Reminiscence therapy is a popular modality that involves stimulating memories of the past by looking at personal photos and newspaper clippings and discussing the past. It is well received by patients and caregivers. It has been shown to improve mood in elderly patients without dementia, but studies of reminiscence therapy have been too dissimilar to draw conclusions regarding its effect on behavioral disturbances in patients with dementia.38
Other therapies that are common in dementia care, such as respite care and specialized dementia units, have simply not been studied well enough to provide any conclusions as to their effectiveness.39,40
CASE When Ms. M is discharged from the hospital, her family enrolls her in an adult day care program, where Ms. M will be able to participate in social activities, exercise, and communal meals. Her daughter asks the family physician what other steps they can take in the home to make things easier on her mother. And as an aside, the daughter admits that while she is glad that she and her family can “be there” for her mother, there have been times when she has simply not felt up to the task.
Help family members care for the patient—and themselves
A recent meta-analysis suggests that caregiver interventions have a positive effect on behavioral problems in patients with dementia.32 Successful programs are tailored to the individual needs of the patient and caregiver and delivered over multiple sessions. Unfortunately, the aforementioned meta-analysis did not provide evidenced-based interventions for specific problems.32 With this in mind, the following are some practical caregiver “do’s and don’ts” that are based on reviews and consensus guidelines.
Don’t take it personally. It is extremely important to help caregivers understand that the disturbing behaviors of patients with dementia lack intentionality and are part of the normal progression of the disorder.25 Caregivers also need to appreciate that hallucinations are normal in these patients and do not require medications if they don’t disturb the patient or place the patient or anyone else at risk.
Don’t try to reason with the patient; redirect him or her instead. Clinicians should offer caregivers suggestions for reassuring, redirecting, or distracting agitated patients rather than trying to reason with them. Encourage caregivers to develop and maintain routines and consistency.6,25 Using a calm, low tone of voice, giving very simple instructions, and leaving and then reattempting care that is refused the first time may also be effective.5 Some experts have suggested techniques such as giving positive rewards for desired behaviors and not rewarding negative behaviors.6,26
Do create a safe environment. Recommend that caregivers create a safe environment. Make sure that they lock up all guns. Also, encourage them to use locks, alarms, or ID bracelets when patients are prone to wandering.25
Do consider a caregiver support program. Caregivers can make a big difference in the lives of patients with dementia, Help caregivers understand that the disturbing behaviors of patients with dementia lack intentionality and are part of the normal progression of the disorder. but only if they have support, as well.
A recent meta-analysis concluded that active involvement of caregivers in making choices about treatments distinguishes effective from ineffective support programs, decreases the odds of institutionalization, and may lengthen time to institutionalization.33 To ease caregiver strain and depression, encourage them to make use of resources such as nursing home respite care and community agencies that include the Alzheimer’s Association (http://www.alz.org).6,44,45
CASE Ms. M’s daughter joins a local support group for families of patients with dementia, where she learns redirection techniques to try when her mother refuses care. The exercise and daytime social stimulation that Ms. M receives through the adult day care program helps her to sleep at night. When Ms. M refuses to take a shower—a challenge the family had before her hospitalization—the daughter does not argue with her. Instead, she returns 10 to 20 minutes later and asks again, or tries a bedside sponge bath with a lavender soap that Ms. M seems to like.
Ms. M’s nighttime wandering is markedly reduced and the family no longer uses any antipsychotic medications. The family physician counsels them, however, about the progressive nature of the disease and encourages them to set up periodic follow-up visits, so that he can see how everyone—patient and caregivers alike—are doing.
Welcoming the reprieves, recognizing the realities
The behavioral and psychological symptoms of dementia are the most challenging aspect of dementia care. Unacceptable behaviors sometimes persist even when aggressively addressing modifiable factors and attempting behavioral interventions (TABLE 2).2,5-7,15,16,24-26,32,41,44-46 Patients with behavioral disturbances frequently require a pharmacologic agent or transfer to a different care setting.