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Chapter 1: Alzheimer’s Disease and Other Dementias: Symptoms, Stages, and Communication Strategies (Mandatory) [1 CE Hour] As a major cause of physical and mental disability, and increased functional dependency, AD affects not only the patient but the caregiver as well. Allied healthcare providers will play a major role in education, communication, and treatment of this disease, and the research shows that their interaction is with the patient and their respective support team. Learning about ADRD, the impact on the brain, AD stages and symptoms, and caregiver burden will enable you to better serve this population. This course will provide insight into the disease allowing you to have deeper understanding into the lives of patients and those who care for them. THIS COURSE FULFILLS THE REQUIREMENT FOR ALZHEIMER’S DISEASE Chapter 2: Code of Ethics for Counselors and Marriage and Family Therapists (Mandatory) [6 CE Hours] 13 This course will fulfill the requirements for continuing education/certification for counselors on the topic of ethical practice. It aligns with the standards and Code of Ethics of the NBCC, ACA, and AAMFT. The course will include best practice strategies to address common areas of ethical concerns in counseling including currents topics such as the use of long-distance counseling through technology. THIS COURSE FULFILLS THE REQUIREMENT FOR ETHICS Chapter 3: Cultural Humility in Behavioral Health (Mandatory) [3 CE Hours] 59 1 The purpose of this education program is to present an introduction to cultural humility and offers tools for psychologists and mental healthcare professionals to use when working with diverse patients in a culturally humble manner. THIS COURSE FULFILLS THE REQUIREMENT FOR CULTURAL COMPETENCY Chapter 4: Preventing Sexual Harassment in the Workplace for Illinois Professionals, 2nd edition (Mandatory) [1 CE Hour] 81 This basic-level course will help Illinois Healthcare professionals identify sexual harassment in the workplace, prevent it, and take appropriate action if it occurs. 92 This course provides a historical context of race and racism and its relationship to the development of racial implicit bias. Research indicates that implicit bias in healthcare contributes to healthcare inequities. By increasing awareness of the many facets of implicit bias, discussing scenarios specific to healthcare that direct relate to patient care, and facilitating thought processes and discussions around the issue, individual healthcare providers can improve the spectrum of care. THIS COURSE FULFILLS THE REQUIREMENT FOR IMPLICIT BIAS AWARENESS Chapter 6: Major Depressive Disorder in Adults: Signs, Symptoms, and Treatment Strategies [3 CE Hours] 101 THIS COURSE FULFILLS THE REQUIREMENT FOR SEXUAL HARASSMENT Chapter 5: Understanding Implicit Bias in Healthcare (Mandatory) [1 CE Hour] This basic-level course aims to educate social workers, mental health counselors, marriage and family therapists, and psychologists about major depressive disorder and its distinctions. This course provides necessary information about major depressive disorder, including the epidemiology of major depressive disorder, signs and symptoms in adults (with a very brief overview of major depression in children and adolescents), causal and influential factors, assessment, diagnosis, treatment, relapse prevention, and outcomes evaluation. Final Examination Answer Sheet 126
©2024: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge in the areas covered. It is not meant to provide medical, legal or professional services advice. Colibri Healthcare, LLC recommends that you consult a medical, legal or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation or circumstances and assumes no liability from reliance on these materials.
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PROFESSIONAL COUNSELOR CONTINUING EDUCATION
Book Code: PCIL1525
What are the requirements for license renewal? License Expires Frequently Asked Questions Contact Hours Required
Mandatory Subjects
NEW! 1 hour - Cultural Competency (beginning January 1, 2025) 3 hours - Counseling Practice Ethics 1 hour - Implicit Bias awareness 1 hour - Sexual Harassment prevention 1 hour - Alzheimer’s Disease and other dementias (once every 3 renewal periods) 1 hour - Mandated Reporter Training provided by DCFS, within 3 months of initial licensure and at least every 3 years thereafter
Biennial renewals are due March 31 of odd-numbered years.
30 (All allowed through self study)
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Book Code: PCIL1525
PROFESSIONAL COUNSELOR CONTINUING EDUCATION
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PROFESSIONAL COUNSELOR CONTINUING EDUCATION
Book Code: PCIL1525
Chapter 1: Alzheimer’s Disease and Other Dementias: Symptoms, Stages, and Communication Strategies (Mandatory) 1 CE Hour Release Date: December 15, 2022 Expiration Date: December 15, 2025 Upon successful completion of this course, continuing education hours will be awarded as follows: ● Social Workers and Psychologists: 1 Hour ● Professional Counselors: 1 Hour Author
Joy Siegel, EdD, MBA , has dedicated her professional life to building a strong community for improved health outcomes. She has consulted with more than 200 community-based organizations and led campaigns for societal issues such as homelessness, cancer, lifelong learning, Parkinson’s and Alzheimer’s diseases, and the arts. Joy has designed annual funds, capital campaigns, social media campaigns, Medicare- and Medicaid-funded programs for dementia and mental illness, loneliness mitigation programs, and many special events for outreach and fundraising. When Joy’s mother was 59, she was diagnosed with Parkinson’s disease, a life-altering diagnosis for herself and the family. Joy became an integral part of her mother’s care team. She also went back to school and earned a doctoral degree in organizational leadership and gerontology and began working in the healthcare sector How to receive credit ● Read the entire course online or in print. ● Answer the final examination questions at the end of the course. ○ A passing grade of 75% is required. Test questions link content to learning outcomes as a method Colibri Healthcare, LLC implemented mechanisms prior to the planning and implementation of the continuing education activity, to identify and resolve conflicts of interest for all individuals in a position to control content of the course activity. Disclaimer The information provided in this activity is for continuing education purposes only and is not meant to substitute for the independent medical judgment of a healthcare provider Disclosures Resolution of conflict of interest
with providers, plans, systems, and communities to create and deliver programs promoting nonclinical aspects of wellness. Joy most recently worked with a regional Medicare Advantage plan designing retention and outreach programs and pilots designed to improve health and minimize loneliness. She is on the faculty at the Nova Southeastern University’s Kiran C. Patel College of Osteopathic Medicine and teaches public health to future healthcare leaders. Her career is an aggregate of personal, professional, and academic experiences that have shown her that community is often the answer. Joy has more than 100 hours of continuing education programs running nationally for allied health professionals, providers, and administrators. Joy Siegel, EdD, MBA has no significant financial or other conflicts of interest pertaining to this course.
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relative to diagnostic and treatment options of a specific patient’s medical condition.
©2024: All Rights Reserved. Materials may not be reproduced without the expressed written permission or consent of Colibri Healthcare, LLC. The materials presented in this course are meant to provide the consumer with general information on the topics covered. The information provided was prepared by professionals with practical knowledge of the areas covered. It is not meant to provide medical, legal, or professional advice. Colibri Healthcare, LLC recommends that you consult a medical, legal, or professional services expert licensed in your state. Colibri Healthcare, LLC has made all reasonable efforts to ensure that all content provided in this course is accurate and up to date at the time of printing, but does not represent or warrant that it will apply to your situation nor circumstances and assumes no liability from reliance on these materials. Quotes are collected from customer feedback surveys. The models are intended to be representative and not actual customers. Course overview
As a major cause of physical and mental disability, and increased functional dependency, AD affects not only the patient but the caregiver as well. Allied healthcare providers will play a major role in education, communication, and treatment of this disease, and the research shows that their interaction is with the patient and their respective support team.
Learning about ADRD, the impact on the brain, AD stages and symptoms, and caregiver burden will enable you to better serve this population. This course will provide insight into the disease allowing you to have deeper understanding into the lives of patients and those who care for them.
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Book Code: PCIL1525
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Learning outcomes Upon completion of this course, the learner should be able to: Define dementia, the symptoms, and various types of dementia. Evaluate the various stages of Alzheimer’s. Recognize the impact of Alzheimer’s disease on activities of daily living and independent activities of daily living within the disease stages. professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient Implicit bias in healthcare Implicit bias significantly affects how healthcare or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact
Identify communication strategies for persons with ADRD Define steps for best practices in caring for a patient with Alzheimer’s. Describe approaches to and guidelines for establishing structured care provisions.
health outcomes. Addressing implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics.
INTRODUCTION
Alzheimer’s disease is one of the leading illnesses affecting the elderly and is the most prevalent dementia. According to the World Health Organization, the number of people in the world that will be diagnosed with AD is expected to reach 82 million by 2030 (WHO, 2022). AD is a public health challenge. In May 2022, the federal government increased funding for AD research to almost $350 billion. As a major cause of physical and mental disability, and increased functional dependency, AD affects not only the patient but the caregiver as well. Allied healthcare providers will play a
major role in education, communication, and treatment of this disease, and the research shows that their interaction is with the patient and their respective support team. Learning about ADRD, the impact on the brain, AD stages and symptoms, and caregiver burden will enable you to better serve this population. This course will provide insight into the disease allowing you to have deeper understanding into the lives of patients and those who care for them.
ALZHEIMER’S DISEASE AND RELATED DEMENTIAS (ADRD)
In 2022 approximately 6.5 million Americans are living with Alzheimer’s disease (Alzheimer’s Association, Quick facts, 2022). Almost 75% of these people are over age 75, and two-thirds are women. By the year 2050 the number of Americans afflicted by ADRD will be close to 13 million. It is important to recognize that this disease strikes a person and also deeply affects their loved ones whose lives are directly impacted by caregiving responsibilities.
Professionals providing direct care to people with ADRD will continue to find the opportunity to work in private homes, daycares, skilled nursing facilities, assisted living facilities, hospitals, and hospice. This is a demanding job that requires compassion, patience, and empathy, as well as the ability to pivot and adjust as the stages of the disease present new challenges. It is recommended that professionals providing care identify a support network in which there can be an idea exchange for appropriate, dignified care as the stages progress.
DEMENTIA
● Paranoia and/or delusions ● Evidence-Based Practice ● Difficulty expressing thoughts ● Loss of ability to read or write
Dementia is a common brain disorder throughout the world characterized by memory loss, cognitive impairment, and ultimately the loss of independence (Zhao et al., 2021). Over time, capacity is diminished, which deeply impacts well- being, self-care, and the ability to perform activities of daily living (ADL). Table 1 lists other disease processes that cause dementia. Symptoms of dementia can include: ● Memory loss ● Poor judgment and confusion
Evidence-Based Practice! It is important that people with any type of dementia-like attributes receive a diagnosis from a trained provider (Ophey, 2021). Experts are needed to ensure diagnostic accuracy with screening methodologies to create and implement care plans that will improve outcomes.
● Confusion with finances ● Wandering or getting lost
● Inability to capture words for objects ● Loss of interest in normal activities ● Inability to perform normal activities
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Table 1. Types of Dementia
Disease
Symptoms
Attributes/Causation
Parkinson’s disease (Ophey et al., 2021)
• Poor executive function • Trouble walking • Unstable gait • Impaired responsiveness to visual cues • Speech impairment • Impaired affect/modified facial expression • Decreased eye blinking • Depression • Dementia • Insomnia • Rigidity/freezing • Shaking • AD traits: Memory loss, confusion, and language • Frontal lobe brain cell damage due to nerve damage • Diagnosis confirmed postmortem • Drastic change in behavior and personality • Aggression • Loss of speech • Loss of decision-making ability • Loss of sense of self-awareness • Will become completely dependent • Progressive dementia • Affects ability to think, reason, and process information • Impaired movement, mood, and behavior
• Basal ganglia cells die, causing dopamine levels to drop • Progressive, chronic disease • Personalized treatments for symptom relief • Exercise can improve symptoms and may protect the brain (Michael J. Fox Foundation, 2022) • No cure
Frontotemporal dementia (Alzheimer’s Association, n.d.)
• Frontal lobe controls language and personality • Also known as Pick’s disease • No cure
Lewy body dementia (LBD) (Johns Hopkins Medicine 2022)
• 1.4 million people living with this disease • Due to unusual deposits of alpha- synuclein protein on brain • Initial diagnosis may be mental/ psychological health • No cure • Caused by constriction or breakdown of blood vessels in and around the brain • Can be the result of a stroke(s) • Symptoms vary by location of actual constriction • Lifestyle factors (diet, lack of movement, smoking) contribute to disease progression • Disease can be allayed by exercise, diet, avoiding alcohol and smoking • Originally referred to as punch drunk syndrome • Caused by extensive hits to the head • Brain has tau protein similar to AD, but presents uniquely in CTE • Some symptoms can be addressed with medication • Diagnosed postmortem • No cure • Also known as pseudodementia • Outcome of a lack of stimulation • Person can improve if they respond to help • Engaging activities, exercise, cognitive- behavioral therapy, medication can all help person recover • Person can return to their prior intellect
• Parkinsonian-like rigidity • Hallucinations, paranoia
Vascular dementia (Mayo Clinic, 2022)
• Problems with reasoning • Impacted judgement, memory, and other thought processes
Chronic traumatic encephalopathy (CTE) (JNaraparaddy, 2018)
• Extreme dementia • Memory loss, confusion • Mood disorder • Personality changes, rage • Can present in mid-life • Person becomes erratic and unpredictable
Depression dementia (Alzheimer’s Association, 2022)
• Lethargy • May or may not appear depressed • Person may not realize that they are depressed • Person can be in denial about opportunity to get better • Person can realize that they are slow moving and uninspired • Person can recognize their memory loss • Person may accept that they have dementia, even before they are diagnosed
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Mild cognitive impairment (MCI) [Alzheimer’s Association, 2022]
• Mild memory loss • Can present as exhaustion • Mild confusion
• Standalone diagnosis • Person can be engaged in their life, can still work • Various reasons for MCI • Can be a precursor to another diagnosis • Can be a side effect of a urinary tract infection (UTI) • Should be monitored by a physician • Root cause is important for improvement or for planning for more severe situation • Person should have medication evaluated/monitored/managed • Frontal variant Alzheimer’s disease • Posterior cortical atrophy
• Person can be aware of their symptoms • MCI may be a symptom of another illness
Atypical Alzheimer’s disease (Alzheimer’s Association, 2022)
• Amnestic problems • Unusually early symptoms impacting executive and motor functioning
Other Dementias (Alzheimer’s Association, 2022) Corticobasal syndrome (CBS) Creuzteldt–Jakob disease (CJD) HIV-associated neurocognitive disorder (HAND) Huntington’s disease
Self-Assessment Quiz Question #1 What is dementia? a. Memory loss that is intermittent. b. A combination of behaviors and impairment that are a result of a brain disorder. c. Immediate diminished capacity. d. A loss of sensation.
Normal pressure hydrocephalus (NPH) Progressive supranuclear palsy (PSP)
ALZHEIMER’S DISEASE
Alzheimer’s disease (AD) is a chronic, incurable brain disorder that is a leading cause of death for people over age 65, primarily women. Accounting for 60%–80% of confirmed cases, AD is the most common type of dementia (Zhou et al., 2021). The World Health Organization (WHO) states that globally, there are approximately 50 million people with dementia currently, and that number is increasing (WHO, 2022). AD symptoms can include personality and behavioral changes, which ultimately lead to total decline as the brain loses the ability to communicate with the body. The actual causes of AD vary, and it can be impacted by lifestyle factors such as age, physical fitness, nutrition and diet, genetics, cardiovascular health, alcohol intake, amount of social connection, and sleep. Alzheimer’s
disease symptoms present due to the formation of amyloid plaques and neurofibrillary tau tangles (NFT) on the brain that impede normal cognitive functioning. The plaques and tangles begin developing 15–20 years prior to the manifestation of clinical symptoms; thus, early detection and a healthy lifestyle are important. Self-Assessment Quiz Question #2 Alzheimer’s disease is the result of the formation of: a. Amyloid plaques and tau tangles. b. Plaque and enamel. c. Tangle and tear. d. None of the above.
IMPACT OF ALZHEIMER’S DISEASE ON THE BRAIN
A typical healthy brain has billions of neurons that transfer signals and information from the brain through the body for overall functioning (Flo et al., 2022). Alzheimer’s disease disrupts the brain as neurons lose the ability to communicate. The disruption occurs in stages that present over time. At this time there is no cure for AD, but a healthy lifestyle may help address symptoms.
Evidence-Based Practice! In March 2022, federal funding for the National Institutes for Health’s (NIH) research on Alzheimer’s disease was increased to $3.5 billion. The NIH leads the global effort to address AD and serves as a resource for those seeking information about this disease. Understanding root causes of AD, as well as actual aging, will help scientists address symptoms as they develop, which may prevent them from worsening (Alzheimer’s Association, 2022).
STAGES OF ALZHEIMER’S DISEASE
The Reisberg Alzheimer’s Scale (see Table 2) is used by clinicians and in residential care settings to provide insight into what stage of AD a patient is in. It also provides expectations for caregivers. Understanding the stage of the person with AD can help identify methods of communication for improved quality of life.
The scale divides the disease into seven stages, with two categories. Category 1, predementia, includes Stages 1–3. Category 2, the dementia stages, includes Stages 4–7.
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Table 2. Stages of AD Stage Description
Clinical Presentation
Stage 1 No evident dementia
• No identifiable dementia; person is mentally healthy
Stage 2 Subjective memory loss and age- related forgetfulness
• Can last 15 years in healthy people • May have difficulty remembering where they have placed things • May not be able to recall names as they have in the past • Subjective cognitive decline • Memory issues may be noticed by loved ones or coworkers • May repeat statements • Patient should visit a physician to understand root cause of MCI • Lifestyle changes can be made to reduce stress, improve diet, and increase physical exercise • Diagnosis by a trained professional can be made with great accuracy • Person may sense a loss of independence • Person may become forgetful with finances, bill paying, organizing the home • Poor time management • Person may inadvertently engage in unsafe behavior (e.g., leave door unlocked or forget to shut off oven) • Patient may be aware but lack understanding • Job performance may be impaired • Concentration may be impacted • High levels of anxiety • Evident decline in activities of daily living • May start to wear the same clothing, be resistant to changing • Needs daily assistance with life management, including finances • Cannot recall daily occurrences, cannot comprehend concepts such as the weather or their current address • Memory is erratic from moment to moment • May exhibit a lack of control, agitation, and aggression • Person will be unable to dress themselves properly • Person will require full-time oversight and assistance for activities of daily living • Bathing issues present—person may not discern water temperature and personal hygiene will be impaired, including toileting and brushing teeth; ultimately person becomes incontinent • Person will exhibit radical changes in emotions and express frustration with inability to communicate • People with AD who have been in good physical health and do not have cooccurring illnesses may be able to maintain some abilities longer • Limited to no mobility • Ultimately, rigid and unable to move • More vulnerable to normal aging diseases that can impact mortality • Person may be in denial or embarrassed • Person may isolate and avoid socialization • Person is unintelligible; speaks very few words • Physical decline is imminent due to lack of self-care
Stage 3 Mild cognitive impairment (MCI)
Stage 4 Moderate cognitive decline; mild dementia
Stage 5 Moderately severe cognitive decline; moderate dementia
Stage 6 Severe cognitive decline; moderately severe dementia
Stage 7 Very severe cognitive decline; severe dementia
Note: Adapted from Alzheimer’s Association (2022) Early detection of AD may impact the stage development of the disease. It may permit time for potential pharmacological interventions, clinical trials, and environmental and lifestyle adjustments. Additionally, proactive approaches may allow time to plan and identify healthcare providers that are engaging in progressive approaches toward the disease.
Self-Assessment Quiz Question #3 Understanding the aspects of clinical stage 4 can help with: a. Potentially minimizing the loss of social connections and isolation. b. Limiting potentially unsafe behavior. c. Both a and b. d. Retraining.
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Instrumental activities of daily living (IADL) are types of activities that someone can do for another person without involving contact, such as grocery shopping, finances, and cooking, while ADL are activities that involve all activities
in personal self-care. If assistance is required with ADL, it will be hands-on assistance such as toileting, bathing, and dressing. Table 3 provides tips for how to manage ADL and IADL in the context of the Reisberg Alzheimer’s Scale.
Table 3. Management of ADL/IADL Through the Reisberg Stages AD Stage ADL/IADL
Caregiver Supportive Activities
Early
Dressing
• Encourage choice • Give autonomy to actively participate in dressing
Personal hygiene
• Provide comb and brush along with encouragement to groom themselves • Aid with shaving, if needed
Bathing and toileting • Assist with bathing/shower as needed • Establish specific bath time
• Help with toileting when needed; respect modesty • Provide easy-to-remove clothing to assist with bladder control • Provide wet wipes for easy cleaning • Monitor for safety • Engage patient in food selection; encourage choice and participation • Engage in grocery shopping, meal preparation, and clean-up • Provide adaptive utensils, as needed • Encourage patient to serve and feed themselves • Cut food, if necessary • Monitor for safety
Eating
Middle
Dressing
• Limit options; encourage choice of comfortable clothing • Create environment to support independence • Allow time for dressing • Aid as needed • Encourage independence • Use adaptive supplies (e.g., hairbrush) • Limit time; stay focused on cleanliness and ease
Personal hygiene
Bathing and toileting • Initiate and monitor bathing activities
• May have to offer sponge bath in kitchen sink • Schedule bathroom visits • Provide direct assistance, as needed • Use dry shampoo if necessary
Eating
• Provide patient with a plated meal • Create protective environment for eating—switch to plastic, easy-to- hold cups and cutlery, if needed • Encourage independences, but provide eating support as needed • Limit choices, but offer options even when assistance is needed to select • Selections should be comfortable, easy to launder, and easy to put on and remove • Continue to encourage independence
Late Note: At this stage of the disease process, the patient will need assistance with most (if not all) ADL/IADL due to the severity of their impaired abilities. Hands-on assistance will be required for all these activities; however, attention should be given to maintaining dignity and engagement when possible.
Dressing
Personal hygiene • Provide as much assistance as needed to maintain appearance • Move slowly; help as needed with shaving, nail clipping, moisturizing • Gestures and directives should be simple and limited to one word • Display pictures of hygiene activities, if possible Bathing and toileting • Provide complete bathing care using supportive durable medical equipment (DME), as needed • Monitor closely with timed, structured bathroom checks
• Patient will lose ability to control bowels and will be incontinent • If using adult diaper supplies, monitor to avoid rashes and maintain cleanliness • Meal should be plated (and at the right temperature) and set out for patient • Adaptive utensils should be utilized • Monitor liquid intake • Provide adequate time for eating • Don’t rush • Patient may need assistance to be able to eat
Eating
Note: Adapted from Borda et al., (2020)
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Always remain calm when supporting ADL and IADL. Gentle statements such as “We are going to go for a walk now—put one foot in front of the other” or “I will hold the cup while you put your coat on” can redirect and minimize agitation. Validate feelings, for example, “I see you are uncomfortable—let me check the front of your shirt.” Let the person see you as a humble ally.
Self-Assessment Quiz Question #4 What is aphasia? a. Fainting. b. Loss of language and impaired comprehension. c. Loss of balance. d. A tingling sensation.
COMMUNICATING WITH ADRD PATIENTS
ADRD patients can have impaired communication and language (Mueller, 2018). These challenges become evident with word retrieval. As the disease progresses, the person becomes unable to recall words, which can result in unintelligible words that make delivering care and support challenging. Additionally, struggles with word retrieval often prompt frustration and agitation that can develop into behavioral issues as the person tries to express themselves. Evidence-Based Practice! Communication with people with ADRD is imperative, and as the disease progresses there will be a reliance on a caring support network. It is incumbent on the professional to accommodate communication needs and styles through progression of the disease. Share ideas and feedback with colleagues to identify innovative ways to communicate with people with ADRD in a manner that is dignified and effective (Alzheimer’s Association, 2022).
The term aphasia refers to the loss of language and impaired comprehension, including reading and writing, as an outcome of the breakdown of neurons (Weekes, 2020). It is important to note that memory loss may present before aphasia. As ADRD progresses the person may have clear difficulty speaking clearly and retrieving words pertinent to the conversation at hand. The person may repeat stories, situations, or words because that is language they can access. They may use words incorrectly and begin using descriptive language rather than names, and they may lose their thoughts mid-sentence. People may revert to their native language and ultimately may avoid speaking and engaging in conversation. Their difficulties with language may result in frustration and anger—be patient.
BEST PRACTICES: CARING FOR THE PATIENT WITH ALZHEIMER’S DISEASE
As AD progresses daily care challenges related to hygiene, such as bathing, can present (Alzheimer’s Association, 2022). There are many reasons for this—people may not want to share that type of intimacy, or the person with AD may have a fear of water, which, combined with eyesight challenges, may be overwhelmingly scary. Limitations in
communication may also prompt frustration and resistance to bathing. Tables 4 and 5 provide further implementations and suggestions for caring for the patient with Alzheimer’s disease. For further insight and suggestions for care, join ALZConnected, a virtual support community for caregivers.
Table 4. Communication Strategies Communication Strategies
Steps
Be patient
• Listen • Provide time for dialogue
• Avoid rushing • Don’t interrupt • Install a “pause” before reacting to impulsive or unexpected communication or behavior from a person with ADRD • Pay attention to context • Recognize that actual words may not correlate with what the patient is trying to communicate • Offer suggestions, but don’t overwhelm with too many choices • Do offer choices to give a sense of control (e.g., “Do you want to go for a walk now or after lunch?”) • Use visual cues (e.g., if the person is cold but cannot express it, show them a sweater) • Keep language simple and avoid cultural slang
Listen and interpret
Pay attention to body language • Look at the person when they are talking • Don’t correct • Maintain eye contact • Have a connection; hold a hand (if permitted)
• If the person seems bored or disinterested, or appears to need to move around, follow their lead—go for a walk, perhaps move from the space you are in and go outside, listen to light music
Be respectful
• Don’t correct • State your interpretation of what they are expressing • Don’t argue or challenge • Recognize your nonverbal cues • Remain calm and relaxed • Avoid speaking with child-like reference
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Table 4. Communication Strategies Communication Strategies
Steps Minimize stressful communication • Pose questions in a manner the person can answer; don’t offer multiple responses
• If the person is struggling, provide reassurance and encouragement • Use visual aids/cues as appropriate to redirect and/or distract • Have a calendar to the show date and schedule • Avoid responses to bad language or defiance • Remember the disease is acting out; the person cannot control aspects of ADRD • Recognize that personality changes occur
Do not criticize, threaten, correct, or argue
Avoid distractions
• Limit loud background noise and unexpected sounds • Create a calm, quiet environment • Arrange lighting to avoid shadows • Let the person be the center of importance • Integrate music, but avoid loud, overbearing sounds
Communicate with visual cues
• Use gestures, such as taking the person to the toilet; opening the door to suggest taking a walk; showing a jacket to encourage dressing to leave the house • Have a large clock to detail time and scheduled activities
Integrate communication breaks • Communication can become frustrating
• Set specific quiet time to mitigate stressful situations
Note: Adapted from Mueller et al. (2018)
STYLISTIC SUGGESTIONS WHEN COMMUNICATING WITH THE AD PATIENT
Affirm, distract, and redirect Affirm the person or action with validating statements: “I see that you are upset”; followed by distracting: “I’m sorry you are upset—would you like to have lunch?” These statements are more manageable for an AD patient who may lack capacity to communicate clearly. Redirection that Respond with warmth and reassurance Focus on the feelings the AD patient expresses. Respond with verbal and physical expressions of comfort, warmth, and reassurance. If the patient is comfortable with touch, Reminisce and maintain a sense of humor Let the patient share stories, as patients will have an easier time remembering their personal history and things from the past. Encourage the person to share photos and personal Embrace the patient, not the behavior ADRD may lead to changes in personality. Compassion will serve the caregiver well when addressing needs and behaviors. For example, if the person wants to sleep on the floor instead of the bed, ensure safety and let them. As a patient senses a loss of control over their life, they may act out. Permit safe choices that may be nontraditional. Healthcare Consideration: It is important that members of the care team collaborate to explore new technological options that can improve communicative opportunities. Assistive technologies can provide monitoring, communication, various therapies, medication reminders, socialization, and education. They can also support a sense of independence (Palmdorf et al., 2021).
can improve the situation could be suggesting a walk or looking at photos. This approach will need to be modified based on the specific context but can defuse difficult situations.
offer your hand as a gesture of safety and kindness. Respect boundaries, go slowly, and let the patient know that you are a loving presence.
images, and if they are open to questions, ask them to share.
Self-Assessment Quiz Question #5 What type of clothing will be helpful for a patient with AD?
a. Items with elastic waists. b. Items with small zippers. c. Overalls. d. Belts.
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Table 5. Structuring Care Initiative Create large, visible calendar
Implementation
Other Suggestions
• Review daily schedule • Reference throughout the day • Allow time for all activities
• Color-code days and events
Maintain structured routine with established times
• Bathing • Dressing • Meals/snacks
Create daily to-do list
• Engage person with AD • Provide them with copy
• Reference throughout the day, if needed • Alexa, smartphone, Google Home • Customize based on responsiveness
Plan activities of interest
• Use technology to engage and set reminders • Do not overbook the daily schedule (to avoid rushing)
Schedule quiet time Dressing
• Wearable items should have elastic waists • All items should be comfortable • Get multiple items of favorite pieces • Slip-proof, slip-on shoes
• Person may want to wear the same thing daily • Limit accessories • Large zipper pulls • Avoid shoelaces, buttons, and buckles • In later stages person will not be able to discern water temperature • Once water is comfortable, allow for dignified experience • Taste may change • Food may need to be prepared in bite-size pieces • Monitor eating habits to avoid hazards • Provide support, as needed; allow the person to be independent • Person may repeat questions and thoughts; continue to respond • Distract person if frustration presents • Take walks, show photos, play music
Bathing/showering
• Install grab bars • Use sturdy shower chair • Slip-proof mat on the floor
Mealtime
• Provide sufficient time for meals • Eat at the same time daily • Prepare nutritious meals that are easy to eat • Engage the person in the preparation process • Maintain a calm atmosphere for meals • Always speak in a calm, reassuring voice • Practice active listening • Validate the person; redirect, don’t correct • Engage person in decision making, as appropriate • Refrain from asking “Do you remember?” • Encourage conversation, validate • Display beloved items and photos throughout the home
Communication
Space
AD spectrum of behaviors
• Angry outbursts • Oppositional behavior • Agitation and aggression • Fear
• Address environmental changes, uncomfortable clothing, allergies, modifications to diet • Caregiving strategies will need to be modified • Logic is not always the best approach
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Caregiver approach
• Recognize challenges • Recognize that the illness is not the person • Constantly modify approach • Maintain perspective • Be kind, compassionate, patient, empathetic • Caregivers need breaks; make time for a “pause”
• Responses may not be logical • Caregiver strength and perspective is invaluable to the person with AD
Caregiver self-care
• Make sure caregiver is not angry, hungry, or tired
• Identify care support team • Ask for help when needed
Note: Adapted from Shin & Habermann (2022)
ACCOMMODATIONS FOR SAFE DISEASE PROGRESSION
As AD progresses people may require oversight provided by a residential community. Most people intend to age in place at their homes, but disease progression may present limitations for safety, mobility, and socialization. Ideally a person would determine a plan of care for themselves in the Adult daycare Adult daycare programs are located throughout the U.S. They allow the person to remain in the home with supervision but have a full structured day in a safe environment. These programs may be run by nonprofits with Assisted living facilities (ALF) ALF may be appropriate for the earlier stages of dementia, as they adjust levels of care to accommodate the disease. And they often have separate memory units to provide Memory units These units are designed specifically for the patient with dementia. Buildings are often structured to safely accommodate wandering and mobility, and they provide structured activities for stimulation and engagement. There Skilled nursing facilities (SNF) Skilled nursing facilities (SNF) are long-term living facilities for people who require extensive 24-hour care. Patients experiencing end-stage AD may move to a SNF for care. These facilities are the most expensive of the residential options and while a short period of time is covered by Hospice Hospice services can be appropriate for end-stage AD. Hospice treatment can be brought to the home, the community, or a unit that provides accommodations for overnight care. Additionally, hospice provides respite care
early stages, but this does not typically happen. Limitations of caregiving combined with an increased need for care prompt loved ones to explore daycare options or residential options with 24-hour care.
a sliding fee scale, or the cost can be covered in part by Medicaid. These programs include meals, activities, toileting support, rest, and potentially transportation.
higher levels of care. These facilities can be paid for by long-term care insurance, private pay, or Medicaid.
is a higher ratio of professional caregivers to patients. These facilities can be paid for with long-term care insurance, private pay, or Medicaid.
Medicare (up to 100 days), there can still be a copayment, followed by the full rate once the Medicare benefit has expired. This can also be private pay or covered by Medicaid.
to the caregivers for a set amount of time during the service. The hospice benefit is typically fully covered, and offers many value-added services; however, the person may have to pay for caregiving assistance if needed.
CARING FOR THE CAREGIVER
Caregivers can suffer from sadness, depression, stress, feeling trapped, overwhelmed, and distressed (Shin & Habermann 2022). Stressed caregivers may find their health compromised. It is important that family caregivers build a supportive network that will help them share the responsibility. Professional caregivers may also find the role stressful. As suggested as a part of best practices, they should ensure that they are getting exercise, eating a healthy diet, having quiet moments, and reaching out for help as needed.
New technology may be helpful for families and professional caregivers (Palmdorf, 2021). Devices include televisions, computers, smartphones, monitoring devices, fall prevention sensory devices, and robots. The goal is to provide supportive patient monitoring and engagement, caregiver connection, and telehealth. Health plans may offer these devices as a part of their coverage, and all are designed to improve outcomes and well-being.
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Caregiver resources There are support resources for caregivers. The stress that a caregiver may experience is correlated to the amount of time they spend caregiving. Identifying ways to have meaningful support for the patient and the caregiver throughout each stage of AD can greatly improve the Case study Sandy, age 78, has been living with her daughter Michelle for two years. Until recently, she could stay home by herself but lately she has been trying to leave the house and wandering is becoming a safety concern. Michelle has decided to enroll her mother in the adult daycare program near her house, but she is worried that her mother will act out and be unruly. At the daycare, she lets the administrator know that her mother has behavioral problems and is often unwilling to stick to a schedule. She also shares that her mother wanders and is unable to sit still. The administrator reassures Michelle that the daycare has the capacity to accommodate Sandy and her disease in an appropriate, comfortable manner. When Michelle picked up her mother after the first day of day care, she noticed that Sandy was tired and sleepy. The administrator shared that Sandy had experienced an amazing day at the center. She participated in the activities, rested, and when she got restless, she was escorted by a certified nurse assistant (can) for a walk around the hallways of the building. Additionally, Sandy had eaten the food, was able to introduce herself, and appeared to be comfortable in the new environment. Michelle was amazed and when they got home, Sandy wanted to rest on the couch and Michelle was able to prepare dinner in a calm environment. Michelle decided that her mother would go to the daycare five days a week. Michelle was also going to benefit from her mother’s new schedule. She no longer had a sense of dread that something would happen to her mother during the day, or that her mother would not have food, or would slip and fall. Michelle became a huge advocate for adult daycare and greatly appreciated the benefits for both the person with AD and the caregiver. Conclusion Alzheimer’s disease is complex, difficult to comprehend, and full of conflicts for the patient and caregivers. Understanding the stages and disease progression allows for planning, lifestyle changes, and integration of safety measures that can improve well-being. As more people are diagnosed, there will be a continued need for research, testing, and communication among the AD community to identify innovative ways to improve. As healthcare providers it is incumbent on us to align with the appropriate professionals who can fill in gaps of care, communication, and shared information to empower and serve our patients with honesty and integrity.
overall well-being of everyone involved. For information about local caregiver support resources, ● Veteran’s Administration National Caregiver Support Line 1-855-260-3274 ● Alzheimer’s Association https://www.alz.org/about Many caregivers are not aware of the benefits of support services such as adult daycare, respite, and other programs. Additionally, there are challenges that can be presented based on preconceived notions and perceptions of services. When addressing concerns of family caregivers, consider the following. ● Family caregivers often have a sense of grief, loss, and guilt pertaining to their loved one, so providing support for the caregiver can be a tremendous asset to the entire care team. ● Providers and healthcare professionals are often unaware of the available resources in the community, so engage and educate them so that they can refer people. ● Create a support network for family caregivers—often they provide insight and recommendations that can be helpful. ● Draw boundaries, as appropriate, between social services and family caregivers—while it is the goal to address each individual situation as it arises, there must be a general focus on service delivery that is for the good of the community served. Understand that caregivers are often exhausted and confronting stress they are unprepared for, combined with grief and loneliness. The synergy between a caregiver, the professional support, and the person with ADRD can be lifesaving and improve the overall well-being of everyone in a difficult time.
This disease requires a comprehensive community approach to ensure that people have access to healthcare and services that can be of value to both caregivers and patients.
WORKS CITED https://qr2.mobi/AlzDisease
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