Dr Rob Thornton, Gerontologist

The term used by health care professionals for behaviour resulting from dementia is referred to as challenging behaviours. This part 1 article will provide some insight into this issue and attempt to show how these situations arise.

For those of us who care for loved ones with dementia the first lesson is not to take the behaviour personally and to recognise that the behaviour results from the disease, not from your intentional actions.

Behaviour that you may deem difficult to deal with usually reflects a need, rather than a problem, the behaviour serves a purpose however is not done on purpose

The key element to dealing with these situations is trying to establish why and to then attempt to meet this need so that it will either stop or at least diminish.

Let us look at a few examples: a person with dementia lives in a sometimes different world and so has different perceptions, thoughts and feelings--at times in the earlier stages of dementia and more frequently during the later stages. For example, a television program may be showing a movie that has violence portrayed and the person with dementia may perceive that everyone in their home is fighting

A man sees himself in a mirror and no longer recognises himself and gets angry telling the “intruder” to get out of the house, and finally a bird attempting to catch an insect on the window may seem as someone trying to break into the house.

Another common challenging behaviour is that the person with dementia can no longer remember information or agreements as a result of a conversation only minutes ago; this is especially the case when a person does not remember a nice thing that you did for them such as brushing their hair only 15 minute before. The thing that we need to remind ourselves is that the pleasure the person with dementia showed to you at the time of brushing their hair was very important, the fact that they may not be able to remember it is unimportant.

As dementia progresses the person’s brain function and thus memories can only be drawn from years ago--ranging from ten to fifty years and, as a result, their memories and conversations are of family and friends from long ago. As recently as last night when I was with a patient with dementia she kept repeating “Jim please do not go”

When later I read her notes Jim was in fact her first husband of only two weeks who was killed in the war. Although her memories had travelled back to some 50 years ago the feelings associated with the loss are as strong as the day it happened.

This scenario reminds us that feelings and emotions largely remain intact, such as love and embarrassment, and sometimes the feelings remain long after the event has occurred. An example of this is a gentleman with dementia who was attending a day respite centre and the activities coordinator started reading the poem ‘Man from Snowy River’, suddenly the man started to recite the poem in full. When his wife collected him from the centre he said “I did it, I remembered” and was very excited, however he had no idea what he had done hours earlier; all he could remember was the feelings associated with the first time he could recite this poem in full.

Lastly when confronted by challenging behaviour we need to remind ourselves that a person with dementia cannot change what they say or do, and thus trying to change a person’s behaviour is not an effective way of dealing with a situation. If we are to give comfort to a person with dementia we need to connect to their feelings associated with their memories and not attempt to correct the facts. As suggested above, like the loss of the person’s first husband, we need to provide a soft hand to hold not state the facts that happened long ago and that Jim is in fact dead.

Next time we will look at ways of dealing with some of the behaviours, thus reducing stress for all who are involved.

By Dr Robert Thornton. Gerontologist 

In this article we will look at other strategies to reduce frustration when communicating with a person who has dementia.

Due to memory impairment persons with dementia need frequent and calm reminders.

The brain of a person with dementia no longer has the ability to retain information and despite you clearly telling them something like “tea is ready” you may find you have to repeat this message a number of times.

When faced with this challenge we need to remind ourselves that we may feel inclined to raise our voices in frustration or remind the person with dementia that you have already told them that “tea is ready” five times already. We can all recall times when we have asked someone to do something and they appear not to hear, or they do not want to hear, and the frustration this may cause!!.

The use of memory aids such as calendars, clocks, etc can assist a person with dementia, at least in the early stages. However, do remember that during their life, some people, even before developing dementia, have a strong response to some dates such as the date when a child or spouse died.

Freud, the famous psychiatrist, believed that in some individual’s anniversary dates can produce very strong unconscious reactions when a person sees or is reminded of a particular date. If this is know about a person with dementia then the use of large calendars and marking of the dates, rather than they day of the week, may trigger a reaction that may not be understood without this insight into their previous behaviour.

As a person’s dementia progresses then measures such as putting labels on things may assist recognition. Even pictures to replace words may be useful as the dementia advances. The failure to recognise family and friends can be very distressful. A strategy to assist in these circumstances is to always say who you are, rather then requiring the person with dementia to remember.

Lastly, we can become frustrated ourselves and so can a person with dementia who cannot remember things. Encouraging a person with dementia to reminiscence allows them to return to events in their lives where they felt more productive and independent. The use of photographs from the past, or songs from their earlier days can stimulate more positive feelings and enhance self-esteem.

It is important to remember the loss of mental abilities in old age occurs in the opposite order in which they are gained in childhood, especially among people affected by Alzheimer’s. So therefore we must be tolerant as a person journeys back to previous stages and provide them with these opportunities.

In the next article, we will look at ways of dealing with difficult behaviour as the person loses their social skills, such as controlling their emotions and responses.

By Dr Robert Thornton - Gerontologist

If you have contact with someone who has diagnosed dementia the following attitude will assist you — “kindness and patience and respect go a long way toward communicating effectively with a person who has dementia”. This, of course, is not easy — especially over long periods of time, however it is important to remind ourselves of guidelines to assist us in reducing the frustration for yourself and those for whom you care.

· Know what you can reasonably expect from the patient. He or she cannot help the limitations imposed by the disease. Persons may be able to find words for something — especially nouns. For example, a person with dementia may say: “it is what I drink before I have dinner” meaning I would like a glass of sherry or; “the person who delivers the mail” meaning the postman, or “I want so and so” meaning I cannot remember the word for this thing.

· Maintain a calm atmosphere: keep your voice calm and reassuring. Even small amounts of excitement can agitate some individuals. We can all relate to attempting to drive a car in very wet weather and either the car radio is very loud or children are fighting in the back seat. What we need in these situations is “a little peace and quiet” as it helps us deal with the stress of driving in difficult conditions. The tone of your voice is much more important.

· Do not argue or scold as this will always cause the person with dementia to overreact. It also possibly that a harsh tone will remind them of situations from the past and one may get a very emotional response. Even though it is difficult, we must remember the behaviour results from the disease, not wilfulness or stubbornness.

· Be consistent, avoid changes and surprises. Keep things in accustomed places, observe a daily routine, go out the same door when you go for a walk. If you need to change the routine then prepare the person; however, avoid lengthy procedures as this will be too confusing. I think we can remember that when we have been upset the last thing we need is a long conversation — we just need to know we will be supported in a non-judgmental manner.

· Limit choices to reduce confusion — the last thing that a person with dementia needs is to have to choose between various types of clothing (i.e., “do you want to wear red, navy or beige today?” — it is just too much! By taking this action that is limiting choices one reduces confusion. At meal times avoid putting out all the utensils that might be needed for the entire meal — rather only provide what is needed for a particular dish. For example, a soon only for soup and bring out the knife and fork for the main meal etc.

Next time we will look at other strategies to help deal with frustration and examine how to manage more difficult situations.

Article by Dr Robert Thornton - Gerentologist

In this, the third article, we will look at Dementia following on from our examination of memory and aging and how we can assist memory functioning, if it becomes problematic

Dementia is a decline of reasoning, memory, and other mental abilities (the cognitive functions). This decline eventually impairs the ability to carry out everyday activities such as driving, household chores, and even personal care such as bathing, dressing, and feeding—the things we call activities of daily living.

Dementia is most common in elderly people; it used to be called senility and was considered a normal part of aging, this is no longer the case.

We now know that dementia is not a normal part of aging but is caused by a number of underlying medical conditions that can occur in both elderly and younger persons.

In some cases, dementia can be reversed with proper medical treatment. In others, it is permanent and usually gets worse over time.

According to Alzheimer’s Australia, it is estimated that over 210,000 will have dementia in 2006, with a million Australians directly involved in caring for family or friends with dementia.

There are more than seventy causes of dementia, with Alzheimer’s disease being the most common—accounting for between 50 to 70% of all cases, once again according to Alzheimer’s Australia. This organisation further states that the average rate of moderate to severe dementia amongst Australians is about one in fifteen aged 65 plus, among people 80 to 84 the rate is one in nine, and among those 85 plus it is one in four.

It is the leading reason for elderly people being placed in aged care facilities such as nursing homes, with persons suffering dementia eventually becoming totally dependent on others for their care. People with dementia also experience declines in any or all areas of intellectual functioning, for example, use of language and numbers, awareness of what is going on around him or her, judgment, and the ability to reason, solve problems, and think abstractly.

These losses not only impair a person’s ability to function independently, but also have a negative impact on quality of life and relationships.

Dementia has many different causes, some of which are difficult to tell apart. Many medical conditions can cause dementia symptoms, especially in older people, and are often categorised into conditions that are reversible and those that are considered irreversible. We will explore these briefly next time and then talk about what we can do to assist somebody with a memory-related disorder.

By Dr Robert Thornton - Gerontologist

Following on from my earlier article on memory and aging, this offering attempts to give you some practical advice about how to keep your memory fit and healthy even though you may already have a condition affecting its performance.
Firstly, a reminder of things that can adversely affect memory and these need to be minimised if possible to assist your memory. Issues like dehydration, sleep problems, stress, anxiety, depression, heat and external noise can all affect your ability to remember things. While it may not be able to eliminate some of these factors, we need to remind ourselves that if we have to deal with multiple issues then we must be kind to ourselves by: • Ensuring we eat a “good” breakfast • Establishing a routine • Undertaking some brain exercises • Cutting the clutter from our environment • Dealing with issues as they arise, not putting things off • Using a list.
The good breakfast technique ensures that you break your fast between the evening meal and lunch. If you avoid breakfast then your ability to maintain sufficient glucose to your brain is compromised and your memory will suffer. A study in Canada found that memory function was improved after a breakfast of unsweetened cereal, milk and juice, compared to those who miss breakfast altogether.
Establish a routine, this may the last thing you want to do if you have had to adhere to a timetable in relation to family and work matters over many years. But routine can assist your memory by establishing a set of tasks that you need to complete in a day, without being too regimental. Keeping a routine helps your memory by the process of constant repetition
Undertake some brain exercises, you exercise your body, or I hope you do, and the same applies to your brain. Activities that engage your brain and challenge it can help to keep your mind exercised. The following are just some of the things that may help—reading (large print books and audio tapes may assist if eyesight is becoming a problem), watching television news or game shows, cards and board games. The choice of activity very much depends on your likes and interests, so avoid undertaking activities that are not you.
Cut the clutter, attempt to keep clutter to a minimum, more mess means less space and hence greater difficulties finding things. When they get mail or magazines are you a person that quickly looks at them and then puts them onto an ever-increasing pile of assorted items? Then, when you want something, it is now out of sight and then out of mind?
Deal with issues as they arise, avoid trying to put things off for some other time. If you think of something you need to do then write it down, because if you do not the thought will disappear.
Using a list, it seems so simple however it does work. Make yourself a ‘to do’ list—it will help you keep track of tasks that need to be done. Remember to allow a realistic timeframe to complete goals from your ‘to do’ list.
As stated by Dr Phil ‘the difference between a goal and a dream is a timeline’. The above are a few suggestions to assist your memory.
In the next article we will start to look at dementia.

MEMORY AND AGING by Dr Robert Thornton

With the increase in media coverage about dementia and related issues it seems that as soon as you mention to someone you cannot remember something an almost immediate response is that you have Alzheimer’s disease!

This is very wrong and makes trivial the needs and concerns that people have when diagnosed with dementia and fails to recognise that all human beings, over time, will loss some ability with regards to remembering and doing things—this fact is very normal from the age of twenty years.

As we get older memory loss is very normal; you simply lose a few brain cells and produce less memory-related chemicals, so we may forget where the house keys are, maybe misplace some items—like putting your handbag or wallet in the lounge room, instead of your usual place such as the bedroom. Or forget an important anniversary or simply have days when you seem to be a little forgetful.

This is ALL normal and, as stated previously, begins in human beings from as early as the age of 20 years. This process may become more acute as we have more things to deal with so, to put it simply, the busier we are the more likely we are to forget to do something or to have trouble remembering where we have put an item.

So if the above is very normal, when do we or others start to think that some something else is going on? In a nutshell, when memory problems start to interfere with everyday life then it could be time to seek professional advice.

A word of warning first. Some people, by their very nature, are very critical of themselves and/or others if they cannot remember things .You know the type—those who are intolerant of mistakes or hesitation—just keep in mind that this is related to their personality problem, not a memory problem.

So back to when to seek medical advice. Well it’s when memory starts to affect your ability to do everyday tasks on a very regular basis. For example:

• Forgetting how to make to make a cup of coffee, a task you have done a thousand times before.
• Problems in recognising people you know very well
• Using tomato sauce as a topping for a birthday cake.
• Forgetting things more frequently than you used to do.
• Difficulty now making decisions relating to banking.

Another important distinction between normal memory loss and abnormal function is that normal memory loss does not get much worse over time, unlike more serious problems that can accelerate over years, at best or worst over months.

Many things can cause memory loss—such as depression, side effects of drugs, a head injury, a high intake of alcohol, and dementia-related problems—so before pushing panic buttons, seek professional help if you or others are concerned. In the next article we will look in detail about how to assist memory and will explore the many causes of memory loss.