November/December 2017

Managing the Behavioral Symptoms of Alzheimer's Disease
By M. Kaleem Arshad, MD, DFAPA
Today's Geriatric Medicine
Vol. 10 No. 6 P. 18

Difficult behaviors occurring in Alzheimer's disease patients can arise from pain, medication interactions, and environmental changes. It's important to identify the source of agitation in order to arrive at a resolution.

As America's population ages, baby boomers are surviving to ages when diseases such as Alzheimer's disease (AD) and dementia are more common, increasing the need for mental and behavioral health services for this older demographic.

While AD is not a mental illness, the neurodegenerative disease can cause symptoms related to mental health status, such as depression, anxiety, agitation, and hallucinations. The behavioral symptoms are what many individuals with Alzheimer's or other forms of dementia and their families find to be the most challenging and distressing effects of the disease.

AD in America
AD is the sixth leading cause of death in the United States, the fifth leading cause of death among those aged 65 and older, and a leading cause of disability and poor health, according to the Alzheimer's Association.

It's estimated that 5.5 million Americans are currently living with AD. Of those, approximately 5.3 million are aged 65 or older—that's one in 10 people in this age group—and these numbers are expected to escalate as the population continues to age.

It's no surprise then that deaths from AD have increased significantly over the years while deaths from other major causes, such as heart disease or stroke, have decreased. In fact, deaths from AD increased 89% from 2000 to 2014, while deaths from heart disease, the No. 1 cause of death in the United States, decreased 14%.

Signs and Symptoms
While memory loss is the most common symptom of AD, there are many other signs that may be indications of the disease. It's important to differentiate these signs from changes associated with normal aging and to pay attention to those that seriously disrupt an individual's daily life, including abnormal memory loss, difficulty solving problems, inability to complete familiar tasks, confusion, vision problems, problems speaking or writing, misplacing or losing things, poor judgment, withdrawal from work or social activities, and changes in mood and personality.

Stages of AD
AD usually develops slowly and gradually worsens over a period of years although the rate of progression varies widely and can last more than a decade. On average, people live for four to eight years after diagnosis, with some surviving more than 20 years with the disease.

Throughout the evolution of the disease, those affected will experience a variety of changes in memory, cognition, judgment, language, movement, and even personality—all to varying degrees.

This progression is categorized in three stages: mild or early stage, moderate or middle stage, and severe or late stage.

Mild AD
In the early stage of AD, individuals may appear to be healthy and for the most part are able to function on their own. However, they may begin to experience memory lapses and thinking problems, such as difficulty recalling words or names, challenges performing everyday tasks, or misplacing objects.

Behavioral Changes
When a person is first diagnosed with AD, fear and denial are common emotions. Once patients begin to recognize these symptoms and how they are affecting their everyday lives, they may become depressed, subdued, and unmotivated to participate in activities they once enjoyed. A formerly outgoing person may become withdrawn or display atypical irritability or anger.

Communication Tips
This is a difficult stage for Alzheimer's patients because while they can still carry on conversations as before, they may find it challenging to recall names, find the right word at times, or even organize their thoughts. Because of this, it's important for physicians and caregivers to communicate empathetically.

The following are tips for successful communication from the Alzheimer's Association:

• Take time to listen to how the person is feeling and what he or she is thinking or may need.

• Give the person time to respond. Don't interrupt or finish sentences unless he or she asks for help in finding a word or finishing a sentence.

• Talk with the person about what he or she remains comfortable doing and about tasks with which he or she may need help.

• Explore which method of communication is most comfortable for the person. This could include face-to-face conversations, e-mail, or phone calls.

Moderate AD
This is the longest stage in the disease progression and typically lasts for numerous years. Individuals with moderate-stage AD experience even greater memory loss. They are forgetting not only names they just learned but also important details of their own lives, such as their address or phone number. With this increased memory loss, patients may also show confusion regarding their surroundings and once-familiar faces. In this stage, patients require a greater level of care for activities such as bathing, dressing, and grooming.

Behavioral Changes
During this stage, individuals suffer significant changes in personality and behavior, may show signs of agitation and irritability, or even have outbursts of aggressive physical behavior. Patients may be restless and spend a lot of time pacing or shredding paper in their hands. It is not uncommon for people with moderate AD to have delusions or hallucinations.

Communication Tips
Patients in this stage are more disoriented, but they continue to need to feel respected, validated, and in control. It's important to show them compassion. To ensure you are effectively communicating with AD patients in this stage, the Alzheimer's Association suggests the following:

• Allow time for responses so the person can think about what he or she wants to say.

• Engage the person in one-on-one conversation in a quiet space with minimal distractions.

• Be patient and supportive. Offering comfort and reassurance can encourage the person to explain his or her thoughts.

• Maintain eye contact. It shows you care about what he or she is saying.

• Avoid criticizing or correcting. Instead, listen and try to find the meaning in what is being said. Repeat what was said to clarify.

• Avoid arguing. If the person says something with which you disagree, let it be.

• Don't overwhelm the person with lengthy requests. Offer clear step-by-step instructions for tasks.

• Speak slowly and clearly.

• Ask yes or no questions. For example, "Would you like some coffee?" rather than "What would you like to drink?"

• Ask one question at a time.

• Give visual cues. To help demonstrate the task, point to or touch the item you want the individual to use. Or begin the task for the person.

• Written notes can be helpful when a spoken word seems confusing.

Severe AD
In the end stage of AD, individuals experience a noticeable decline in total functionality and require daily assistance with everyday tasks such as eating, dressing, and bathing. In addition to greater memory loss, patients also endure a loss of most physical abilities, such as walking, swallowing, and controlling bladder functions, and may no longer be able to speak coherently.

Behavioral Changes
Negative behaviors, such as anxiety, anger, and aggression, tend to worsen in the severe stage of AD due to the emotional distress of the disease's progression. Patients may also experience more delusions, hallucinations, sleep disturbances, and physical and verbal outbursts.

Communication Tips
As memory loss becomes more severe in later stages, patients may lose all ability to communicate and will rely heavily on their physicians and caretakers to monitor their pain and comfort or give them nonverbal cues of their needs.

The Alzheimer's Association recommends the following communication tactics for treating patients in the severe stage:

• Treat the person with dignity and respect. Avoid talking down to the person or as though he or she isn't there.

• Approach the person from the front and identify yourself.

• Encourage nonverbal communication. If you don't understand what is being said, ask the person to point or gesture.

• Sometimes the emotions being expressed are more important than what is being said. Look for the feelings behind words or sounds.

• Use touch, sights, sounds, smells, and tastes as forms of communication.

Behavioral Changes: What They Mean
AD is a neurodegenerative disease and, as it progresses, brain cells begin to deteriorate, causing behavioral changes such as those described in the stages above. However, it's important to note that especially in later stages, there may be other factors influencing these behaviors.

To determine what is triggering behavioral changes in patients, physicians must thoroughly evaluate them using physical and mental status examinations and laboratory and imaging studies.

Behavioral symptoms may arise from several causes, including the following:

• Medications: The side effects or interactions of some prescription medications, including antipsychotics often used for AD, may influence patient behavior.

• Pain and discomfort: If a patient is unable to communicate about how he or she is feeling, it is likely the individual will not receive treatment to relieve pain and other symptoms, causing irritability and anger.

• Hearing or vision problems: Some patients may experience hearing or vision loss as the disease progresses and, if not repaired, this may cause confusion or frustration.

• Change: Change can be stressful for anyone, but it can be especially difficult for a person with AD to manage. Big changes such as moving to a new nursing home or being admitted to the hospital and small changes such as being asked to change clothes can result in fear and fatigue.

Once the cause of a problem is determined, a proper care plan should be developed to address the source and provide the patient with the highest possible quality of life.

Treatments for Behavioral Side Effects
AD affects each person differently; therefore, no two patients should be treated the same. Care should be delivered to meet an individual's needs, encouraging long-term successful management of the physical, emotional, and cognitive health challenges associated with the disease.

Medications such as risperidone and haloperidol are often prescribed to AD patients to treat behavioral symptoms and help them avoid higher levels of care in nursing homes and special care units. However, there are other treatments that can be used in combination with or in place of these medications, such as the following:

• Individual and group therapy: For patients showing signs of anger or fear, emotional support from family, peers, and a counselor is highly important. Group therapy has been shown to improve both cognitive and behavioral symptoms for AD patients.

• Social stimulation: Without social interaction, individuals with AD may become subdued and depressed. Activities as simple as going for a walk, listening to music, or spending time with pets can enhance a patient's quality of life and minimize behaviors related to psychosis.

• Diet and hydration: Managing a patient's nutrition and water intake is imperative to preserve good brain function. Older adults are at increased risk for dehydration because the sensation of thirst decreases with age. This can lead to muscle weakness, headaches, and sleepiness.

While there is no curative treatment for AD, there are many things physicians and caregivers can do to ensure patients live as comfortably as possible as the disease progresses. Being alert to behavioral changes and addressing those changes immediately is imperative to maintain patients' overall well-being. And most importantly, it's crucial to create a compassionate environment that promotes long-term healing and security.

— M. Kaleem Arshad, MD, DFAPA, is a board-certified addiction, adult, and geriatric psychiatrist at Oceans Behavioral Hospital Greater New Orleans, an affiliated hospital of Oceans Healthcare. He is a diplomate of the American Board of Psychiatry and Neurology.

USEFUL ALZHEIMER'S-RELATED RESOURCES
The National Institute on Aging recommends the resources listed below for coping with communication and behavioral problems related to Alzheimer's disease.

• Alzheimer's Caregiving: Changes in Communication Skills (www.nia.nih.gov/health/alzheimers-caregiving-changes-communication-skills)

• Communicating With Patients Who Have Dementia (http://azalz.org/wp-content/uploads/2013/07/Dementia-Patients-Communication.pdf)

• Communication: Tips for Successful Communication During All Stages of Alzheimer's Disease (www.alz.org/national/documents/brochure_communication.pdf)

• Creating Moments of Joy for the Person With Alzheimer's or Dementia by Jolene Brackey

• Enhancing Communication (https://uwaterloo.ca/murray-alzheimer-research-and-education-program/education-and-knowledge-translation/products-education-tools/by-us-for-us-guides/enhancing-communication)

• Learning to Speak Alzheimer's: A Groundbreaking Approach for Everyone Dealing With the Disease by Joanne Koenig Coste

• Validation Techniques for Dementia Care: The Family Guide to Improving Communication by Vicki de Klerk-Rubin

• When Words Have Lost Their Meaning: Alzheimer's Patients Communicate Through Art by Ruth Abraham

• Alzheimer's and Hallucinations, Delusions, and Paranoia (www.nia.nih.gov/health/alzheimers-and-hallucinations-delusions-and-paranoia)

• Bathing Without a Battle: Person-Directed Care of Individuals With Dementia by Ann Louise Barrick, Joanne Rader, Beverly Hoeffer, Philip D. Sloane, and Stacey Biddle

• Behaviors: How to Respond When Dementia Causes Unpredictable Behaviors (www.alz.org/national/documents/brochure_behaviors.pdf)

• Coping With Agitation and Aggression in Alzheimer's Disease (www.nia.nih.gov/health/coping-agitation-and-aggression-alzheimers-disease)

• Family Guide to Alzheimer's Disease: Volume 2 — Behavior Issues (https://lifeviewresources.com/products/family-guide-alzheimers-disease-volume-2)

• Managing Personality and Behavior Changes in Alzheimer's (www.nia.nih.gov/health/managing-personality-and-behavior-changes-alzheimers)

• Safe Return: Alzheimer's Disease Guide for Law Enforcement (www.alz.org/national/documents/SafeReturn_lawenforcement.pdf)

• Tips for Coping With Sundowning (www.nia.nih.gov/health/tips-coping-sundowning)

• When a Person With Alzheimer's Rummages and Hides Things (www.nia.nih.gov/health/when-person-alzheimers-rummages-and-hides-things)

• Activities of Daily Living: An ADL Guide for Alzheimer's Care by Kathy Laurenhue

• Alzheimer's Basic Caregiving: An ABC Guide by Kathy Laurenhue

• Caregiver's Guide to Understanding Dementia Behaviors (www.caregiver.org/caregivers-guide-understanding-dementia-behaviors)

• Remembering Home: Rediscovering the Self in Dementia by Habib Chaudhury