Managing Activities of Daily Living

Compared with those who have never raised children, those who have done so enjoy an advantage in Alzheimer's care. They have lived with toddlers. That's what people with Alzheimer's disease are most like&nbsp-- 2-year-olds. Of course, they're bigger, heavier, stronger, and they look like adults. But during the mild and moderate stages of the disease when loved ones usually do the caregiving, they often act like toddlers.



It can be very upsetting to treat a parent or spouse like a 2-year-old; the person you know and love is not a toddler. But the person you know is gone, replaced by a mere reflection of that person who has a progressive brain disease.



Fortunately, just as parents learn to manage toddlers, you can learn to cope with Alzheimer's care. The key is to get organized, and plan how best to manage the disease:


  • Dressing

  • Bathing

  • Grooming

  • Toothbrushing and dentures

  • Incontinence (urinary and fecal)

  • Meal preparation

  • Eating

  • Choking

  • Exercise

  • Recreational activities

  • Loving contact


Dressing


  • People with Alzheimer's often become distressed by having too many choices. Limit the person's wardrobe to a small number of possibilities.




  • Limit colors so that no matter which slacks, shirts, skirts, blouses, or sweaters the affected person chooses, they'll all go together and not clash.




  • Keeping socks matched can be a real problem. Buy 10 identical pairs of socks. That way, any two make a matching pair.




  • Eliminate accessories: belts, scarves, ties, jewelry, and eventually even sweaters. Keep outfits as simple as possible. Look for pants and skirts with elastic waistbands.




  • Loose-fitting clothing is most manageable. This is particularly true of underwear. If it's loose, it works even if the person puts it on backwards.




  • Look for clothing that does not need ironing or special care. You already have enough to do.




  • Lay out clean clothes every morning for the affected person. Help the person dress.




  • Buttons and zippers often frustrate people with Alzheimer's disease. If you dress the person, these items add extra time and hassle. Replace buttons and zippers with Velcro wherever possible. Velcro tape is available at fabric stores.




  • The same goes for shoelaces. Look for slip-ons or shoes with Velcro closure.




  • Look for reversible shirts and jackets. That way, there's no "inside out."




  • Forget slips and pantyhose for women with Alzheimer's disease. To get a bra on a woman with the disease, have her lean forward to settle her breasts in the cups. Or forget the bra, and have her wear a loose pullover undershirt.


Bathing


  • Try to preserve the affected person's pre-dementia routine. Someone who showered in the morning will probably feel most comfortable continuing to do that instead of taking baths in the evening.




  • Bathing is a very complicated task, and as Alzheimer's disease progresses, its complexity becomes quite daunting -- and often upsetting -- to affected individuals. Break the task down into its simplest component parts. Don't say: "Time for your shower." Instead say: "Take off your shirt. Good. Now take off your pants. Great. Now..."




  • People with Alzheimer's often resist bathing. If this becomes a problem, they don't have to bathe every day. But try not to get drawn into negotiations about whether a bath is necessary. When it's time to bathe, simply shepherd the person through the process.




  • Don't use bubble bath products, bath oils, or anything that can make a tub or shower slippery.




  • Getting into and out of a bath can be difficult for people with Alzheimer's, especially if they are heavy, clumsy, or have balance problems. Bath rails and other aids are available. One approach that many caregivers endorse involves a plastic stool and a hand-held shower-massage-type hose. Buy a stool whose seat is on about the same level as the top of the side of the tub. Place the stool in the tub. Have the person sit on the stool with feet out of the tub. Then swing the person's feet around into the tub. Use the hose for wetting and rinsing. Then reverse the process to get the person out of the tub.




  • If you fill a tub, use only a few inches of water.




  • Don't leave anyone with Alzheimer's disease alone in a tub or shower. That's asking for trouble. If the phone rings, let the machine answer, or have a phone installed in your bathroom.




  • It can be awkward to insist that loved ones with Alzheimer's wash their genitals, or that women wash under their breasts. But you have to insist, or do it yourself. Otherwise, rashes can develop.




  • If the affected person really resists bathing, try sponge baths.




  • Make sure that the person gets well-dried afterward. Try cornstarch to keep skin-fold areas dry, for example, under breasts, or in thigh creases.




  • People with Alzheimer's tend to sit or lie down a lot, which increases risk of bedsores and other skin ulcers. Bath time is a good time to inspect the person for red areas, rashes, etc. If you see any, consult a physician.


Grooming


  • Have the person's hair cut short in a style that's attractive but, above all, easy to take care of.




  • Women who went to beauty parlors regularly may enjoy continuing to do so for a while. But eventually, such outings may become upsetting. When that happens, stop going.




  • If the person bathes using the stool-and-hose approach described in the discussion of bathing, hair can be easily washed while bathing. Another option is to wash hair over the kitchen sink using the spray nozzle.




  • Be sure to rinse the person's hair well.




  • Keep finger- and toenails trimmed short. Short nails are easier to keep clean and less likely to get injured or cause injury to anyone else.




  • If a woman has always worn make-up, she may feel best continuing to do so for as long as she understands what it is.




  • Grooming, bathing, and dressing people with Alzheimer's disease takes tremendous energy and the patience of a saint. You may be tempted to let them lounge around in a bathrobe all day. But try to keep them dressed and presentable. Many caregivers report that this makes it generally easier to manage their loved ones. Compliment how they look. Encourage them to admire themselves in a mirror.


Toothbrushing and dentures


  • It's important to maintain oral hygiene. People with Alzheimer's disease who retain their natural teeth should keep flossing for as long as they can. Once they can not longer handle it, you may have to let it go. But continue brushing their teeth. Some dentists recommend foam applicators instead of brushes. See what works best for you.




  • Dentures often cause problems for people who do not have dementia. For those with Alzheimer's disease, the problems multiply. If a person with dentures gets a diagnosis of Alzheimer's, immediately discuss with a dentist the possibility of trading the dentures for permanent dental implants. Implants are a good investment of time and money in the early stages of the disease because they eliminate dentures.




  • If the affected individual wears dentures, have them checked frequently to make sure they fit well. Ill-fitting dentures increase of mouth sores, and discourage people from eating, which threatens health and can exacerbate dementia.




  • Dentures should be cleaned daily. Affected individuals should do this for as long as they can, with you guiding them step-by-step when that becomes necessary. Eventually, you will have to assume responsibility for denture care.


Incontinence (urinary and fecal)


  • The ability to deal with one's own toilet functions is fundamental to competent independent living and personal dignity. Anyone who needs help managing urination and defecation usually feels ashamed, depressed, and quite possibly infuriated. In addition, it can be very challenging emotionally for caregivers to intervene in what is usually regarded as a personal and private activity, and one that might elicit strong feelings of disgust. But just as parents quickly get used to changing babies' diapers, you can adjust to assisting the person with Alzheimer's disease in the bathroom. Take a few deep breaths and read on.




  • Both urinary incontinence (wetting) and fecal incontinence (soiling) may be caused by medical problems that can be treated. If you notice wetting or soiling, do not ignore them. Instead, pay close attention: What exactly is the problem? When does it happen? Is it occasional or persistent? Is it linked to anything else? Then take your observations to a physician and insist on a thorough medical evaluation.




  • One reflexive response to urinary incontinence is to have the person drink less. This is a big mistake. Adequate hydration is critical to well-being, and even minor dehydration can cause confusion. Additional confusion is the last thing people with Alzheimer's disease need.




  • If incontinence is related to a mobility problem&nbsp-- not getting to the toilet in time&nbsp-- consider placing porta-potties strategically around the house, especially in the person's bedroom, if night-time accidents are a problem. If the problem is related to problems undoing clothing, substitute Velcro for buttons or zippers, and elastic waistbands for belts, buckles, and snaps.




  • Sometimes people with Alzheimer's can't find the bathroom, especially in new settings. Decorate the door in bright colors to make it easier to find. Sometimes they mistake wastebaskets for toilets. Put lids on wastebaskets or get them out of sight. Take the person to the bathroom regularly, every 90 minutes or so.




  • Many people have idiosyncratic ways to refer to urinating and defecating. Listen closely and learn how they refer to these functions. As language ability fades, "I have me" may mean "I have to pee." Nonverbal forms of communication may also mean "I have to go," for example, dropping one's pants.




  • Adult diapers, or "briefs" or "disposables," can be a godsend. They help keep urine and stool off of clothing and furniture. Today's brands are easy to put on and take off. Some come with plastic over-covers with elastic around the thighs. These help prevent leakage, but may chafe. Experiment to see what works best for you and the affected individual.




  • If you're concerned that incontinence might damage furniture or ruin mattresses, encase mattresses in plastic covers, and place washable cushions on furniture.




  • Urinary incontinence produces a persistent odor in clothing. One way to minimize this is to give the person cranberry juice to drink. It helps deodorize urine.




  • After the affected person defecates, it's important to clean him or her up quickly because skin irritations and painful rashes can develop quickly.




  • Use dry toilet paper, or wet it. When necessary, use alcohol-soaked wipes. Just be sure to dry the skin in the anal area afterward. Leaving the area wet contributes to irritation and rashes. Powder or cornstarch can help.


Meal preparation


  • Don't feel that you have to cook three meals a day on top of everything else you do as a caregiver. You have all sorts of alternatives. The key to happy, nutritious meals is getting well organized. Plan how you want to handle meals, when you want to cook, when you'll rely on prepared foods or take-out or restaurant delivery, and when you will rely on Meals-on-Wheels-type programs. Plan a week or a month at a time. Then you'll feel that you have the situation under control, and won't feel victimized by the relentless demands of meal preparation.




  • Eating involves complicated thought process and often, social interactions that might prove upsetting to people with Alzheimer's disease. To minimize hassle and behavior problems, adopt meal-time routines. Serve simple fare. And don't subject the affected individual to big dinner parties. Stick with small numbers of people.




  • People with Alzheimer's generally prefer to eat the foods they are used to eating. This may cause problems if, say, they had hamburgers three times a week, and you're a vegetarian. However, with careful shopping, it's not difficult to accommodate personal tastes and still serve nutritious, easy-to-fix meals. Several types of vegetarian hamburgers are available.




  • When cooking, don't leave the affected individual alone in the kitchen. If the doorbell rings, bring the person with you to answer it. Or consider installing an intercom.




  • When you cook, make large amounts and freeze as much as possible.


Eating


  • Retire ceramic dishes and use unbreakable plastic. If the person knocks dishes off the table frequently, you can obtain plates and cups with suction cups at baby-supply stores. Retire sharp-pointed steak knives and go with less hazardous butter knives.




  • Many people with Alzheimer's disease have trouble seeing their food. The dining area should be brightly lit. Use contrasting colors to keep food visible, for example, a blue tablecloth makes a white plate more visible. A white bowl makes red tomato soup more visible.




  • People with Alzheimer's may become confused or upset sitting down to a plate with three items on it: a salad, sandwich, and piece of fruit. Serve things one at a time.




  • Cut everything into bite-size pieces.




  • Utensils demand considerable dexterity. Many people with Alzheimer's disease feel more comfortable eating with their fingers. That's fine.




  • Messiness is inevitable as the disease progresses. Don't berate the person. It's nobody's fault. Use easy-cleaning plastic tablecloths, and consider fitting the person with a bib or smock.




  • Some affected individuals leave food around the house, or hide it. This may attract mice or insects. Often the reason for stashing food is that people with Alzheimer's are anxious that snacks will be unavailable when they want them. Leave a fruit bowl or cookie jar out, and remind them about it.




  • Sometimes people with Alzheimer's flatly refuse to eat. Don't get into a struggle. Leave them alone for a few minutes, and then offer food again.




  • Sometimes they want to eat again immediately after having eaten. Offer little nibbles: a cracker, a few grapes, a cube of cheese.




  • If affected individuals eat things they should not&nbsp-- flour, raw pasta, etc. -- move it out of their reach or secure it in a locked or childproofed cabinet.




  • Always check that hot foods and beverages are not too hot.




  • If you spoon-feed a person with Alzheimer's, don't overfill the spoon. As an alternative consider giving a straw.


Choking


  • Sometimes people with Alzheimer's forget to chew their food or can't quite manage normal swallowing, and choking becomes a real risk. True choking is different than gagging or coughing. In gagging and coughing, some food meant to descend into the stomach along the food tube (esophagus) instead enters the windpipe (trachea), and the person gags or coughs it back out, with no interruption of breathing. In true choking, the food becomes tightly lodged in the vocal cords and the person cannot gag, cough, or even breathe. Unless the food is removed, the person quickly suffocates. Because choking blocks the vocal cords (larynx), chokers cannot talk, so they can't ask for help, not to mention that people with Alzheimer's may be too confused to realize what has happened to them. Typically, they clutch at their throats and look surprised and frightened.




  • The object blocking the trachea is like a cork in a plastic bottle. If you squeeze the bottle forcefully enough, the air in the bottle&nbsp-- or in this case, in the person's lungs&nbsp-- pops the cork out. That's the theory behind the choking rescue technique known as the "Heimlich maneuver":





    • If the person cannot talk or cough, don't panic. That only upsets the person with Alzheimer's. As calmly as possible, say: "Here, let me help you."




    • Then step behind the person, and clasp your hands around his or her abdomen below the ribcage.




    • Make a fist with one hand and hold the thumb side in.




    • Then grasp the fist with your other hand and thrust your fist forcefully in and up.




    • If one forceful thrust does not restore free breathing, repeat the procedure.







  • If the person is overweight or bigger than you and you're unable to reach all the way around, use the same grasped-fist technique, but apply the upward thrusts higher up on the chest.




  • If the choker loses consciousness despite your best efforts, lay the person down gently face-up and apply upper abdominal thrusts with the heel of your hand. Then turn the person's head sideways and check the mouth for dislodged food.




  • If the choker is unconscious by the time the trapped object has been expelled, call 911, and begin cardiopulmonary resuscitation (CPR). If you don't know CPR, a 911 operator can talk you though it.




  • Don't slap adult choker's backs. Back-slapping was recommended until studies showed that they may lodge objects more permanently in the throat.




  • Of course, the best way to deal with choking is to prevent it. If the affected person has shown any problems chewing or swallowing, do not give foods likely to trigger choking, among them: nuts, raisins, popcorn, and hard candies. Stick to softer foods. In addition, choking risk increases later in the day as the person get tired. Be especially vigilant at dinner and afterward.


Exercise


  • Exercise has many well-documented health benefits, but here are the ones most likely to make it easier to care for people with Alzheimer's disease: Exercise is calming. It contributes to longer, better-quality sleep. It helps preserve balance and coordination. It helps relieve constipation. And it provides feelings of competence.




  • Consult with the affected person's physician about what kind of exercise is appropriate to the person's medical situation. Just about everyone who is ambulatory can take walks. Walking is excellent exercise, especially for elderly people.




  • Don't make a big deal out of exercise. Just tell the person that it's time to go for a walk. Or set a modest goal: "Let's get a cookie at the bakery."




  • Don't push the person (or yourself) beyond the limits of comfort. A walk around the block is an excellent start. After a week or so, move up to two blocks, and so forth. Increase the duration and strenuousness of exercise very slowly.




  • Like everything else in Alzheimer's care, exercise fits best into the day if it's part of a routine&nbsp-- a daily walk before lunch.




  • People with balance problems can exercise sitting down, doing gentle, yoga-style arm movements. Local senior centers or the Alzheimer's Association can provide more information about seated exercise.




  • Have fun, and encourage your loved one to have fun, too.


Recreational activities


  • Alzheimer's disease does not mean the end of all enjoyment in life. Especially during the early stages, affected individuals derive considerable comfort and satisfaction maintaining their recreational interests: listening to music, watching TV, reading (try books on tape), going to concerts, gardening, going to church, playing with pets, dining out, shopping, etc.




  • A good way to keep affected individuals active is to enroll them in an adult day-care program. Some are affiliated with nursing homes, which can make that transition easier later on for both you and the affected person.




  • As abilities deteriorate, look for activities that the person can still do: pushing a child on a swing, using scoop toys in a sandbox, listening to old, familiar songs, browsing through picture books, taking a ride in the car. Frequently, musical abilities&nbsp-- singing and playing instruments&nbsp-- linger longer than caregivers expect.




  • As Alzheimer's disease progresses, television usually becomes problematic because plots become too complicated to follow, and the noise and rapid cutting from scene to scene are disturbing. Look for nature programs, or buy or rent special-interest videos: a log burning in a fireplace, or nature programs focusing on meadows, forests, or coral reefs.




  • Limit visits with friends to one or two people at a time. Tell mentally competent friends and relatives not to reminisce about past experiences with the person&nbsp-- who may not recall them&nbsp-- but rather to focus on the present moment: having some cake, or taking a walk together.



Loving contact


With all the responsibilities and problems involved in caring for people with Alzheimer's disease, it's easy to forget the importance of loving touch. A pat on the back, back-rubs, foot massages, hand massages, hugging or holding hands are calming, and they communicate love and safety in a way even people with a fair amount of dementia can understand. Several studies in Alzheimer's care units show that massage exerts a calming influence and minimizes behavior problems.