for the patient.  I have to make the "home" colorful because people with dementia need 4x as much color contrast as the average person so neon colors work great.  Common items are dentures, glasses, hearing aides, canes, purses, wallets, and money.  Create this colorful home for the item and practice with the patient over and over placing the item in it's new "home' ...I like to tell him/her that we're going to "hide" the item (if they are really paranoid about theft).  It takes 3 weeks to establish a new habit with a patient so plan on spending a few weeks establishing this new ritual.  You can watch for progress as they need less and less help to find the "home", put their item away, and then retrieve it again.  Also watch the patient become less and less anxious about someone taking the item.