Alzheimer's Disease

Etiology

Diagnosis

Signs and Symptoms

Care Management Strategies

Caregiver Support

References

Post-Test

Catastrophic reactions can occur when the AD patient becomes upset over a particular situation. The patient may become anxious, agitated or angry. The person may cry or become combative. Moods may change rapidly. The patient may appear to be just obstinate, when in fact their response is something they can’t control. Caregivers need to identify specific triggers to these reactions in an attempt to avoid them.  Some precipitating factors may include changes in their environment, large groups of people, loud or a varied noises or being asked to complete a difficult task. Interventions that can help reduce catastrophic reactions center on creating a familiar predictable routine. Simplify complex processes like bathing with step-by-step instructions. Tell the patient what you are going to do and then provide acknowledgement and reassurance. Don’t rush--provide the patient with enough time to respond. Identify when the patient is at their personal best and schedule more difficult tasks during that time. Not all of us are morning people, whether we have AD or not! Allow your patient to do what they can and monitor for early signs of frustration and intervene when necessary to assist them in completing the task.  Assessing and monitoring the whole patient is critically important. The presence of pain, a change in medications or a new physical illness can disrupt the AD patient enough to cause cognitive and behavioral changes and contribute to catastrophic reactions. Early identification and treatment may help.

Mace and Rabins (2002) describes the six R’s of behavior management. They provide a template for thinking through problems that may occur when caring for someone with AD. The six R’s are:

• Restrict. If the behavior is harmful to the patient or someone else then we must stop it. At other times, trying to stop the patient may make them more upset.
• Reassess. Be a detective and investigate other new causes for the problem. Do they have trouble seeing because they are not wearing their glasses? Is there a better time of day for this patient to have their bath? Do they have a cold?
• Reconsider. Put yourself in your patient’s shoes. Sometimes people are unable to recognize how impaired they are and may get upset and anxious when we try to help.
• Rechannel. Redirect behaviors so they are safe and not destructive. A couple of good examples of redirected behavior follow. The first is that of former nurse now living in a nursing home that continuously wandered the halls looking for patients to care for. The staff gave her a stack of nurse’s notes for documentation. She sat and charted. In a short while she finished her work and went back to bed. Distraction can be a very useful intervention. The second is of a wife caring for her husband with AD at home reported that he had a hammer overhead, ready to strike her. He said, “I’m going to hit you.” She calmly responded, “let’s have lunch first.” He put the hammer down and was led to the kitchen table. What would the outcome have been if she yelled at him and grabbed for the hammer?
• Reassure. If your patient has become upset or angry, take time after the episode to say, “it’s alright and I still care for you.” Sit down with the patient and make eye contact. Be sincere in your reassurances. Sometimes a gentle pat on the hand or a hug may convey this feeling better for some patients.
• Review. When your day is done, review how your interventions were met. Would you do something differently? What went well? Can you identify what precipitated the behavior? Were there any warning signs you missed?

I use a couple of other R’s in my clinical practice as well. They are:

• Recognition. Identify yourself to the patient when you are caring for them or talk over the phone. Use a calm, gentle slower approach.
• Routine and Repetition. Establish a care routine that incorporates the remaining strengths of the patient. Use the time when the individual patient is at their best to perform more challenging ADL’s. Remember that the routine will need to change as the disease progresses. Develop a strategy to assure staff continuity of care. When communicating with the person with AD, make questions simple and ask in the same way if the patient was unable to respond the first time. Use gestures or point to help if verbal communication is challenged.
• Recreation. Try to include something fun into your care day that involves some physical activity based upon the interests and abilities of your patient. Go out for a walk, get them dancing or do some exercises while seated in chairs.
• Respond to feelings. Use principles of validation therapy and acknowledge the person where they are now and provide reassurance.
• Reminiscence. Long-term memory is often preserved for a while. Some patients may enjoy looking at old photos or listening and singing along to songs from their past. Sometimes prayers and hymns learned long ago are still remembered and may be a source of peace.
• Reward and Respite. Don’t forget the family caregivers. Let them know the good job they are doing. Pay attention to how they look and feel. Do they look more tired or are they less patient? Identify how they are taking care of themselves.