Anxiety & Alzheimer s Disease Anxiety is a normal feeling that everyone experiences now and again. In some people, however, these feelings can be very strong and persistent. This can interfere with a person's everyday life. This feeling of fear, uneasiness, and apprehension is particularly coming during the early and middle stages of the disease. In individuals with Alzheimer s disease anxiety can manifest in: - Social withdrawal or decreased engagement in once pleasurable activities - Angry outbursts or following family members from room to room because they no longer fully understand what to do or expect, or what is expected of them - Psychological symptoms: feeling worried, tired, restless & irritable, experiencing feelings of dread and having problems concentrating - Physical symptoms: fast or irregular heartbeats, shortness of breath, excessive sweating, dry mouth, trembling, dizziness, nausea, diarrhoea, stomach aches, headaches, insomnia, frequent urination, excessive thirst, muscle tension or pains Causes of Anxiety Many of the things that can cause people to feel depressed can also cause people to feel anxious, and vice versa. The exact causes of these conditions vary from person to person and there are often several contributing factors. Possible causes of anxiety include: - traumatic or upsetting events - these can trigger high levels of anxiety that continue long after the event is over - lack of social support or social isolation - the effects of certain illnesses or the side-effects of medication - bereavement - the person may be upset my misperceived threats, abrupt changes in their environment, or fear & fatigue of making sense of what s around them - lack of activities, with feelings of boredom and aimlessness - feeling stressed or worried over issues such as money, relationships or the future - having a past history of depression or anxiety - having a genetic predisposition to depression or anxiety The causes of anxiety in someone who also has dementia are likely to be similar to those for anxiety in general. However, in the early stages of dementia these conditions may be linked to a person's worries about their memory and about the future. Chemical changes in the brain, caused by the dementia, may also lead to anxiety. 1 P a g e
Behavioural Approaches to Anxiety Alzheimer's disease affects different parts of the brain at different times and at different rates, making it hard to predict how your loved one will behave on any given day. Behavior problems such as aggression, suspicion, or wandering are caused by damage to the brain and are not something that your relative can control, "keep in check," or prevent. It's especially important to remember this when individuals with Alzheimer's do or say things that can be interpreted as hurtful. It is important to try and identify the cause of the behaviour. Often an individual may be reacting to the Alzheimer s diagnosis, and the course of the disease. Anxiety may involve fear of being alone or particular stresses, such as financial worries. Change is often a problem, such as a new caregiver, hospitalization, or travel. Parts of the daily routine, such as bathing or changing clothes, may induce anxiety. The key to managing challenging behaviors is to accept the brain-behavior relationship so that the behaviors can be viewed through a compassionate lens and with a non-judgmental attitude. Once you have identified the possible sources of the anxious behaviour you can try to minimize their impact with Behaviour Management and the A-B-C Chain. Antecedent- what occurred before a challenging behaviour or what set the stage for it to occur? Behaviour- what is the problematic action? Consequence- what happened directly after the behaviour? For example: Does your loved one wander or become agitated when in a chaotic place such as a grocery store, when normally they are calm? How do you react after the behaviour? Do you stay calm or become defensive? It is important to look at several instances over time to see if a particular antecedent or consequence has a trigger reinforcing the behaviour. After you have tracked and analyzed the behaviour try to develop new ways to deal with it. The key is to change the antecedent and/or consequence. REMEMBER: Your loved one cannot control or prevent behaviours on their own; it is up to you to change what happens. Strategies in Dealing with Anxious Behaviours Create a calm environment: get rid of triggers in the home that could set off anxiety, such as machines that make abrupt or unusual noises and bright lights. Make sure the person is comfortable: check to see if the person is feeling pain, hunger, or thirst. Ensure a comfortable temperature and that the bathroom is easily accessible. 2 P a g e
Simplifying potentially frustrating tasks and routines: Assist with bathing, dressing and chores that loved ones find harder to do Give them a chance to burn off excess energy: accompany your loved one on walks, or have them attend your local Adult Day Program. Other helpful strategies may include: - Distraction or redirecting the individuals attention - Avoid becoming confrontational or over excited - Allow rest and quiet between potentially stressful activities, and ensure there is adequate light to reduce the potential for confusion - Structured activities can be calming - Listen to your loved one as they express frustration, they may provide you with clues to upsetting behaviour - Provide reassurance that you are there to provide love, help and comfort - Provide simple, clear and positive answers - Provide plenty of supervised activity to channel their energy and reduce the frequency of wandering. Often wandering may be goal directed e.g. loved one may think they are going to work Specific Behaviours Aggression: Aggression in Alzheimer's disease can take the form of shouting, cornering, raising a hand to someone, or actually pushing or hitting. Unfortunately, aggression among people with Alzheimer's can occur suddenly and seemingly without warning. It's very important to try to identify what triggered the aggression so that the antecedent can be eliminated or modified. Focus on your loved one's feelings and react in a calm and reassuring way. Be sure that all distractions, such as loud noises or potentially frightening shadows or movements, are reduced as much as possible. Redirecting your relative to a pleasant activity can be remarkably effective. Agitation: As Alzheimer's disease progresses, your loved one might exhibit agitation, which includes becoming restless, anxious or upset. This can also elicit pacing, dependency, or a tendency to obsess over details of a particular situation. To address agitation, really listen to your relative as she expresses her frustration. She may give you a clue about what is upsetting her, which can then be used to devise a new strategy or approach. It's also helpful to reassure your loved one that you are there to provide help and comfort. If it seems like your relative needs something to do, redirecting her to an enjoyable activity, such as a game or art project that you know she finds pleasurable can often improve the behavior. Agitation is also commonly due to a noisy or distracting environment, so relocating your loved one to a calmer area may be all that is needed. 3 P a g e
Apathy: While apathy, which can include listlessness and passivity, may not seem like a behavior problem, it can be very troubling to care for someone with Alzheimer's who doesn't want to do anything. Even though your loved one is ill, it's important to keep her moving and active as much as possible in order to maintain physical health and to prevent depression. In fact, apathy is sometimes a symptom of depression, so persistent apathy should be reported to a physician. Try engaging your relative in enjoyable activities, but adapt them so she can participate at a level that is comfortable and not overwhelming. Even just a small amount of activity is better than none at all. Confusion: Alzheimer's disease often causes confusion. Your loved one may become confused about person, place, and time. In other words, he may still know who he is, but he may not recognize others; he might also be unable to identify where he is or name the current time, date, or year. People with Alzheimer's disease also become confused about the purpose of objects, such as keys or pencils. As frustrating as this can be for caregivers, the best way to respond is to stay calm and provide simple, clear, positive answers when your loved one asks for help. For instance, if he seems confused about the purpose of a fork, simply say, "Here's your fork for eating your food." It can also help to demonstrate how the item is used. Never scold your relative for becoming confused about things she used to know. Hallucinations: Hallucinations are sensory experiences that seem real to people with Alzheimer's disease, yet they are not really happening. The most common hallucinations are visual (seeing something that isn't really there) and auditory (hearing something that isn't really there), but hallucinations can also occur in regard to taste, smell, and touch. Because hallucinations seem so real to those with Alzheimer's, it is not helpful to try to convince them that they are imagining things. Instead, acknowledge your loved one's feelings, try to reassure her that you are there to help, and redirect her to a pleasant activity. Another thing to consider is whether the hallucination is actually bothering your relative. If it's a pleasing hallucination, for example, your loved one sees birds and flowers outside a window that are not really there, then there may be no benefit in trying to discourage or minimize the behavior. Repetition: As Alzheimer's disease progresses, your loved one might start repeating a sound, word, question, or action over and over again. While this is usually harmless, it can be extremely unnerving for caregivers. Repetition is usually a sign that your loved one feels fearful or insecure; he may be looking for something comfortable and familiar; something he has some degree of control over when he engages in repetition. To address repetition, look for a specific antecedent or reason for the repetition as well as for the emotion behind the behavior. This will reduce your chances of responding impatiently with your loved one. If the repetition takes the form of an action, try turning it into an activity that makes him feel useful. For instance, if your relative is constantly fidgeting with his hands, try giving him some laundry to sort or some napkins to fold. 4 P a g e
Sundowning: Sundowning is a phenomenon unique to Alzheimer's disease where the person becomes more confused and agitated in the late afternoon and early evening. Several theories have been proposed about why sundowning occurs, such as increased confusion due to darkness and shadows, fatigue, and a reduced ability to tolerate stressful situations. The best way to approach sundowning is to make late afternoons and evenings as simple and relaxing as possible. Reduce distractions or unscheduled activities, and keep rooms well-lit until bedtime. Suspicion: A combination of memory loss and disorientation can cause your loved one to perceive situations in atypical ways. He may become suspicious of others, including you, and make accusations of theft, infidelity, or other offensive behavior. As hard as it may be to be accused of something you did not do, try not to become offended. Remember that the behavior is due to the way the disease is affecting your loved one's brain. Don't try to argue with your relative or convince him or her of your innocence. Instead, share a simple answer or response, such as, "I see that you're upset about your missing wallet, so I'll do my best to find it for you." Avoid giving wordy or complicated explanations. Redirection to another activity can be very effective in these situations. It's also helpful to store "back-ups" of items that are frequently misplaced (e.g., baseball caps, purses). Wandering: One of the more dangerous behaviors among individuals with Alzheimer's, wandering may be goal-directed (when your loved one may think that she is going to work or going "home" to a childhood residence) or non-goal-directed (when your relative wanders aimlessly). Make sure your loved one has plenty of supervised activity to channel her energy and reduce the frequency of wandering. If she is intent on wandering, redirecting her to another activity can be a simple yet effective strategy. Interestingly, Alzheimer's disease affects perception in such a way that environmental interventions can help curb wandering. For instance, a painted black square or a dark doormat on the floor in front of a doorway may look like a hole to your loved one, preventing her from exiting. 5 P a g e