Challenging Behaviors: Special Issues for Family Care

Reprinted from: Coping With Challenging Behaviors: Educational Strategies for Work With Alzheimer’s Families*
By Elizabeth A. Hinman-Smith, M.S.W. and Lisa P. Gwyther, M.S.W.

Introduction

In general, people with dementia will respond best to a stable, familiar environment and an established routine. Their activities should emphasize remaining abilities and strengths. Allowing a person with Alzheimer’s disease to participate in normal activities will help to maximize the person’s functioning and will help preserve self-esteem. Despite these precautions, difficult or frustrating situations will occasionally arise for the person with dementia and their caregiver. When this happens, the most useful overall strategy is to distract the demented person with a new topic or pleasurable activity. In this way, memory loss can be used to advantage...the source of the argument or frustration is often soon forgotten when something else is focused on.

Challenging Behaviors

• Bathing
• Dental and Mouth Care
• Dressing and Grooming
• Eating
• Incontinence
• Wandering
• Sleep Problems
• Communication
• Repetitive Speech & Gestures
• Catastrophic Reactions
• Hiding Things
• Aggressive Behaviors
• Sundowning
• Inappropriate Sexual Behaviors
• Fear
• Shadowing
• Hallucinations-Delusions
• Profanity and Obscenity
  
  

Special Issues for Family Care

• Activities
• Driving
• Handling Money and Valuables
• Holidays
• Visiting the Doctor/Dentist

Bathing

"Mother just refuses to take a bath now...it's such a struggle to keep her clean. She was always very meticulous about how she looked before and now it's a fight to get her in the tub."

• Try to follow as many of the person's old routines as possible (morning vs. evening; bath vs. shower)
• Simplify tasks and try to do one step at a time. (e.g. run water, towels ready, undress, etc.)
• Allow as much independence as possible. Remember to respect the person's privacy and sense of dignity.
• Try to be as calm and gentle as possible. Try not to rush or force the person through the task. Talk him through, if needed.
• Adjust your expectations, if need be. A bath may not be necessary every day, thought it is important to keep them clean. If the person is incontinent, it will be especially important to keep the genital and buttocks area clean to promote good health.
• Be flexible and creative. A sponge-bath can serve the same purpose as a bath or shower, but may be more acceptable to the person being bathed, because she can remain partially covered.
• Work towards a safe and inviting environment - be sure the room is warm, that the water is a comfortable temperature, and that the tub is equipped with non-skid surface and a grab bar. Do not leave hair dryers or razors within reach of a confused person.

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Dental and Mouth Care

"John seems to forget he needs to clean his teeth. It's gotten so I have to show him how each time, to get him started. I didn't believe he'd ever remember."

• Check to make sure the person brushes his teeth regularly. Remind and/or talk him through each task as needed.
• Be sure dentures fit well. A trip to the dentist to ensure good fit may be worthwhile, especially if the person's weight has changed significantly since the original fitting.
• Be sure to include fruit, such as apples, in the person's diet. They can help to clean the teeth and gums.
• If you need to assist the person in cleaning his teeth, you may find the task less pleasant by wearing thin plastic gloves. This is also more sanitary.
• Be sure to inform the dentist if the person is likely to become agitated or upset by a dental appointment. It may be necessary for you to stay in the room for reassurance while work is being done.

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Dressing and Grooming

"My wife insisted on wearing the same clothes every day for days on end. We had to take them to wash only on the nights we could get her into her nightgown. So, I bought two more outfits of the exact same blouse and slacks. Now she changes into fresh clothes and we rotate the clean with the dirty."

• Allow the person to dress herself as long as she can, even if it takes more time then it would with your help.
• If the person needs help, give step-by-step instructions and take one task at a time. Or, you might try arranging clothes by laying them out in the order they are to be put on.
• Encourage the person to choose her own clothes, but make the choice easier by avoiding a large selection from which to choose. Keep only seasonal clothes in the closet. If they insist on wearing the same outfit everyday, try buying the samepieces in duplicate so they can be rotated.
• Clothing should be comfortable, but attractive. Watch for changing size needs subsequent to weight loss or gain.
• As the person becomes more impaired, try easy-care clothing, like sweat-suits, slip on shoes or those with Velcro closing, pants or skirts with elastic waists, Velcro closings.
• Keep the room warm and well-lit while the person dresses. Draw blinds or close door for more privacy.
• Try to conduct dressing at a regular time - part of the day's routine.

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Eating

"Daddy used to clean his plate and then have seconds. He was always a good eater. But now he never seems hungry - we have a hard time getting him to eat, though he still likes sweets the best."

• Try to reduce noise, glare, and other distractions from eating. (e.g. Turn the television or radio off during meals, although some people may find that soft music is calming during a meal.)
• Avoid patterned placemats, plates, and tablecloths. Serve only one food at a time. Set place with only those utensils that are necessary.
  
• For some people, bowls will work better then plates. You may also wish to try dishes with rubber rims on the bottom, or placing a damp washcloth under the plate to reduce sliding. You may try large handled silverware or flatware with rubber tubing on the handle, which is easier to grip.
  
• Bendable straws or cups with lids and spouts may make liquids easier to handle.
  
• Try feeding five or six small meals a day for the those who eat to little or want to eat constantly.
  
• Watch chewing and swallowing carefully. Storing food in the mouth and swallowing difficulties can lead to choking.
  
• Be sure the person gets enough liquids.
  
• For those with trouble with using utensils, try "finger foods." Examples are as follows: French fries, cheese cubes, fruit slices, small sandwiches, fried chicken, spare ribs, chicken "nuggets," fish sticks, raw vegetables cut into sticks, crackers,
  hard boiled eggs, pickles, bread sticks, cookies, hot dogs, pizza, soup or juice in cup, stuffed meat rolls (e.g. cheese rolled slice of ham), pita bread sandwiches.

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Incontinence

"I know he feels bad when he soils his clothes...and so do I. It's hard not to get upset when it happens, especially at night when I need to change the bed."

• React to episodes of incontinence with calm understanding. Scolding will only make the person more upset and lower his self-esteem.
  
• Check with your physician to be sure the incontinence is caused by progressing dementia, and not another underlying medical problem.
  
• Keep track of when accidents occur...could they be avoided by a nightlight in the bathroom? Establish a routine of taking the person to the bathroom based on when accidents occur.
  
• Limit caffeine intake, especially before bedtime. Do make sure the person gets plenty of fluids during the day, but try limiting them just before bedtime.
  
• Continue to maintain balanced nutrition and exercise - this may help bowel incontinence.
  
• Try products designed for adult incontinence. Examples include adult diapers or rubber pants, rubber sheets, or home health equipment like portable commodes or elevated toilet seats with grab bars.
  
• If necessary, remove wastebaskets and/or flower pots from high visibility areas.
• Keep the door to the bathroom open to provide the person with extra visual cues.
  
• Watch for non-verbal cues like restlessness, pacing or undressing.

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Wandering

"Lately, she has started just taking off - she thinks she had to be going somewhere all the time. I'm afraid she'll go out of the house when my back is turned and get hurt."

• Make sure the person carries some form of identification with their name, address, phone number, and pertinent medical information in it. Ideally, the person should wear a medical bracelet or necklace, purchased at a drug store. They could also carry an identification card in their pocket, wallet, or purse.
  
• Keep a clear recent photo on hand to help police and neighbors with identification should the person become lost.
  
• Change your door latch or lock - often people with Alzheimer's disease are unable to learn how to use a new lock. You may also consider placing alarms and bells on outside doors.
  
• Leave a nightlight on in the hall and bath to prevent "losing the way" at night. If the person does lose their way during the night, gently redirect them back to bed.
  
• Put knives, matches, scissors, etc. that could cause injury. Some caregivers may find it necessary to lock doors to the kitchen, basement, or other potentially dangerous areas.
  
• Put a stop sign on the outside doors, or camouflage them with a curtain or screen.
  
• Be sure the person gets exercise daily - this should help reduce excess energy and encourage restful sleep.

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Sleep Problems

"My husband used to get up often at night and was very confused. I finally got him to rest in his recliner in front of the TV and he calmed down and fell asleep. He seems to feel more secure there."

• Create an atmosphere that encourages sleep. Try a warm bath, soothing music, warm milk, comfortable blankets and pillows, low lighting.
  
• Be sure the person gets exercise during the day, especially if fresh air is involved, as weather permits. Try to limit daytime naps.
  
• Limit caffeine intake during the day -- switch to decaffeinated coffee, tea or soda.
• Be sure to take the person to the bathroom just before bed.
  
• If they become restless at night, reassure and coax them back to bed when possible. If restlessness continues, you might try resting them in a comfortable chair with the radio or TV on softly. Some people with AD find a recliner more securefor sleep then a bed.
  
• Place a nightlight in the hall and bathroom to provide the person with visual cues to help guide them to the bathroom and back.
  
• Keep the bedtime routine and morning wake-up time part of the person's regular schedule.
  
• Use medications with caution. Consult with your physician for suggestions on sleep-aids. Some over-the-counter remedies may make the person drowsy during the daytime and disrupt normal sleep/wake patterns.

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Communication

"Some days I can't understand a word he says. When I ask him to repeat things, he gets angry with me."

• Choose short simple sentences, but speak to the person as an adult. Speak slowly and repeat if needed, using the same wording.
  
• Give the person extra time to respond to your statement. It sometimes takes a person with a memory impairment a little longer to process information and formulate an answer.
  
• Carefully monitor your tone of voice. Even when the person has trouble understanding your words, they can and are adept at reading emotional messages like irritation and anger. Try to remain calm and speak in a low tone.
  
• Give the person one instruction at a time. If necessary, break down instructions into separate tasks.
  
• If you cannot understand the verbal content of what the person says, try to respond to the emotional content. This can help the person feel better understood.
  
• Do not bombard him with questions -- you could cause a catastrophic reaction.
• Watch for signs of frustration. Try to use statements rather then questions. Try "It's time to take your bath now" rather than "Would you like to take your bath nowor later?"
  
• Do not assume he cannot understand what is being said. Do not talk about him as if he is not there. Always treat him with respect since lucid or insightful periods can continue well into the course of the dementia.

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Repetitive Speech and Gestures

"Sometimes she'll ask the same question over and over again. It's okay for awhile, but then it gets to me. I get frustrated and snap at her...then we both feel bad."

• Using a calm voice, respond to the questions with a brief simple statement. Try using touch and direct eye contact when you respond. They may just need some extra reassurance. Try and respond to the emotional content of the statements.
  
• Try distracting the person with a pleasurable activity such as going for a walk, having a snack, looking through old pictures, or going for a drive. Play music, or give the person a repetitive and simple task, like separating or rolling coins, sweeping,vacuuming, folding towels, etc.
  
• Use a simple written message for those who can still read. (e.g. "Joanne will be home at 5:00)
  
• Do not discuss plans for activities or appointments until just prior to the event. This will help the person avoid asking about it days ahead of time.
  
• Try ignoring the behavior. This can make the person angry or agitated, but sometimes questions will stop if they are not reinforced by your behavior. Ignoring may be an especially good idea when the caregiver is irritated, as it keeps the patient from picking up on angry tones of voice.
  
• Check with your physician. Sometimes movements like rocking or tongue rolling are related to medications.

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Catastrophic Reactions

"Sometimes she gets so angry. She never used to be that way -- she was a gentle person. Now you never know what will set her off."

• Remove the person from the stressful situation or place. Simply the environment by reducing extra people, clutter, noise, activities.
  
• Keep tabs on when the catastrophic reaction occurs. Is there a pattern (e.g. time of day, type of activity, specific person) that can be identified and altered?
  
• Distract the person with a calming and pleasurable activity. Try soft music, a walk outside, a favorite snack.
  
• Try to establish and stick to a regular daily routine. Schedule the more stressful activities during times when the person is most rested. (e.g., plan baths for the morning if they tend to be tired and irritable at night.)
  
• Encourage daily exercise to reduce excess stress and energy.
  
• Do not try to reason with the person. The ability to reason logically is impaired in a person with dementia. Trying to reason with them may only make things worse. If you feel threatened, remove sharp and dangerous objects from the area and stayout of reach.
  
• Try to calm them with slow movements or gentle touch. Approach the person from the front and use a soothing, reassuring voice.
  
• Limit choices and state directions clearly. Offer activities that the person is able to do and watch for frustration levels.

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Hiding Things

"I have to be sure to get to the mailbox before he does. Last month he hid two bills and we got late notices before I even knew things had come due."

• Limit the number of possible hiding places by locking drawers and cabinets, closets and extra rooms.
  
• Carefully check clothes baskets, hampers and trash cans before emptying.
  
• Lock up valuables when possible. Try to limit the amount of money carried by the person.
  
• Do not scold or accuse the person of hiding things. Do not try to reason with them. Instead, reassure them and help them look. In this way, you may become familiar with favorite hiding places.
  
• When possible, keep spares of frequently misplaced items on hand, like glasses, keys, etc.
  
• Try to distract the person with other activities.
  
• Do not become defensive if the person accuses you of taking things. This is a normal reaction to gaps in memory and increasing confusion. Try to remember that the person is not being purposely malicious. He cannot remember what happened to his things, and it protects his waning self esteem to blame it on someone else.

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Aggressive Behaviors

"When he says something that's not true, I try to correct him. Then he gets angry. There's just no arguing with him. It scares me how angry he gets at times."

• Try to distract the person with a pleasurable topic or activity. Arguing with him won't help and will likely make things worse. If necessary, leave the room and give the person time to calm down.
  
• Look for patterns in behavior. Does the person always get angry at bath time? Try to narrow down to the specifics about what makes him angry. Would more privacy or independence be possible?
  
• If an activity or topic can be avoided, do so. If not, get help from other family members and friends. Try to schedule the activity when most rested.
  
• Try to stick to a regular routine when possible. This will help minimize the number of unexpected and stressful events he must handle.
  
• Try to ignore the angry behavior, if distraction and support do not work. If the situation is threatening, try to make sure he is unlikely to harm himself and stay clear until he calms down.

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Sundowning

"Lately Mamma gets really agitated, fidgety, and irritable around suppertime. She gets all "revved up" and it's hard to settle her down for bed."

• Be sure the person is getting adequate rest or "down time" during the day. Fatigue will increase the likelihood of late afternoon restlessness.
  
• Schedule more involved or taxing activities for earlier times during the day. For example, baths can be done earlier in the morning or large family meal could be held midday.
  
• Try a late afternoon snack or an earlier dinner. Even a glass of milk may reduce agitation.
  
• Distract the person with activities she enjoys. Invite her to assist you with simple tasks, like putting the plates on the table.
  
• Be calm and reassuring in you interactions.
  
• Be sure the person gets some physical activity during the day. Suggest going for a walk. If all else fails, allow the person to pace where you can keep an eye on her.
• You might also try soothing or familiar music.
  
• Be sure the person's environment is well-lit. You may find it helpful to draw curtains and turn on inside lights as it grows dark outside.

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Inappropriate Sexual Behaviors

"Lately Mom has been trying to undress at the Day Care Center. It just started in the last two weeks. If she starts doing it when she is out with me, I don't know what I would do."

• Even though the behavior may be upsetting or embarrassing for you, try not to overreact. The person is likely reacting to what feels good and does not remember the rules we were taught about proper social behavior. As a result, it is usuallybest to remain calm, distract the patient with another activity, or remove her from the situation.
  
• Respond to improper sexual advances calmly and firmly.
  
• Note the environmental circumstances of the behavior. Is the person removing their clothes simply because they are too warm? Is she touching her genitals because she needs to void? Do the clothes fit correctly?
  
• A counselor may help the caregiver sort out conflicting or ambiguous feelings toward a spouse with dementia. They may also suggest alternative forms of intimacy, other then intercourse. Your support group may also provide suggestions and emotional support.
  
• If the person becomes overly aggressive (or conversely fearful of intimacy) it may be necessary for the spouse to sleep in a separate bed or bedroom.
  
• Consult your physician. In some cases, medication may temper sexually aggressive or violent behaviors.
  
• Decide ahead of time how you will react if sexually inappropriate behavior would occur in public or private. Thinking things out will help you remain calm if problems arise.
  
• Protect yourself. Being a caregiver does not mean you should tolerate abusive behavior. Try to anticipate problems before they arise and seek help, as needed.
  
• Remember that although dementia will ultimately affect the sexual and intimate aspects of the marriage, both the person with dementia and their caregiver will still have the basic human desire for touch, warmth, and intimacy.

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Fear

"He gets so nervous and scared sometimes. It seems especially bad when he's someplace new. He even gets frightened when he can't see me, even though I'm in the next room. Sometimes he thinks someone is trying to break in."

• Reassure the person. Face him, using eye contact, a gentle touch or hug, and a calm and soothing voice.
  
• Try to determine what is precipitating this response. Remember that nearly anything in the environment can be misconstrued as threatening.
  
• Try to avoid loud or confusing noises. Do not have the TV volume turned up loud. Sometimes TV shows scare people who cannot separate a TV situation from real life.
  
• Try to shop and run errands on off hours, like first thing in the morning. Avoid malls on Saturday afternoon.
  
• Let the person know that you will be there to protect and look after him.
  
• Try to distract him with an activity he enjoys.
  
• Some people with dementia find it reassuring to have a cuddly stuffed animal or security object, like a purse or favorite hat.

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Shadowing

"He never gives me a moment to myself. I can't even take a shower or use the bathroom anymore without him pounding on the door looking for me."

• Clinging behavior may be caused by an environment that is overwhelming for the person. If he is scared or confused, he will likely seek out and stay with a familiar reassuring caregiver. Reduce excess noise, activity or clutter.
  
• Provide the person with a cuddly "caregiver substitute". Examples include soft dolls or furry stuffed animals. Pets may also provide a friendly distraction and be both a source and object of affection. Try an audiotape of the caregiver in thekitchen, or other familiar sounds.
  
• Other activities may divert the person. Provide him with a meaningful but repetitive job, magazines, or photo albums. Old, familiar songs may also give pleasure and reassurance.
  
• Reassure. Let the person know that you love him and you will not abandon him.
  
• Remember to schedule regular time away or yourself. Clinging behavior can be very stressful.

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Hallucinations and Delusions

"Mom always thinks she sees a man on a bicycle outside the window. She's not afraid, but insists he's there. Daddy always teases her that he's going to go out and run her suitor off. It makes her laugh."

• Do not argue with the person over what they see, hear, feel, or smell. For the person, these visions and thoughts seem very real. Reassure her and respond to her feelings about it. "I don't see the bear in the back yard, but it must be scary. Don'tworry -- I won't let it harm you."
  
• Reduce clutter, extraneous noises, or confusing aspects in the environment. Check out any real basis to the fear. For example, the person may "hear people" in the next room because the television is on, or may see someone because of a shadow on the wall.
  
• Do not argue with someone over false belief. The person will not be able to remember your reasoning or rationally weigh your points. Say, "I know you are afraid I might leave. I won't," rather than "How could I possibly have the time for anaffair?" Respond to the emotional content of the statement and distract the person with other activities or another topic.
  
• Be aware that the person may believe her parents are still alive. Reminding her they dies twenty years ago may be like hearing the news for the first time. Again respond to the emotional content and distract. "You mother was a great lady -- I know you miss her."

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Profanity and Obscenity

"My husband was always a polite Christian person...always considerate of others. Now he swears like a sailor. I find it so offensive. Before his illness, he'd never dream of using such words."

• The person may forget social skills of a lifetime or respond on impulse. As a result, he may resort to the use of profanity or obscenity, especially when he is upset or agitated. Remember that the person is not deliberately trying to upset you, but is affected by a disease that compromises his behavior and impulses control.
  
• Try to remain calm. You can try to correct the use of profanity by gently requesting the person refrain from using it. If that does not work, try to ignore it. If the person receives no reinforcement for such behavior, he may stop with time.
  
• Explain to those present (grandchildren, etc.) that "grandpa" has an illness that prevents him from behaving the way that he would like to, and that he occasionally uses words he should not.
  
• If the situation becomes pronounced, distract the person with a different topic or activity and if necessary, remove him from the situation.

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Special Issues for Family Care

Activities

"My wife can't handle the cooking anymore. She also doesn't work on her needlework. She's idle so much of the day, but I don't know what to give her
to do."

• Do not try to teach new skills or re-train for old hobbies. Some long-term memory is better preserved than short-term memory. Try to build on well-learned and preserved abilities. Some people, for example, can sing or play instruments that they learned long ago.
  
• Look for activities that last no longer that half an hour. The person's attention span is shorter than normal.
  
• Try activities that are familiar, simple, repetitive, and do not require much decision making. Examples include sweeping, vacuuming, folding towels, raking, picking up sticks, stringing beads, rolling coins, stuffing envelopes, walking the dog, andshelling peas.
  
• Break tasks down into component steps if necessary. For example, "set the table" can be broken down into placemats, plates, napkins, silver, glasses.
  
• Help get the person started by verbally guiding her or demonstrating the desired behavior.
  
• Try to keep activities on an adult level. Allow the person to continue doing as much as she can by herself. Household or yard work helps her remain as a contributing member of the household.
  
• Adjust your expectations to fit the remaining ability. The task may not be done as well as it would have if you had done it, but remember the importance of the person's self-esteem.
  
• Be patient and flexible. Give the person a little more time to do things. Be on the lookout for how to adapt tasks so she can participate.
  
• Watch for frustration. If the person becomes upset or agitated, step in to help or distract with another, pleasurable activity, break or snack. Remember, outings and passive entertainment can be quite successful.

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Driving

"I worry about him driving. He does alright on familiar roads, but his judgment and sense of direction aren't as good."

• Offer to drive for the person.
  
• Gently tell the person that you are concerned about his eyesight (concentration, memory, reaction time) and feel safer for you to drive.
  
• Take the keys from the person and substitute another set of keys that doesn't fit the car if needed. This lets him keep keys while making driving impossible. Sell or remove the car if necessary.
  
• Dismantle the car (install kill switch, disconnect the battery, remove the distributor cap) so it won't start.
  
• Have their physician advise them not to drive.
  
• Have the physician write a letter to the Department of Motor Vehicles requesting the person be road tested in light of the diagnosis.
  
• Distract the person with another activity.

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Handling Money and Valuables

"Last week I looked in his wallet and there was $900. I called the bank and he'd made a $2,000 withdrawal last week. I have no idea where the rest is!"

• Look into long-term tools for financial management like durable powers of attorney, trusts or conservatorship, or joint bank accounts. Consult your attorney, your accountant, of a financial counselor for the best options for your individual situation.
  
• Remove credit cards from the person's purse or wallet.
  
• Keep lots of family pictures and identification cards in the person's wallet. Keep a small amount of money. Small bills may seem like more. For example, try a five and five ones instead of a ten dollar bill.
  
• Arrange for direct deposit of checks when possible. Watch the mail carefully for checks you are expecting.
  
• Locate valuables such as stock and bond certificates, wills, deeds, titles, life insurance policies, good jewelry, etc. and place them in a safety deposit box.
  
• Notify the bank that the person is memory-impaired and that you should be notified of any (large) transactions before they are processed.

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Holidays

"The holidays can be bittersweet time for caregivers. But there are ways to make them fun and relaxing for family members and patients."

• Do not give gifts that require a lot of care or attention. Be aware that expensive of fragile gifts may be broken or lost.
  
• Be realistic as to how much holiday activities the person with dementia (and the caregiver) can handle. Holidays are stressful for everyone and caregivers may need to adjust expectations about how much holiday entertaining they can do.
  
• Avoid too much food, drink, and people.
  
• Gift ideas for caregivers include: tickets to a show, concert, movie; "respite visits" to give the caregiver time off; offers to run errands for the caregiver; dinner out or dinner delivered to the home; books; housekeeping tasks done or paid visits by a housekeeping service; subscription to favorite magazine; coupon for 1 day (or more) at an adult day care; telephone gift coupon for long-distance calls.
• Gift ideas for the person with dementia include: an identification bracelet; a taxi charge; a stuffed animal to hug; a picture album filled with family pictures; exercise equipment (a stationary bike, jump rope, membership to a swimming pool); comfortable, easy care clothes; music, tapes or records -- especially familiar old tunes; radio; tickets to a musical or concert; favorite food; a pet; home health equipment (safety bars for bath or shower); lap robe; bird feeder.

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Visiting the Doctor/Dentist

"I know we should have her checked at the doctor's office, but she refuses
to go."

• Look for ways to prevent catastrophic reactions before they occur. If the person often becomes agitated in a room full of people, is there an anteroom where the family can wait privately (or an unused exam room)?
  
• Bring favorite snacks and activities (e.g., photo album) with you to distract the person or occupy waiting time.
  
• Avoid telling the person far ahead of time. This only increases the likelihood that the person will worry about the appointment unnecessarily.
  
• Do not argue, but distract with a different topic or gloss over verbal objections. Be matter of fact. "It's just your turn for a check-up."
  
• Take someone with you who can stay with the person while you speak with the physician, or who can help you look after them if needed. Do not leave a memory-impaired person alone in the waiting room.
  
• Let the receptionist and physician know ahead of time that the person is confused.
• Try to make the appointment for the least busy time of the day.
  
• Make the appointment for the person's best time of the day. If the person tends to sundown, try a morning appointment.

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*Reprinted with the permission of Memory and Movement Disorder Clinic
Joseph and Kathleen Bryan Alzheimer's Disease Research Center (ADRC)
Division of Neurology, Department of Medicine, Duke University Medical Center
Supported by an educational supplement grant (AG05128) from the National Institute on Aging, 1990.