Simple steps improve quality of life for Alzheimer’s disease patients

The daughter of your 74-year-old Alzheimer’s client leaves you an urgent voice mail message. Her mother, whom she cares for at home, was admitted to the hospital for minor surgery, and the three-day stay has stretched to seven because her mother has become incontinent. She claims her mother was never incontinent at home and charges that hospital staff "must be doing something to upset her."

The truth is that many Alzheimer’s patients become agitated and even aggressive in response to stress. This stress results in a variety of negative behaviors that cause or exacerbate health problems, including incontinence, insomnia, loss of communication skills, aggressive episodes, and wandering.

More importantly, these behaviors often result in lengthened hospital stays and put nursing home placements in jeopardy. As the case manager, you are in a perfect position to mediate between the nursing staff and family and try to identify and alleviate the possible causes of these undesirable behaviors. By learning some simple techniques to reduce stress in Alzheimer’s patients, you can work with nursing staff to help your clients function at the highest possible level, improve their quality of life, and minimize their medical costs.

"Not every hospital or nursing home has a special Alzheimer’s unit, and even those that do cannot cover all the material necessary to manage the Alzheimer’s patients in a basic staff training course," says Cindy Stinson, RNC, CNS, a consultant with Health Education Resources and an instructor at Lamar University in Beaumont, TX. "In addition, many facilities are short-staffed. Nurses have to float to different areas. If your Alzheimer’s client enters the hospital for surgery, the nurse caring for that client may be a general surgical nurse with no experience with adult dementia patients."

Five stressors commonly produce negative behaviors in Alzheimer’s patients, Stinson says. These include:

• fatigue;

• change of environment, routine, or caregiver;

• misleading or inappropriate stimuli, such as excess noise;

• internal or external demands to achieve that exceed functional capacity;

• physical stressors, such as pain, infection, or depression.

Patients with Alzheimer’s also often become aggressive due to simple frustration caused by their inability to communicate their needs and desires, says Debbie Everett, MTS, a chaplain with Edmonton General Hospital in Edmonton, Alberta, Canada, and a specialist in institutional ministry. "It helps if we view negative behavior as the soul yearning for something it lacks rather than simply working to stop the behavior."

Everett recalls a woman with Alzheimer’s who was always aggressive. "The woman couldn’t speak more than two or three words in a row. One day during a hymn sing at the nursing home where she lives, the woman began singing. She was able to sing every word of the hymn. Not only did she recall every word, but she had an incredibly lovely voice with a very wide range. I soon found that if I was with her and she became aggressive, she immediately calmed down if I began singing a few notes." Everett documented the patients’ positive response to music in her chart. "We made sure all the nurses knew that music immediately reduced her aggression and brought her peace and contentment," Everett says.

In her book, Forget Me Not: Spiritual Care for People with Alzheimer’s, Everett provides a spiritual assessment tool case managers can use to determine what activities, hobbies, or possessions will bring their clients peace. If your clients’ disease process is too advanced for them to respond to questions on the assessment, Everett says family members and friends can be interviewed instead.

The assessment is divided into four areas:

• subjective meaning of illness;

• approaches to hope;

• support systems;

• concept of God or a higher being.

"The tool attempts to find out what the patient normally has done in the past when afraid or stressed," Everett explains. "The assessment looks at issues such as: Did this person normally pray, walk, or meditate? What hobbies, activities, or tangible things has the patient always loved? What faith symbols or rituals are important to the patient? What food, music, or holidays did this patient always enjoy?

"I look at this assessment as an examination of how this person lived and what would bring them meaning and hope now in the presence of this disease process," Everett says.

7 areas, multiple solutions

Seven areas cause conflicts between Alzheimer’s patients and nursing staff in both acute and long-term care settings. Case managers often can make suggestions to help diffuse these situations, Stinson says. The areas include:

• communication;

• hygiene;

• nutrition;

• elimination;

• pain control;

• comfort;

• safety.

Communication problems almost always are an issue with Alzheimer’s patients, Stinson says. Several techniques can help improve communication between the Alzheimer’s patient and nursing staff or other caregivers.

"The key to communication is to keep it simple and direct," Stinson says. "Alzheimer’s patients can’t process implied information or multiple messages. You must always be very literal. Definitely avoid expressions such as: ‘You can’t cry over spilled milk.’ These have no meaning for the Alzheimer’s patient." (For a list of recommendations for communicating with adult dementia patients, see box, above right.)

The often strict schedules nursing staff must maintain also can cause conflict. Aides quickly become frustrated if patients refuse to bathe on schedule, for example, Stinson says. "The first step for the case manager is to interview the family about the patient’s normal bathing routines. It’s possible this patient is accustomed to bathing at night, and the hospital has been trying to bathe them in the morning."

Some suggestions Stinson says may help ease hygiene conflicts include:

• Avoid showers. Many adult dementia patients are confused by the water coming down on them and do better with tub baths, she says.

• Try distracting the patient with soft music or low talking.

• Try massaging the patient in the bath.

• Use colored towels instead of white ones. A simple, colored wash cloth often helps distract patients.

• Have a same-sex nurse or aide bathe the patient.

• Prepare in advance. Never leave the patient alone to go back for a towel or bar of soap.

"Bathtime is also a good time to check the patient for rashes and red marks. As the disease progresses, patients are more prone to ulcerations and skin breakdowns. Bathtime may be the only time the patient allows a nurse or aide to see them without clothes," Stinson says.

As Alzheimer’s disease progresses, patients often have difficulty feeding themselves. "They may forget how to use utensils, chew, or even swallow. Self-feeding helps patients maintain dignity, but helping Alzheimer’s patients feed themselves may take flexibility and creativity," Stinson says. Her suggestions for easing struggles at mealtimes include:

• Narrow food choices on the tray.

• Use finger foods.

• Try covered toddler cups to avoid liquid spills.

• Never leave bones on the plate.

• Never give patients styrofoam cups, plates, or paper napkins. Alzheimer’s patients often regress into toddler- and infant-like stages in which they put everything in their mouths, Stinson says. If you use disposables, patients often try to eat them, she cautions.

• Place a damp washcloth under the plate to keep it from sliding.

• Make liquids into popsicles.

• Make meals into sandwiches. Place the meat and vegetable between slices of bread and used mashed potatoes as glue, she says.

Take a deep breath and blow

Incontinence is another common response to stress in Alzheimer’s patients, Stinson says. "It’s not uncommon for a family member to complain that, ‘Mother was never incontinent at home.’ The family feels that the nursing staff must be doing something to upset mother, but in truth, this is simply a stress response." Her suggestions for solving elimination conflicts include:

• Place the patient on a two-hour voiding schedule.

• Place the word "Toilet" on the bathroom door.

• Leave a light on so patients can find the bathroom at night.

• Praise appropriate behavior and ignore inappropriate behavior.

• Dress patient in clothing that is easily removed. Encourage the use of Velcro.

• Try distracting the patient. "Give the patient a magazine to read in the bathroom, and allow the patient to get up and down rather than insisting they sit still until finished."

• Give patient a glass of water and have them blow bubbles. This often helps patients who have trouble voiding, she says. "Behaviors such as decreased appetite, lethargy, hostility, and agitation also may signal constipation or a urinary tract infection. Suggest that the staff check your client for bowel distension and bowel sounds."

Pain often leads to negative behaviors such as yelling, irritability, changes in vital signs, and increased agitation in Alzheimer’s patients. "Alzheimer’s patients are unable to tell nursing staff that they are in pain," Stinson says. "The first thing that should be evaluated if a patient begins yelling or acting out is the possibility of pain or discomfort."

Here are a few suggestions Stinson says may lead to better pain management in Alzheimer’s patients:

• Avoid use of Demerol, which is associated with increased restlessness.

• Suggest prescribed analgesics be given on a regular schedule. "Alzheimer’s patients won’t know how to tell nurses they need pain medications," she says. "If your client is post- op or taking pain medication for any reason, suggest it be given on schedule rather than on demand."

Creating a peaceful environment

Comfort and safety often go hand-in-hand. For example, many Alzheimer’s patients fall when rushing to reach the bathroom in a poorly lighted room. Stinson says these tips may improve the comfort and safety of your Alzheimer’s client:

• Select a quiet room.

• Avoid misleading stimuli, such as ice machines, fire alarms, busy hallways, and public address systems.

• Keep television turned off until the patient asks to watch it.

• Cover or remove artwork in the room. Patients may view people or animals represented in artwork as real-life intruders, Stinson explains.

• Cover mirrors. Alzheimer’s patients often don’t recognize themselves in a mirror and believe there is an intruder in the room, she says.

• Provide a consistent routine with at least two rest periods. Darken the room so patients will understand they should sleep.

• Make sure glasses, dentures, and hearing aides are in place.

• Remove excess clutter from the room and clear a direct path to the bathroom.

• Remove catheters and IVs as soon as possible. In addition, if catheters and IVs are covered, patients are less likely to try to pull them out, Stinson says.

• Place orienting signs in clear view. "Alzheimer’s patients retain the ability to read long into the disease process. Place a sign that says something like: ‘Mr. Jones, You are in the hospital. You are in Room 102. You have a broken hip. You should not get out of the bed without assistance.’"

(Editor’s note: For more information on creating a peaceful environment for adult dementia patients, see box, p. 152.)