Effective Nursing Interventions for the Management of Alzheimer's Disease(*).
Subject: Alzheimer's disease (Care and treatment)
Nursing (Practice)
Nurses (Vocational guidance)
Cognition disorders (Care and treatment)
Author: Maier-Lorentz, Madeline M.
Pub Date: 06/01/2000
Publication: Name: Journal of Neuroscience Nursing Publisher: American Association of Neuroscience Nurses Audience: Professional Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2000 American Association of Neuroscience Nurses ISSN: 0888-0395
Issue: Date: June, 2000 Source Volume: 32 Source Issue: 3
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 72433379
Full Text: Abstract: Alzheimer's disease (AD) is a progressive neurodegenerative disease that causes severe deterioration of functional and cognitive abilities. As the leading cause of dementia in adults, it affects one in every 10 people who are more than 65 years of age. There is a vital need for neuroscience nurses with knowledge of AD to provide high-quality care for the growing number of patients. The use of effective nursing interventions for the management of AD can help nurses promote independence and quality of life for AD patients. Nursing care must include interventions that focus on maintaining AD patients' functional and cognitive abilities as well as on preventing further disability and decline. Nurses can implement these measures in acute, long-term, and home healthcare settings.

Effective nursing interventions are vital to managing patients with Alzheimer's disease (AD). Progressive and severe deterioration of functional and cognitive abilities results in disruptive behaviors that can be incapacitating and even harmful to AD patients. The cognitive and behavioral problems associated with AD require specific nursing interventions to provide for the safety and well-being of patients. Certain measures have been found to be effective in providing high-quality nursing care that helps maintain function and promote independence and quality of life for people with this devastating and incurable disease. This article focuses on those interventions.

Nursing Interventions for Cognitive Problems

Cognitive deficits are recognized in all three stages of AD. Most noticeable in the first stage (possible Alzheimer's disease[6]) is loss of recent memory. Although people with AD usually recognize this problem, often they try to hide or deny it. Toward the end of this stage, some visuospatial impairment becomes evident. For example, AD patients easily lose their way home because they can no longer identify familiar places, signs, or markings.

More serious cognitive deficits develop in the second stage (probable Alzheimer's disease). There is both profound recent and remote memory loss. The person is also likely to experience anomia (the inability to find the right word) and agnosia (the inability to recognize an object). The person may also experience apraxia (the inability to perform motor activities despite intact physical capacity for functioning) and therefore may no longer be able to perform simple activities of daily living (ADL) such as feeding or dressing oneself.[6]

Severe cognitive problems develop in the third stage (definitive Alzheimer's disease). There is gross impairment of all cognitive functions.[6] The person is disoriented in time and place and is incapable of recognizing his or her own spouse or children. Toward the end of this stage, the AD patient may be completely mute.

Nursing interventions can be effective in helping AD patients cope with cognitive deficits. More important, nursing interventions can enhance the patient's remaining cognitive and functional abilities to promote a better quality of life. The nursing interventions discussed here are for memory impairment, language difficulties, and impairment of visuospatial function, which are common cognitive deficits associated with AD.

Memory Impairment

Nurses may suggest ways for caretakers to help AD patients cope with and compensate for memory impairment. Nurses should foster the utilization of AD patients' remaining cognitive abilities and support their independence as much as possible. Caretakers and patients should be instructed about the use of various types of memory aids. Written reminders placed in strategic places can help someone with AD remember to perform an important task such as locking the door or turning off the iron.[3] Such a reminder must be brief and placed in clear view if it is to be beneficial. Object cues also can be used as reminders. For example, a timer can be set to remind the person to turn off the stove after cooking; hanging a coat by the front door on cold days can remind the person to wear it.

A memory place is another type of memory aid.[8] Caretakers should set up a specific place for an AD patient to keep the items used every day (e.g., keys, glasses, money). It is also important for caretakers to maintain a daily routine, which serves as another type of memory aid. Activities such as eating, bathing, and dressing should be performed in the same order and at the same time every day to help the AD patient remember that each of them should be performed every day.

Another method is the use of telephone reminders.[8] For a person who can remain unsupervised at home, relatives or friends should be instructed to call throughout the day. These calls provide a way to check the person's safety while maintaining independence.

Techniques for enhancing memory have proved useful, and they should be included in the care of AD patients. For example, nurses and caretakers can help patients design memory wallets, each of which contains 10 related statements about a personal topic.[8] The patient is encouraged to discuss the topic by elaborating on each statement. This exercise helps improve long-term and short-term memory by requiring the person to retrieve stored information. It also helps the patient maintain language abilities and communication skills. Memory wallets should contain statements describing both long-term and short-term memories. For example, statements describing an important past event (e.g., the person's wedding day) enhance long-term memory. A recent event (e.g., a visit with a family member) should be recorded immediately afterward to enhance short-term memory. This exercise is most effective when it is employed every day. Memory tapes can be used in the same way; they are especially useful for AD patients who have visual impairments.

These nursing interventions are most useful in the first stage, when patients have only minimal memory loss. Because the severity of memory impairment increases significantly as AD progresses, memory enhancement techniques are not as effective for patients in the second and third stages.

Language Difficulties

Language difficulties occur relatively early in the course of the disease, usually after there has been some decline in memory. Written and verbal communication problems may appear.[1] Speech errors (e.g., saying "bagoon" for "balloon") may become especially problematic.[2] Patients may become frustrated when they try to communicate their thoughts or needs, and caretakers can become equally frustrated in trying to understand them.

In the first stage of AD, a few simple measures can help the patient communicate more easily. The most important is to show a caring attitude when the patient is trying to speak.[10] Touch and eye contact help convey this message. Allowing ample time for a patient to talk or respond to questions is also very important. This measure supports efforts to communicate and encourages the patient to speak more freely.

Some AD patients lose the ability to remember a word, or they use the wrong word when conversing. This problem can be very frustrating for them. Caretakers can offer a guess as to the forgotten word or can provide a correct word when the wrong one is used. Some AD patients appreciate this help. However, some become very upset when helped or corrected, so caretakers must remember to avoid helping or correcting them in the future.[5]

Writing is an effective means of communication for patients in the first stage. Written instructions and reminders can help patients who have maintained the ability to read. As AD progresses, however, reading becomes more difficult, and eventually patients are not able to make sense of written materials or completely lose the ability to read.[8]

Reading should be encouraged, especially in the first stage, to help the patient maintain cognitive functioning and language comprehension. Caretakers can read aloud to stimulate conversation as well as imagination. Reading may offer the added benefit of calming an AD patient.

Patients with later-stage AD experience more debilitating language problems. In the second stage, anomia and agnosia often occur. These problems drastically impede the AD patient's ability to communicate. Talking to others can be threatening and exhausting for a patient who suffers from one of these impairments, but nurses must encourage and facilitate efforts to communicate. It is vital to engage later-stage patients in conversation as much as possible.

Interventions have been found to be especially successful in helping second-stage AD patients communicate. When caretakers listen attentively, patients are helped to communicate more easily and effectively.[8] Listening carefully can help the caretaker decipher a patient's word substitutions and generally understand what the patient is trying to say.

Conversations with an AD patient should be kept simple. Sentences should be short and literal, and they should follow the subject-verb-object format. To keep the patient oriented throughout the conversation, caretakers should repeat their sentences as often as needed and should periodically summarize what has been said. Continuous praise and encouragement promote successful communication with AD patients, especially during the second stage.

To question an AD patient, it is advisable to ask one specific question at a time, requiring a yes-no or multiple-choice answer.[5] For example, ask whether the patient prefers to wear the red dress or the blue dress. Avoid asking which dress she wants to wear; this type of question tends to be confusing.

Other interventions have also been found helpful in communicating with AD patients. One of them is reminiscence therapy. This technique encourages patients to recall thoughts and feelings from their past and to relate these experiences to other people. This intervention promotes conversation and helps patients establish closer relationships with others.[9] Reminiscence therapy should be employed in the earlier stages. AD patients tend to speak very little once they have progressed to the third stage, so caretakers must initiate and foster all conversations with them. Topics of particular interest (e.g., a favorite grandchild, a special event, a hobby) are most effective in stimulating conversation. The use of props or pictures can help the patient focus on the conversation.

Caretakers must keep in mind that AD patients need constant prodding to converse[8] and that they should use a soft voice when conversing with AD patients. AD patients need to be kept especially calm, because they can easily become agitated when trying to communicate.

Music therapy is a very effective method to enable communication for patients in the third stage. Even though the patient's speech usually is impoverished, the ability to sing familiar songs remains intact. Music provides a way for AD patients to communicate when they no longer have the ability to use speech. Most important, music helps preserve quality of life.[7]

Impaired Visuospatial Functioning

Nursing interventions are necessary to facilitate visuospatial functioning in the second and third stages of AD. Maintaining a familiar environment is especially important to promoting the safety and independence of an AD patient with impaired visuospatial functioning. AD patients also are more likely to maintain self-care abilities and mobility in a familiar environment that provides safety. For example, furniture should be kept in the same arrangement to avoid confusion and prevent falls.

Nurses should instruct caretakers to give only one instruction at a time, because patients with visuospatial disabilities cannot comprehend two tasks simultaneously. It is advisable to give a nonverbal cue along with the verbal instruction. Doing so can help the patient more easily understand and follow instructions. For example, asking a person with visuospatial problems to sweep the floor while handing him a broom is more likely to be understood than asking him to get a broom and sweep the floor. The second set of instructions entails two tasks but no visual cue.

Impaired visuospatial functioning can cause an AD patient to become disoriented in time, place, and person and to become and look bewildered.[3] Addressing the person by name and introducing oneself is important when approaching an AD patient. Caretakers should give a short explanation before taking any action. Doing so helps reduce the fear that AD patients are likely to experience. To gain the patient's attention and confidence, it is most important to speak and move slowly and quietly. These measures also facilitate comprehension and functioning.

Nursing Interventions for Behavioral Problems

Behavioral problems can occur in the middle and late stages of AD. The behaviors can range from the mildly bothersome to the very hazardous, with serious consequences. Nursing interventions to prevent disruptive behaviors can be very effective. However, behavioral problems cannot always be anticipated. AD patients often are not capable of controlling their emotions. Disruptive behaviors can arise quickly in response to fear, anxiety, frustration, or agitation, which are emotions that AD patients frequently feel. When a patient experiences these feelings, nursing interventions should be directed toward calming this person and preventing injury. Nursing interventions to eliminate the causes of the behavioral problems should also be implemented. Effective nursing interventions are available for several of the common behavioral problems associated with AD.

Catastrophic Reactions

Catastrophic reactions are exaggerated responses to minor stressors. They may be expressed by AD patients in response to physical discomfort, fatigue, overstimulation, frustration, or confusion. For example, AD patients may display an outburst of anger toward the caretaker when they are feeling frustrated about requiring assistance with feeding or dressing. Prevention of catastrophic reactions should be a standard part of a patient's nursing care plan.[4] It is important that nurses make a careful assessment of the circumstances triggering catastrophic reactions and design measures to avoid them. For instance, if a particular activity seems to initiate a catastrophic reaction, the caretaker should be instructed to avoid the activity or to redesign it to be less stressful. It is helpful to keep everyday routines consistent and simple. It is also important to decrease stressors. External stimuli that may increase anxiety (e.g., excessive noise, crowds) should be eliminated.[5] Allowing AD patients to rest after a major activity helps to reduce their level of stress.

Nurses and caretakers need to give immediate attention to a patient who is experiencing a catastrophic reaction. Engaging patients in some enjoyable activity can help to distract them and curtail the reaction. Nurses and caretakers need to remain especially calm, interacting cautiously and slowly to lessen the chance they will incur harm. It is also important to continue communicating during this time.

Sleep Disturbances

Injury to brain cells caused by AD can result in gravely disrupted sleep cycles. The change in sleep patterns that occurs with aging can add to this significant problem.[4] AD patients may sleep periodically throughout the day and be awake all night. This pattern interferes with normal daily functioning and can be very disruptive for both patients and caretakers.

Several measures have been found useful in helping AD patients who have abnormal sleep habits. The patient should be placed in a quiet, dimly lit bedroom, and factors that contribute to disrupted sleep (e.g., excessive noise, light) should be eliminated. Patients should be encouraged to engage in activities that are conducive to sleep. Listening to soft music before bedtime may help alleviate feelings of anxiety and promote sleep. It is also recommended that patients be discouraged from taking several long naps during the day.[10]

Patients should be kept active during the day. Exercise, especially walking, should be encouraged throughout the day. Activity expends energy and promotes more restful sleep.[10] A bedtime routine should be established and followed, so that patients recognize that it is time to go to sleep. A warm bath or a light snack can be offered as part of regular bedtime preparation. However, drinks containing caffeine and alcohol should be avoided because of their stimulant effect. Finally, a safe place to wander should be provided for patients who continue to have sleep disturbances.[10]

Wandering

Wandering is one of the more serious behavioral problems associated with AD because of its potentially grave consequences. A wandering patient can easily lose his or her way and may not be found for a long period of time or not at all. Measures to prevent wandering are essential. Alarms should be installed on doors and windows to alert caretakers about possible wandering. Frequent supervised walks, scheduled throughout the day, are especially helpful in decreasing wandering, both because patients become tired from the exercise and because they have the feeling they have gone somewhere.

For patients who continue to wander, other measures are needed. Calling the patient by name and redirecting him when he begins to wander help to distract him and to prevent further wandering. Placing an identification bracelet on an AD patient does not prevent wandering, but it does help a patient who has wandered to return home safely.

Sexual Activities

Preventing AD patients from performing sexual acts in public is another nursing goal. Providing a private place for a patient who wishes to engage in sexual activities effectively eliminates public performance of these acts. It is important to demonstrate acceptance of the patient's need for sexual activities but to require that they be conducted in private and not be intrusive for other people.

Caretakers need to be aware that the patient's need to be touched may be a reason for sexual activities.[3] Holding the patient's hand or giving the patient a gentle pat on the arm or back may help fulfill the patient's sexual needs. Nurses need to be especially professional when they are providing personal care so that it will not be not interpreted as a sexual activity. The patient should be addressed by last name, and the nurse or other caretaker should explain the care before providing it, so that the actions will not be misinterpreted.

Delusions and Hallucinations

Delusions and hallucinations can be very frightening and threatening to an AD patient. Caretakers must demonstrate an especially caring attitude toward a patient who is experiencing such phenomena. Nurses and caretakers should neither acknowledge nor deny the reality perceived by the patient in delusions or hallucinations.[5] At the same time, the nurse or caretaker must reassure the patient that care and protection will be provided whenever delusions or hallucinations occur.

Some AD patients are not adversely affected when delusions or hallucinations arise. For these patients, distraction may be the only intervention necessary to help them cope. A change in the environment may also be helpful in mitigating certain delusions or hallucinations. Removal of a mirror in which hallucinatory persons have appeared to the patient or illumination of a dark area to prevent the appearance of a hallucinatory person may be all that is needed.

Depression

People with AD often become demoralized and have low self-esteem. The loss of cognitive abilities hinders them from engaging in enjoyable everyday activities and may lead to a cycle of self-directed thinking in which they feel incapable of doing anything meaningful and, consequently, do nothing meaningful. Feelings of worthlessness and eventual depression are a result of this cycle.[8] Nursing interventions for depression should be directed toward distracting the patient from self-directed thinking. AD patients should be encouraged to engage in activities that are perceived as meaningful. A person who worked as a veterinarian may enjoy caring for the family dog or giving advice to others about their pets. Some AD patients may receive great satisfaction from making items to be donated (e.g., clothing, toys for orphaned children). It is important, however, for nurses and caretakers to help patients select activities that are compatible with their cognitive and functional abilities. Patients who engage in activities that give joy and a sense of pride have increased feelings of self-worth and are less likely to experience depression.

Summary

The high-quality care that neuroscience nurses must provide for AD patients includes nursing interventions that utilize patients' remaining cognitive and functional abilities. It is especially important for neuroscience nurses to implement interventions to help prevent or delay the development of disabilities and to promote independence. Alzheimer's disease patients can thus be enabled to function at their highest level, to preserve their self-esteem and dignity, and to enjoy the highest possible quality of life.

References

[1.] Bayles KA, Tomoeda CK: Caregiver report of prevalence and appearance order of linguistic symptoms in Alzheimer's patients. Gerontologist 1991; 31(2): 210-216.

[2.] Biassou N, Grossman M, Onishi K et al: Phonologic processing deficits in Alzheimer's disease. Neurology 1995; 45(12): 2165-2169.

[3.] Burnside I: Nursing care. Pages 39-58 in: Treatment for the Alzheimer Patient: The Long Haul, Jarvik LF, Winograd CH (editors). Springer, 1988.

[4.] Clark W, Lancaster MM: Management of difficult behaviors. Pages 165-181 in: Alzheimer's Disease: A Handbook for Caregivers, Hamdy RC, Turnbull JM, Clark W, Lancaster MM (editors). Mosby, 1994.

[5.] Cutler NR, Sramek JJ: Understanding Alzheimer's Disease. University Press of Mississippi, 1996.

[6.] Hamdy RC: Clinical presentation. Pages 102-116 in: Alzheimer's Disease: A Handbook for Caregivers, Hamdy RC, Turnbull JM, Clark W, Lancaster MM (editors). Mosby, 1994.

[7.] Lancaster MM, Abusamra LC, Clark WG: Management of difficult behaviors. Pages 150-170 in: Alzheimer's Disease: A Handbook for Caregivers, 3rd ed, Hamdy RC, Turnbull JM, Edwards J, Lancaster MM (editors). Mosby, 1998.

[8.] Mace NL, Rabins PV: The 36-Hour Day. The Johns Hopkins University Press, 1991.

[9.] Soltys FG, Coats L: The SolCos model: Facilitating reminiscence therapy. J Psychosoc Nurs 1995; 33(11): 21-26.

[10.] Tappan RM: Interventions for Alzheimer's Disease. Health Professions Press, 1997.

(*) The neurological bases for these interventions were addressed in "Neurobiological Bases for Alzheimer's Disease," Journal of Neuroscience Nursing 2000; 32(2); 117-125.

Questions or comments about this article may be directed to: Madeline M. Maier-Lorentz, MSN RN, 2017 First Avenue, Suite 204, San Diego, CA 92101. She is a doctoral student at Capella University.

Copyright [C] 2000 American Association of Neuroscience Nurses 0047-2603/ 00/3203/00153$1.25
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