In the early stages of dementia, cues such as reminding patients what day and year it is can help with memory, Gray said. However, as the disease progresses, he cautioned, cueing doesn't last. Reminiscing with the patient is helpful, because ancient memories are burned in deeply and remain available, said Gray. Caregivers should talk about the old days, but also realize that as time goes on, these memories will become less available.
Regarding language, Gray recommended that clinicians and caregivers speak slowly and simply, and ask questions that require only a yes or no answer. He recommended further that they present only one idea at a time, since presenting demented patients with too many choices can be overwhelming. Nonverbal cues, such as body language, also work well. A powerful nonverbal cue is the handshake, according to Gray. Many times just extending a hand is enough to encourage a recalcitrant patient to accompany their caregiver.
During a visit to the physician's office, clichés can serve as social lubrication, and keep things upbeat. "Hey, I like that tie." "Where'd you get those shoes?" This sort of general social conversation can keep the tone of the interview at a very pleasant level, said Gray.
Loss of executive cognitive functions becomes obvious as the patient becomes increasingly unable to engage in activities that require planning, anticipation, sequencing, orchestration, goal-directed activity, response inhibition and abstraction. For example, Gray said, patients may be able to make toast for breakfast, but unable to manage the planning required to prepare a meal.
Signs of the dysexecutive state include disinhibition and poor judgment. This includes disrobing, sexual displays and hoarding. With a disrobing problem, it is helpful to alter the way clothing is worn, Gray advised. For example, he suggested that if there is a drawstring, it should be turned to the back, or double-knotted. For inappropriate sexual displays, he advised redirection, limitation, looking for antecedents, privacy and distraction with manual activities.
The notion of hoarding is important, Gray said. "Folks [go] on patrol, touring, picking up sugar packs, picking up dentures [and] putting them in, putting on glasses, but they may be [someone else's] glasses.
"Apathy also falls under the dysexecutive state. If a patient is apathetic, the best thing to do is try to engage them. If they're playing cards, play cards with them, or if they're raking the yard, rake with them," he said.Psychiatric Syndromes
Gray touched briefly on effective ways clinicians can address psychiatric syndromes. With someone suffering from delusions and hallucinations, he advised, "Don't argue, don't confront, don't deny; give honest, noncommittal answers. Try to understand patient explanations."
He recommended optimizing sensory output with things such as improved lighting, glasses and hearing aids. Caregivers should remain visible and available, and help the patient focus on familiar aspects of the situation by using voice endearments and favorite belongings. Minimizing opportunities for failure and self-harm, and maximizing physical comfort can help in cases of depression. Engaging the patient in, and encouraging them to perform, simple, familiar, successful tasks may also ease their distress.
For someone suffering from anxiety, Gray recommended reassurance, affection and distraction, and keeping patients' hands busy in a serene milieu. He warned that asking for explanations may worsen the situation.Agitation
With agitated patients, said Gray, clinicians should advise caregivers to sit with the individual, assess their needs and pains, and look for possible environmental triggers. Irritable patients can often be distracted and redirected if caregivers plan demanding activities for patients' best time of day. To curb yelling and screaming, caregivers should manage affects and not overreact. They might try using music, perhaps asking the patient to sing along; or encourage tactile activity.
Resistant patients, said Gray, respond best if the caregiver focuses on positive aspects and rewards, and is willing to compromise. It is important to remind and assist, not take over, and always be ready to gently try again.
For catastrophic reaction, Gray said, "It is important to keep calm, manage affects, reduce choices and stimuli; look for environmental triggers; and distract with tasks."
For aggression, Gray suggested looking for cues that the patient is decompensating and letting the patient relax. Clinicians need to be receptive and patient, and lead the patient to a quiet area.
In conclusion, Gray asked physicians to remember the person with the hardest job of all-the caregiver. "Studies estimate that between 50% to 75% of the caregivers of demented individuals have significant episodes of clinical depressive symptoms that may require antidepressant medication," said Gray. "Be sure they know about adult day care, respite care and any other options that may help them."