|
NON-PHARMACOLOGICAL
MANAGEMENT OF ALZHEIMER'S DISEASE
|
| DR.S.SHAJI. |
| Consultant
Psychiatrist, Bethsada Hospital, |
| Vengola P.O.,
Perumbavoor |
| Clinical
symptomatology in Alzheimer's disease can be divided into three primary
domains. ie. cognitive, functional and behavioural. Cognitive deficits
include impairment in memory, thinking, language, comprehension.
calculation, learning capacity and judgment. As per definition of dementia
impairment in cognitive functioning should be severe enough to affect
activities of daily living. A number of behavioural problems also occur in
association with these changes. |
| At the
moment there is no curative treatment for Alzheimer's disease. So the
treatment is aimed to improve the quality of life of the patient and the
caregivers and to reduce caregiver's distress. In order to achieve these
aims we need interventions at different levels ie. individual, family and
community. |
| MEMORY
LOSS IN DEMENTIA |
| Recent
memory impairment is characteristic of dementia. Most people with dementia
are likely to remember the distant past more clearly than what has occured
more recently. Long-term memories are comparatively preserved during the
early stages. However these long - term memories also will eventually
decline. |
| People with
dementia will have problems in acquiring new information and there may be
loss of sense of time. They may eventually lode their ability to recognise
people, places or things. How can we help these people with memory problem
? Techniques like memory aids, reality orientation and reminiscence
therapy may be helpful especially during the early stages. |
| MEMORY AIDS |
| Memory aids
such as lists, diaries and clear written instructions can be helpful if
the person is willing and able to make us of them. Displaying large
clearly labeled pictures of relatives will help the person to keep track
of who is who. Labeling the doors of the rooms with words and bright
distinctive colours can be helpful. Memory aids will not be so useful in
the later stages of AD. |
| REALITY
ORIENTATION |
| Reality
orientation is a technique that is widely applied all over the world.
There are two approaches to reality orientation. |
| Class room
reality orientation involves intensive stimulation for periods varying
from 30-60mts a day. During these sessions patient is given orientation to
the day of the week, the month, the day of the month, the year, what the
weather is like and so on. |
| RO board,
written instructions, clocks, calenders, maps and posters can be used to
enhance reality orientation. The other form of reality orientation has
been called 24 hour reality orientation. Thus usually takes place in a
hospital ward or residential home. Instead of being presented with an
intensive information session. the subjects are oriented in their relavant
every day activities throughout the day. |
| REMINISCENCE
THERAPY |
| By making
use of term long term memories we can bring back pleasurable throughts and
association which may sometimes have a calming effect upon the sufferer.
Music particularly that relating to the past can have similar effect. when
these activities are carried out in group it is sometimes possible to
stimulate interaction between group members. |
| Behavioural
Pathology in Alzheimer's disease |
| A number of
behavioural changes and psychological disturbances can occur in a person
suffering from dementia. These bahavioural symptoms can lead to
premature institutionalization, increased cost of care and significant
loss in the quality of life of the patient and his caregivers. Reisberg
and Colleagues identity seven major categories of behavioural domain
symptoms in AD. These symptoms can be grouped in to: |
| A Paranoid and
delusional Symptoms |
| * "People are
stealing things" delusion |
| * "One's
house is not one's home" delusion |
| * Spouse or
caregever is an imposter |
| * Delusion of
abandonment |
| *
Delusion of
infedility |
| *
Suspiciousness
/ paranoid ideas other than above. |
| B Halucination:
Visual, auditory, olfactory and tactile hallucination |
| C
Aggressiveness: Verbal outbursts, physical threats or violence |
| D Diurnal
rhythm disturbances: Day/night disturbances, Disturbed Sleep |
| E Affective
disturbances : Tearfulness / Depressed mood |
| F Anxiety and
phobia |
| G Activity
disturbances: Wandering, purposeless activities inappropriate
activities |
| Alzheimer's
disease often pose severe management problems for those who provide care.
since AD attack each patients brain in different places and at different
rates of speed, each patient's behaviour is different. Behavioural
management techniques will help caregever's to mange the behaviour of the
patient as they change over time and will help to allow them to adapt and
change interactions overtime. |
| ABC Model of
behavioural management |
| Behaviour always
occurs in three parts. We can call it as A.B.C. |
| A. |
A
traggering event (often an antecedent or cause) |
| B.
|
Behaviour
itself
|
| C. |
Consequence
of the behaviour (What happens because of the behaviour) |
| As you
observe a behaviour, you will learn to look for these three parts and they
will be your key to changing the behaviour. |
| Before you
can deal with behavioural problems you have to be very clear about what
the problem is. The first step is learning to
observe and describe what is going on clearly and objectively as possible. |
| Defining
the problem behaviour is important Applying the ABC's of behavioural
management involves. |
| 1. |
Learning to
observe and define the behaviour |
| 2. |
Developing a
plan to change the behaviour |
| 3. |
Evaluating
your plan and revaluating to make your plan more effective. |
| 4. |
Changing you
plan and revaluating to make your plan more effective. |
| LIVING WITH
AND CARING FOR A PERSON WITH AD |
| Here are
some general guidelines for better care |
| 1) Establish
and Maintain a routine |
| A
routine
can bring order and structure in to an otherwise confused daily life and
it may provide more security for a person with AD. Sudden changes in the
Environment may created confusion. |
| 2) Support
person's independence |
| It is
necessary that he person remains independent as long as possible. It helps
to maintain self respect and decrease the burden of care. |
| 3) help the
person maintain dignity |
| The person
you care for is still an individual with feelings. What you and others say
and do can be disturbing to the patients. Avoid discussing the person's
condition in his presence. |
| 4) Avoid
confrontation |
| Confrontational
approach can only make a situation worse. Remember that it is the disease
that is causing the disturbed behaviour and not the person's fault. |
| 5) Keep
tasks simple |
| Try to make
things as simple as possible. Offering too many choices can be confusing
to the patient. |
| 6) Make sefty
important |
| Loss of
physical co-ordination and memory increase the chances of accidents and
injury. so care must be taken to make the environment as safe as possible. |
| 7) Help make
the best of a person's existing abilities |
| Some
planned activities can be enhance a person's sense of dignity and self
worth by giving purpose and meaning to life. |
| 8) Maintains a
sense of humor |
| Lean to
laugh with the person with AD as humor can be a great stress reliever. |
| 9) Encourage
fitness and health |
| This
include proper nutrition, appropriate exercise prompt treatment of
infections etc. |
| UNDERSTANDING
AND COPING WITH DIFFICULT BEHAVIOURS |
| Difficult
behaviours may be related to personal care issues like eating, bathing,
dressing, toileting and sexual behaviour. In order to tackle the problem,
we have to identity what the problem is ? and we have to infer the
possible causes. The caregivers have to develop some creative approaches
that is most suited to the individual's characteristics and the situation.
Developing some realistic goals is also important. Difficult behaviours
like aggressive behaviour wandering, suspiciousness, repetition and loud
verbal noises can occur. |
| Suggested
strategies include avoiding the problem if it is possible, diffusing the
problem to prevent further complications and to deal with the problem if
has already occured. |
| SOME
SPECIAL ISSUES IN THE MANAGEMENT |
| Communication |
| Effective
communications is an exchange of thoughts, information and other message
from one person to another. Since AD patients have brain impairment it can
be very difficult for them to understand and communicate. Remember the
following while communicating. |
| *
Gaining attention - Make sure that you have the person's attention. Before
you try communicate try to make eye contact with the person as this will
help to focus their attention. |
| *
Speak slowly, clearly and simply |
| *
Use short simple sentences |
| *
Use only one idea at a time |
| *
Use direct leading statements |
| *
When necessary repeat the statements using same words. |
| *
Emphasize non-verbal communication |
| *
Avoid questions |
| *
Eliminate distracting noises and activities |
| *
Allow time to communicate |
| *
Do not talk about the person in his presence |
| *
Use humor when appropriate |
| Wandering |
| Wandering
can be both puzzling and stressful for the cares. There are many reasons
why the patients wander away from home as the dementia progresses. The
reasons include. |
| *
Changes in the environment |
| *
As a continuing habit |
| *
Lack of exercise |
| *
Boredom |
| *
Pain or disconfort |
| *
And as response to anxiety and confusion. Following are some of the tips
that can be helpful |
| *
Keep the surroundings calm and predictable |
| *
Make sure that the person carries some form of identification |
| *
Involve the person in regular activities or exercise. |
| *
If the are is safe and secure, allow the person to wander |
| *
Keep an up to date photograph. |
| Violence
and aggression |
| People
with dementia some times seems to be have in a very aggressive way. |
| Frequent
causes of agitation in the demented patient may be due to factors related
to the individual or environment |
| Factors
related to Individual |
Environmental
Factors |
| Acute
medical illness |
Over
stimulation |
| Medication |
Under
stimulation (Boredom) |
| Pain |
Over
Crowding |
| Sensory
impairments |
Too Warm or
too cold environment |
| Fatigue |
inconsistency
in routines and or in caregiver |
| Basic needs
(Hunger, thirst, fears) Psychiatric syndromes |
Provocation
by others or physical restraints |
| Preventive
measures include |
| *
Reduce demands made on the person |
| *
Explain things to the person |
| *
Find out tactful ways of offering help |
| *
Try not to criticize the person |
| *
Watch for warning sings such as anxieties or agitated behaviour offer more
reassurance if appropriate. |
| *
Avoid confrontation. Distraction may be helpful at times |
| *
Find out activities to stimulate the person's interest and make sure that
they have enough exercise |
| *
Make sure that the person has regular health checkup and consult G.P. |
| Coping
measures include. |
| *
Keep calm, try not to show fear alarm |
| *
Try to draw the persons attention to a calming activity |
| *
Give the person more space |
| *
Find out what caused the reaction and try to avoid it in the future |
| *
If violence occurs |
| -
Seek help |
| -
Talk to someone for support |
| -
Do not try to punish the person |
| Eating |
| Meal
times can be stressful, particulary as dementia progresses. Here are some
tips for better care. |
| *
Offer meals at regular time |
| *
Consider small group dining |
| *
Serve only one food at a time |
| *
Remove other distracting items from the table |
| *
Remind the person how to eat |
| *
When the person has difficulty in swallowing consult the physician |
| Incontinence |
| Incontinence
may be due to treatable medical conditions like UTI, prostatic
hypertrophy, side affects mediation or due to severe constipation.
Treatable conditions should be detected and treated. |
| Useful
strategies include |
| *
Create a schedule for going to the toilet |
| *
Label the toilet door |
| *
Leave the toilet door open so that it is easy to find |
| *
Make sure that the cloths can be easily removed |
| *
Limit drink within reason before bedtime |
| * Get
professional advice. |
| Inappropriate
Sexual behaviour |
| This
include undressing in public, fondling the genitals or touching someone in
an inappropriate way. |
| * Do
not over react to the behaviour |
| * Try
to distract the person to other activities. |
| CARING
THE PERSONS WITH DEMENTIA IN THE COMMUNITY |
| 1.
Domicilary care |
| 2.
Day care |
| 3.
Family Intervention programmes and |
| 4.
Self help groups are the major components of the community care of the
person with dementia |
| DOMICILIARY
CARE |
| Most
of the persons with dementia live at their homes with their family. Many a
times the support given by the family may be inadequate or inefficient due
to the lack of understanding of the disease process, inability to deal
with the behavioural problems associated with dementia or due to
interpersonal problems or caregiver's distress. Trained man power is
essential to look after the person in the community. If we train health
workers to deal with these problems it will be very useful. |
| DAY
CARE |
| The
day care provides respite to the caregivers and rehabilitation to the
patient. The programme is very helpful to those families where all the
family members are working or those who are unable to take care of the
patients due to family disharmony or lack of personnel. Regular attendance
in these programme enables close monitoring of the physical and
psychiatric status of the patients so that early intervention and
treatment is possible. |
| FAMILY
INTERVENTION PROGRAMME |
| Dementia
does not simply affects the person who has it. It profoundly changes the
lives of those family members who are close to that person. Care giving in
dementia is time consuming, frustrating and a demanding task which can
leave the caregiver, frustrated, depressed angry and alone. |
| Psychotherapeutic
intervention with family members is a critical aspect of the treatment.
Psycho education is the most important components of the programme.
Providing information about the nature, course and prognosis of the
illness help the caregivers to lowers their expectations about the
patients which in turn reduces the intensity of frustration. These
programme is aimed to change the perception of the caregivers, to enhance
problem solving skills and to provide support. |
| SELF
HELP GROUP - CAREGIVER'S MEETING |
| Caregiver's
meetings provide support in a group setting. Group allow for the
ventilation of feelings and the development of a group process. It
provides opportunities for caregivers to come together, empathise with
each other, share their problems and solutions, and a knowledge and affirm
each others caregiving efforts. Living with and caring for a person with
dementia demands newer and newer coping strategies from the caregiver.
Caregiver's meeting provide and opportunity to learn how to cope better as
demands are changing. What can a support group do ? |
| * It
support relatives or friends so that they can cope more easily. |
| *
Common experience, problems and solutions. |
| *
Works o principles of sharing and co-operation. |
| * An
outlet of pent-up emotions. |
| *
Reduce feelings of helps ness and despair. |
| *
Provide a chance to discover that there to situation is not unique. |
| * To
exchange ideas and disseminate information. |
| *
Improve problem solving skells. |
| *
Offer advice and support |
| * A
social event - a break for the carer. |
| Caregiver's
Ten commandments |
| A
good quality care depends on the physical and mental health of the carer.
Available literature indicates that most of the carers are facing various
problems like emotional disturbances, reduced social life, embarrassment,
anxiety and depression. following are some of the guidelines for
alleviating the burden of care. |
| 1.
Take care of yourself |
| 2.
Conserve your energy |
| 3.
Accept your feelings-Anger, frustration or sorrow |
| 4.
Develop realistic expectation of yourself avoid too many "I should
feeling". |
| 5.
Practive problem solving |
| 6.
Avoid impulsive changes. |
| 7.
Practice becoming more flexible |
| 8.
Learn to laugh |
| 9.
Seek and accept help and support when you need it |
| 10.Creative
a refuge from stress and escape when you need it. |
| At
present Alzheimer's disease is an incurable illness. Even if there is no
cure many things can be done to improve the quality of life of the patient
and to alleviate Caregiver's distress. Non-Pharmacological treatment
strategies should always be tried first to avoid unnecessary drug use
excess disabilities from adverse drug effects. |
| REFERENCCE |
| 1.
Advice Sheets-Alzheimer's Disease Society Caring for dementia (1997) |
| 2.
Alzheimer's disease - Help for caregivers. Who, Geneva, Alzheimer's
disease international London. |
| 3.
Brunello, N, Langer, S.N.,Rasagni, G (Editors)(1998) : Mental Disorders in
the elderly, New therapeutic approaches. S. Karger Medical nad scientific
publisher, Basel (Switzer land) |
| 4.
Gordon Wilock 91990) Living with Alzheimer's disease. Penguin books,
Wrights Lana, London |
| 5.
Linda Teri 91991) : Managing and Understanding behaviour problems in
Alzheimer's disease and related Disorders. Alzheimer's disease education
and referrel center. National institute of ageing, Maryland |
| 6.
Serg Gauthier(1990) : Clinical diagnosis and management of Alzheimer's
disease 2nd edition Martin Dunitz Ltd, the Livery House, London |
| This
article is based on the paper presented in the Indo - Us conference on
recent advances in medical management of the elderly which was held at
Amrita Institute of Medical Science, Cochin on February 12th 2001. |
|
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