Alzheimer's, Dementia, and Related Issues

Alzheimer's disease and related disorders are grouped by the general term "dementia" in this course. Alzheimer's is a progressive, devastating disease that starts slowly and progresses over time to interfere with activities of daily living. Alzheimer's is not a normal part of aging and the highest risk group is age 60 and up, and the occurrence doubles every five years after age 65 (Alzheimer's Foundation, 2009). This disease accounts for 50-80 percent of all dementia cases in the United States (Alzheimer's Organization, 2011). Dementia is the loss of cognitive functioning: thinking, remembering, and reasoning to such an extent that it interferes with every aspect of daily living. Although there are many different types of dementia, CNAs must learn to understand all aspects of dementia to better care for their residents.

Alzheimer's disease, discovered by Dr. Alois Alzheimer, in 1906, still has no real way to be diagnosed, except through autopsy.

Working with Alzheimer's residents takes a great deal of patience, understanding, and compassion. It is not always easy to care for these special residents as they get agitated easily and may become angry and aggressive (Winston, 2010). Their moods change quickly, and caregivers need to adapt to each new situation. Knowing your residents and being able to anticipate their needs is so important. When you can anticipate, you will be able to diffuse a tense situation before it actually begins.

Behavior management begins with good communication skills. Good communication skills are the key to effective and safe practice. When a resident becomes agitated and starts to "act out," direct caregivers must learn to control the situation, keeping the environment safe for everyone in the area. Communication is difficult, at best. People with dementia have trouble with communication and react with frustration and anger. The best way to manage agitation and anger is to prevent it. Learn to anticipate the residents' needs before they start to act out. Aggressive behavior is usually born from frustration. Alzheimer's residents are not able to verbalize their needs, hence the frustration.

Tips for good communication:

• Always approach from the front
• Identify yourself
• Use a calm voice and relaxed body language
• Use simple words

Because dementia affects every part of the brain, residents will need more intense assistance as the disease progresses. No one progresses at the same rate, and the most likely scenario in long-term care would be 20 residents, all with a different degree of dementia. Each resident will do some things that others would never do (Alvare, Fuzy, & Rymer, 2009). Learn to be aware of the "triggers" that set off residents. If you know that one resident will act out in a noisy environment, try to place the resident in a quiet place. Identifying triggers and the emotions that follow is the basis of cognitive-behavioral therapy. It is a strategy that will give you a way to think through difficult scenarios and help to find solutions (Atkins, 2008).

Some triggers to look for:

• What is happening around them at the time of agitation?
• Is it too noisy? Too much stimulation?
• Hot? Cold?
• Scared? Confused? Tired? Frustrated with an activity?
• Was the resident shouting? Cursing? Threatening with hands/fists?
• Tired? In pain? Bored?
• Has the person recently moved to new surroundings?

Be sure to document everything you observe about the shouting, agitation, and any other behaviors, including the date, time, and what is happening. Be sure to share the information with your co-workers at a staff meeting or shift change. This is important because of continuity of care. You and your co-workers can then look for ways to remove the causes and solve the problem.

Validation therapy is letting the resident believe they live in the past or in imaginary circumstances (Alvare, Fuzy & Rhymer, 2009). Validating is giving value to what the resident is living at that time. Remember that arguing with a dementia resident is like arguing with a small child. You will never win.

Safe approaches must be used when dealing with agitated or angry residents. Never approach a dementia resident from behind. If you try to touch a dementia resident, and they do not see you, they become startled and will try to hit you. Good eye contact is important while standing right in front of the resident. Talk to the resident quietly and calmly. If you remain calm, so does the resident. Please remember that if the resident is angry, it most likely is not because of you. Do not take what they say personally because the resident is most likely unaware of their words on you.

A quiet environment is essential to help reduce agitation. This also helps the resident hear and understand what is being said. Turn off the television and radio during meals so the residents can better focus on the food. If the resident does become agitated, try to remove the resident to a quiet area.

Remember to watch your body language when dealing with Alzheimer's or dementia residents. If you appear angry or threatening to the residents, they will act in kind. Do not cross your arms or put your hands on your hips. Sometimes dementia residents cannot understand spoken words and depend on body language to understand.

Some of the common behaviors are:

• Anger
• Anxiety
• Wandering
• Pacing
• Getting undressed anywhere
• Stealing or rummaging
• Resisting care
• Hitting
• Was the resident scolded, ignored, or sedated?
• Recent change in medication?
• Recent changes in eating, drinking, or toileting?

There is a difference between verbal and non-verbal communication. When talking to a resident, keep your voice calm and soothing. Always smile when talking to the resident. Tell the resident what you are going to do before you do it, then proceed slowly. Use short sentences, call them by name, and establish eye contact. Make the person feel important. Never argue with a dementia patient because you will not ever win. Arguing with these residents is like arguing with a toddler.

If the resident is pacing, try to figure out why they are pacing. Is the resident agitated or angry? Is the resident clenching their fists or grinding teeth? These are sure signs of agitation. If the area is noisy, try to assist the resident to a quiet place. If the resident refuses to move away, try to assist everyone else in the area.

Wandering is done for a reason, even though we may not understand why. We must make sure that the person is safe while wandering. A few signs that wandering will begin restlessness and new disorientation. If you see these signs, redirect the resident if at all possible. Offer finger foods or an activity you know the resident likes. Know your resident, and anticipate behaviors before they begin. If you work in a home setting, be sure all doors are locked at night. If in a long-term care setting, frequent rounds must be made at night. Get rid of clutter in their rooms and turn on soothing music.

Rummaging or stealing is taking things that belong to someone else. The dementia resident may think the item belongs to him. Try to redirect the resident away from the area. If this is not possible, watch the resident carefully. Do not tell the family that the resident is "stealing, " which causes added stress (Alvare, Fuzy & Rhymer, 2009). Talk to the family about the behavior so they are prepared when they visit.

There are many reasons why a dementia patient gets agitated. First and foremost, we must keep the patient safe. Keep the noise level down, keep things a simple as possible and use soft music. Remember to get help if the agitation turns into violence.

The following are some reasons why agitation begins, and what you can do to help decrease the agitation:

• Remove upsetting things when agitation is apparent
• Keep things simple
• Use soft music
• Schedule 30-minute rest time
• Get help if agitation turns to violence

The risk of violence is always an issue when caring for dementia patients. They are not comfortable with new situations or routines. They like the same routine day in and day out. The patient can become agitated Whenever their routine changes, no matter how small the change. The patient may feel threatened or feel he/she has no choice in the activity. You may not know their past histories, so if a patient gets upset, you may have triggered a bad memory. Never ask "why" because the patient may feel threatened because the answer may not be apparent. You may ask, "What is bothering you?" but, again, they may not know the answer. You may need to give the resident an outlet for anger, but make sure they are in a safe place. Remember that anger can turn to violence. Stand near the door and do not block the exit in case the violence becomes too much for one person to handle.

Caregivers taking care of elderly people who may become violent or abusive should be advised:

• Do not be confrontational
• Do not take personal offense (not directed at you)
• Stay calm, do not raise your voice
• Do not attempt to steer the resident away by touching (action could easily be misunderstood)
• Do not corner the agitated person, as this will increase feelings of threat/alarm
• Do not tease or ridicule a person
• Do not use restraints

It is important to use appropriate responses for effective behavior management. Not all of these responses can be used in every situation:

• Stay calm, speak slowly and clearly (Getting anxious or upset in response may escalate the aggressiveness)
• Respect the person's space. Everyone has a different "personal space." Remember to give the hostile person plenty of room (so you will not get hurt)
• Provide reassurance that he will not be hurt in any way
• When necessary, direct other people to draw back and not interfere. The more people, the more the patient will get agitated.
• Encourage the person to talk rather than act out his anger
• Ask what is troubling them, then try to identify the reasons for the hostile behavior (Consider factors such as privacy, independence, boredom, pain, or fatigue). Avoid those activities or topics that anger the person. To help find any patterns, you might keep a log of when the aggressive episodes occur. (Russell, Barston & White, 2007)
• Listen to the person, act interested in the issues, and be flexible and accepting
• Attempt to redirect the hostile behavior

There are always warning signs before the violence erupts, so the caregiver must be attuned to every resident and know their triggers. If you see any of the following signs, you may be able to defuse the situation before the violence begins:

• Clenched fists
• Marked increase in movements
• Bragging about having hurt people in the past
• Verbal or facial expressions of rage
• Possession of destructive items
• Self-destructive behavior (verbal or non-verbal)
• Suspicion of others
• Anxiety, stress, or manic excitement
• Fear of self or others
• Not able to verbalize their feelings (increases anger, frustration)
• Provocative acts

There are ways to prevent or decrease aggression in any setting. Dementia takes people out of the world of words, logic, and reason and brings them into a landscape of feeling and sensing (Doraiswamy & Gwyther, 2008). So if we can remember this statement, it should make our intervention easier.

• If the person wants to "go to work," do not interfere
• Draw the person's attention away from the activity
• Validate the person often to avoid attention-seeking outbursts
• Be calm, move slowly
• Look for behavioral patterns in repeating assault, and make the appropriate changes needed
• Separate assaulting types from the victim types and be aware of their movements
• Provide short rest periods (30 minutes)
• State the desired behavior in simple terms and the affirmative

Let us review the rules of behavior management:

• Behavior is a way to communicate for people with dementia
• Do not try to use reason, do not try to argue
• Keep the resident environment as stable as possible (dementia residents like routine)
• If the behavior is new, think of an acute reason (urinary tract infection, other infection)
• Think about what kind of life history the resident has
• Think about the reasons for the behavior (anger, pain, hunger)
• Use redirection to prevent undesired behaviors
• Use the reward system for acceptable behaviors

The basic activities of living (ADLs) that CNAs are concerned with include bathing, dressing, eating, continence, getting in and out of bed and walking. These are the personal tasks we all do on a daily basis. When we can no longer perform these necessary functions, we become dependent on someone else. The CNA is an integral part of these daily tasks.

In one study, it was observed that almost 50% of people who turn 65 in any given year in America, enter into an old age home because they are unable to carry out activities of daily living. What this means is that these people are unable to take care of themselves, and require assistance to do so (Thadani, 2010).

When assisting resident with ADLs, remember to go slowly and do not expect the resident to be complacent with all aspects of care. If the resident refuses care, do not argue, stop what you are doing, and come back later. Always be aware of the resident's anger and anxiety levels.

Nursing assistants provide care to Alzheimer's resident according to their own needs (Nursing Assistant Education, 2009). It is important to know which stage of dementia the resident is in at the time of care. As the resident progresses through each stage, your approach will change.

See the individual, not the task:

• Put yourself in the resident's shoes: if the resident refuses care, step away
• No choices- when to get up, go to bed, take a shower (etc.)
• Empathy- the most essential trait in quality dementia care
• Respect the need for personal space-we all have this need, not just dementia residents
• Watch your tone of voice-eye contact, calm
• Constantly explain what you are doing
• What you say is less important than how you say it
• Keep responses short and simple
• If you ask a question, use the "20 second" approach-wait 20 seconds for an answer
• Give resident choices- "Would you like to wash your hair first or at the end of the shower?"
• Be flexible
• Establish a secure routine following the resident's wishes
• Be realistic about the residents' physical, intellectual, emotional health, care focus, environment, and spiritual (PIECES).

The following are examples of ADLS and tips on how to perform them:

Bathing dementia residents is a challenge. Prepare the resident before bathing, explaining what will be happening step by step. Respect the fact that bathing can be very scary. Be gentle and calm. Have all your supplies ready to go, and give the resident a few to carry (shampoo, soap, etc.). Make sure the bathroom is well-lit and is at a comfortable temperature (Alvare, Fuzy, & Rymer, 2009). Be respectful of the resident's privacy. Bathing is unnecessary daily, so try a sponge bath if the resident is agitated or resistant to care.

Mealtime for dementia residents is a very important activity. Eating is a complicated ritual. It is demeaning to the resident to be fed. Every dementia resident is at risk for malnutrition. Ensure the resident has their dentures in. Ask families what the resident's favorite foods are. Finger foods are a good way to get Alzheimer's residents to eat. If they get agitated, just give them finger foods (food on the go). Keep the noise level down during meals. Do not have the television or radio on, as these are distractions. Soft music helps keep the residents calm. If the resident must be fed, sit down, make eye contact, and talk to the resident even though he might not understand you. This is dignity and respect.

Assisting residents to dress can be time-consuming and stressful. Show the resident the clothes and ask permission to help. Please make sure that the clothing is clean and in good repair. If you lay the clothes on the bed or chair, the resident may need help accomplishing the task. If the resident appears tired, give him a few minutes of rest.

Planning structured, individualized activities that involve and interest the person with Alzheimer's (AD) may reduce many of the more disturbing behavioral symptoms of AD, such as agitation, anger, frustration, depression, wandering or rummaging. Therapeutic activities should focus on the person's previous interests, cue the person to old and recent memories and take advantage of the person's remaining skills while minimizing the impact of skills that may be compromised (Fisher Center for Alzheimer Research foundation, 2010). If the activities are planned well, and are geared to this particular population, dementia residents benefit greatly. Understand the resident's world, where they are right now, and the environment will be more pleasant for everyone.

One of the reasons Alzheimer's residents act out is due to boredom. With boredom comes pacing, agitation, and anger; all behaviors we try to prevent. Be compassionate, use soothing music of the resident's choice, and have group activities that are comfortable for all. This means that residents in approximately the same stage of dementia should be together. This is not always possible, so plan activities in advance. Know your residents' preferences so you can tailor the activities to their needs.

Getting to know your residents is the key to tailoring activities to meet their needs. You can ask the resident and family and friends:

• Family history
• Life history- what resident did for a living, favorite movies, music, pets they may have had, spiritual practices, hobbies, food preference, reading, writing

Look for ways to connect with the resident to improve interactions. Activities are easier to accomplish if the resident trusts you and feels that you have an interest in their world.

Activities should be meaningful. Hence you need to get to know and understand your residents. Activities should draw on their abilities and interest. Do not assume that a person can do an activity. Remember that long-term memory is less affected in dementia, so past abilities are most likely remembered (Florida Health Care Association, 2008). Try to avoid activities that are childish, but do not avoid this type if the resident asks. Here are a few examples of activities:

Exercise: Everyone benefits from exercise-never too old to start. Even moderate exercise can help elders. The following are a few examples of exercises. These can help improve balance, flexibility, and endurance.

• Dancing
• Walking
• Movement to music
• Chair or bed exercises

Music: Alzheimer's residents may not remember how to turn on the radio or recall how to dance. Bringing music back into their lives is meaningful and can bring smiles to their faces. Music activities can help reduce aggressive behaviors, withdrawal and help maintain physical functioning.

• Familiar music from their younger years
• Singing
• CDs, tapes, and even records

Games: Playing games bring people together, reinforcing social skills. Just remember that dementia residents may not remember the rules!

• Hangman
• Board games when appropriate
• Wii
• Puzzles, crossword puzzles when able
• Bowling
• Play ball-beach balls
• Bingo- always ask the resident if they want to play, be aware that many people do not like this game!

Arts and Crafts:

• Playing with Play dough or clay (non-toxic)
• Painting-finger painting is always fun!
• Stringing beads
• Making decorations for holidays

Reminiscing: Talking about the past can be comforting to dementia residents.

Celebrating birthdays, putting photos in albums, making memory boxes to place outside their rooms, and watching old movies or television shows can trigger memories. Ask the family to bring in items from home to help with these activities.

Use a quiet room with the residents away from the general population, and encourage them to participate in activities. One of the busiest times on a unit is at change of shift. The sudden increase in people and noise makes it confusing (FHCA, 2008). Having an activity on the patio, or away from the noise and confusion, will keep the stress and anxiety levels of residents (and staff) to a minimum. Keep activities short. Never force a resident to attend activities, and please remember that doing the activity is more important than the end result.

The benefits of meaningful activities include reduced nervous tension, decreased pacing and restlessness, reduced negative behaviors, and decreased wandering. When dementia residents are happy, everyone involved is happy. Their feeling of self-worth is kept intact. Dementia residents like to go on outings, even if only for a ride in the car. Taking a wheelchair stroll through the neighborhood is usually relaxing.

Encouraging self-care can be deemed an activity. If the resident is easily distracted while performing ADLs, make it a fun time. Play music you know the resident enjoys, and talk about "the good old days" as a form of reminiscing. Engage the resident in the conversation if at all possible. When you can set this precedent, the resident will begin to look forward to participating.

When working in a long-term care facility, it is best to have some sort of quiet activity happening during the change of shifts. This is a confusing time not only for the staff but for the residents too. There is a lot of noise and people coming and going. Keeping the residents busy will decrease their stress and anxiety levels.

The Alzheimer's/dementia caregiver is often called the hidden or second victim of Alzheimer's/dementia (Alzheimer's Association, 2009). Undoubtedly, the caregiver role is stressful in any setting, especially the home setting. Enormous pressures are placed on caregivers (Alzheimer's Association, 2009). The caregiver will most likely have to reduce work hours or resign. Financial pressures are difficult at best. Having to deal with guilt, anger, loneliness, isolation, to name a few, have a significant impact on caregivers.

Stress is the state of being frightened, excited, confused, in danger, or irritated (Alvare, Fuzy & Rymer, 2009). Not all stress is bad. Learning what your reaction to stress is and how to manage stress is vital to the caregiver role. Taking care of yourself is essential. Self-care is not selfish, and it helps build self-esteem. Taking care of yourself enables you to take better care of your patients and even your co-workers. Your job is easier when you are healthy. When you are stressed, so is the patient. The following chart shows the stress warning signs and symptoms. If you feel your stress level is getting too high, step back, take a deep breath, and try calming down. 

A stressor is something that causes stress. Stressors are situations experienced as a perceived threat to one's well-being or position in life (Mayo Clinic Staff, 2010). How we react to stressors defines our sense of well-being. Recognizing the stressors that may affect you is an essential step in dealing with stress. There is good stress that everyone has in their lives. But, the stressors that cause harm are the ones that we need to be aware of. Have you recently lost a loved one? Have you been fired from your job? Are you going through a divorce? Have you been sick? These are all questions you may ask yourself. Then, when you have sorted out which stressors affect you the worst, you can begin to make a plan (Help Guide, 2010).

Most people ignore their emotional health until there's a problem. But just as it requires time and energy to build or maintain your physical health, so it is with your emotional well-being. The more you put into it, the stronger it will be. People with good emotional health can bounce back from stress and adversity. This ability is called resilience. They remain focused, flexible, and positive in bad times and good (Help Guide, 2010).

Your ability to tolerate stress depends on many factors, including the quality of your relationships, general outlook, emotional intelligence, and genetics (Help Guide, 2010). Sometimes just talking to someone about your stress level helps. Talk to your co-workers that you trust or your supervisor. To develop a plan, think about the nice things you can do for yourself, what the sources of stress are, what you can do to change your life to reduce stress, and learn to cope with the stress (Alvare, S., Fuzy, J., & Rymer, S., 2009). When you realize your stressors, you can begin to manage your stress levels better. When your stress is under control, your residents will behave better because they will not feel as stressed.

Alzheimer's/dementia affects everyone around the patient. It affects the nursing staff as well as the family. Working with dementia patients daily takes its toll on the caregiver, whether nursing staff or family. Frustration levels run high. Sometimes the family must cope with feelings of embarrassment. Their loved one may "act out" in public, say things they should not, and hurt themselves or others.

Family members respond to the role changes, especially when the child becomes the parent. It is the same for CNAs. You begin to feel like you are the parent, and this can stir up many negative as well as positive emotions. Learning to cope with stress is the best possible way to help your families and patients. It does not matter if you work in a facility or home setting; working with distressed families is always difficult.

Family members can also be a good resource. They can help you learn more about the resident (Alvare, Fuzy, & Rymer, 2009). Make sure you have a good relationship with the family. It is good for you and the resident. The more you know about the resident's likes and dislikes, the lower your stress level.

Always respect the families' differences. They may be a different culture or religion than you and have different values. Check with your supervisor if you are unsure what to do or say. Let the family know that you understand their anxieties. Just verbalizing your understanding helps the family.

Financial burdens usually increase partly because there are more medical expenses and expenses for home care. One of the family members may have to give up working outside the home, which adds to the stress levels of everyone involved. As dementia increases, the caregiver's responsibilities increase, and the family will lose the freedom they are used to having. The family must make tough decisions as the disease progresses, including whether or not to place the patient in a long-term care facility. After the family decides to place the person in long-term care, they may begin to feel all their "power" will be taken away, and they will have no say in their loved one's care. Anger and stress levels are extremely high during this time. Learning to communicate with family members is important. Explaining what you are doing with the patient is important. Asking the family for ideas helps keep them "in the loop."

If the environment is not right, the resident reacts negatively. Bright lights may improve the symptoms. Keep noise to a minimum. Provide a safe area for agitated residents, keeping clutter down. Always keep the furniture arranged consistently. Remember, dementia residents need routine.

Sundowning is a difficult behavior to cope with. Sundowning is when the resident becomes confused at the end of the day. There are many theories, but no one is certain about the cause. Fatigue may play a part in Sundowning. If the resident gets tired during the day, allow time for a short nap (30 minutes). Play soothing music, keep the lights on, and have familiar items in the residents' rooms to reduce the effects of Sundowning.

Dining is an important part of the dementia residents' day. The dining room should be calm and uncluttered. Low, soothing music should be played, and noise should be minimal. Serve foods with reduced sugar and no caffeine to lower the risk of agitation and Sundowning.

Dementia residents pose a challenge during meals. Dementia is a progressive disease that eventually robs one of their memories, including how to eat, chew and swallow. Food may not interest a dementia resident, or they may forget what food is for. Residents with Alzheimer's disease require a higher intake of energy (Calories) to maintain body weight (Spindler, Renvall, Nicholas, Ramsdell, 1996). Because of this special need, caregivers must pay attention during meals. Meals should be offered at consistent times every day. Sit down when assisting with meals, and make eye contact. Minimize distractions while in the dining room. Talk to the resident, and keep the task of eating simple (Alvare, Fuzy & Rymer, 2009). Use adaptive equipment as needed, including large spoons and small bowls for the food. Keep the table clear of all extra items because Alzheimer's residents forget what specific items are for. They may put salt and pepper in their milk or catsup in their coffee. Finger foods are helpful, especially when the resident cannot sit for periods of time. When they begin to fidget, it is best to let them get up and wander before getting too agitated. Giving finger foods allows them to continue to eat while wandering. Do not serve food that is too hot. Use contrasting colors on the table, such as colorful plates and tablecloths. If a resident needs to be fed, take your time. Do not hurry a dementia resident.

When eating becomes a problem, sit with the resident and cue often. Tell the resident to "pick up the fork, put the food in your mouth, chew and swallow." It takes patience and understanding to feed dementia residents. Feeding tubes are not usually recommended for dementia residents. Because dementia is progressive, with no hope of a cure, the idea of prolonging life should not be an option. The quality of life rather than the quantity of life must be examined. Feeding tubes do not prevent malnutrition or extend life (Li, 2002).

Many situations do not work when trying to feed Alzheimer's residents. Do not treat the residents like a child or talk down to them. Do not mix foods together, as this adds to the confusion. Never allow a resident to eat alone at the bedside.

Ethics is the knowledge of right and wrong (Alvare, S., Fuzy, J., &Rymer, S., 2009). All residents and patients have the right to:

• Respect and dignity
• Privacy
• Confidentiality
• Freedom from abuse and neglect
• Control over their own money
• Have their personal property
• Know about their medical condition and treatments
• Choose their own doctor(s)
• Make decisions about their medical care

All residents and patients have the right to be respected and treated with dignity (Winston, 2010). Dementia residents should be afforded the same respect and dignity as all other residents.

Ethical issues require us to know the difference between right and wrong. The issues for caregivers include:

• Autonomy: To have the freedom to make choices for oneself
• Beneficence: The act of doing only good for the residents
• Nonmaleficence: Do no harm
• Justice: Be fair or just
• Veracity: Obligation to tell the truth
• Fidelity: Moral duty to be faithful to commitment
• Confidentiality: All health information is confidential-respect for an individual's control of health information

Patient autonomy vs. Physician responsibility:

• Adult patients have the right to refuse
• Adult patients may demand procedures, interventions, treatments
• Physicians are not obligated to provide interventions in their professional judgment that do not benefit the patient
• Advance directives-Legal papers that direct us about the resident's wishes about who will make medical decisions for them
• Durable Power of Attorney: Whoever is appointed can consent to medical treatment and manage the resident's financial matters
• Living Will: Expresses the resident's instructions concerning end-of-life issues

It is essential to make these decisions while you are still healthy. Once a person is deemed incompetent, it is too late. If the resident has no living will or health care surrogate, extreme measures must be taken at the end of life. Once a living will is made, it must be followed by the healthcare team.

Alzheimer's/dementia disease affects a family's emotional, physical, and financial well-being. Sometimes the family becomes overwhelmed and does not know how to find help. Caregivers are obligated to assist the family as well as the patient. Knowing where to turn for help is important.

There are local Alzheimer's Associations that families can reference for help. Joining a support group is also helpful. Knowing where to find help is imperative if you work in the home care setting. The family can call the Alzheimer's Association at the local or the national level. Find out where the Alzheimer's care units are in your community. Perhaps there are adult daycare centers available. There even may be a respite center, where the patient can stay for 1-2 weeks while the family rests or takes a vacation. All states have a council on aging that will assist families. There are also Ombudsman programs to ask for help. Asking the family physician for help is an option. The following are resources to suggest to the families.

The Alzheimer's Association
1-800-272-3900 (24/7 help line)
www.alz.org
Provides information about Alzheimer's disease and other dementias, organizes family support groups, sponsors educational forums, supports research.

Safe Return
1-800-572-1122
www.alz.org/safereturn
A national program created by the Alzheimer's Association to identify wanderers and help them return home.

Eldercare Locator
1-800-677-1116
www.eldercare.gov

National Council on Aging
Online resource offers a searchable list of programs that can help with health care costs.
www.benefitscheckup.org

Alzheimer's disease and related dementias are devastating, not only to the patient but to the family as well. Alzheimer's starts slowly and progresses over the years, affecting every aspect of the patient's life. Caregivers are subjected to highly stressful situations. Behavior management is the key to safe caregiving. Learning to confront and deal with aggressive or abusive behaviors helps the caregiver take good care of the patient as well as themself. Learning to anticipate the residents' needs affords the caregiver a better relationship with the resident.

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