Alzheimer's Disease

Talking about intimacy and sexuality is never easy, from the time we are youngsters until we are very old and wise. For some, sex is enjoyable, for others it is embarrassing and for others still it is frightening. Nevertheless, sex is part of our lives, and when combined with Alzheimer’s Disease, it can problematic.

It is important to distinguish the differences between intimacy and sexuality to better address the challenges created by dementia. Intimacy is a "warm friendship," while sexuality is the use of words, gestures, movements or activities that attempt to display physical affection. Sexual activity in healthy relationships helps people to stay in good physical condition and helps to reduce physical and psychological stress.

Dementia’s Impact on Sexual Relationships

Even the most confused individual affected by dementia is still a sexual being. Dementia does not mean just memory loss as the common perception. It is a form of brain damage that can affect many different aspects of consciousness, motor skills and executive function, in addition to memory. With respect to sexual behavior, your loving partner may no longer remember how to arouse and satisfy you; may develop impotence from blood pressure medications; may become hypersexual or unable to understand the consequences of his/her actions in public; may lose social skills and charisma; may lose self-esteem; or may engage in impulsive, thoughtless or indifferent behavior.

Your loved one may engage in sexual behavior such as public masturbation, undressing or inappropriate sexual advances. You should not feel responsible for these behaviors, they are the result of your loved one’s brain disease and are not a reflection on you. Accusations of infidelity or hypersexuality may make you feel misunderstood and angry. Take time to reassess the situation. Is your loved one seeking reassurance or a boost in self-esteem? Is it simply a breakdown in judgement? Understanding the behaviors in these terms depersonalizes the impact.

Caregivers to loved ones with dementia, especially spouses, express many concerns.

Guilt: for refusing a spouse’s sexual advances, for wanting a satisfying intimate relationship, for simply wanting a personal life, for wanting the burden to end.

Frustration: with problems that arise during sex, with demented spouse’s inability to satisfy or appear interested in your sexual needs, with the inability to relate to your loved one due to his/her diminished mental capacity.

Resentment: for having to suppress one’s own needs, over your loved ones accusations of infidelity, of your marriage vow to care "in sickness and in health."

Embarrassment or Confusion: over changes in spouse’s behavior, by sexual advances by your spouse who no longer recall’s your name, by repeated advances even after sexual episodes early in the day, over emotional intimacy that has been lost.

Fear: of acting selfishly, of attending to one’s own needs, of wounding pride if you refuse sexual advances, of raping your spouse because they really can’t give informed consent.

Effectively coping with these changes in your relationship are essential. Start by doing things that reduce stress and enhance your self-esteem. Keeping a journal can help you to release your pent up feelings. Most importantly, develop a support system of peers who you can comfortably share your feeling and experiences. This may seem awkward at first – however once you recognize that this is an issue, you can begin to grow from it. Many Alzheimer’s support groups have a mix of children caring for aging parents and spouses caring for their partner. Seek out individuals who are "most like you" to share a cup of coffee, ask the facilitator to raise the issue cautiously, suggest a guest speaker, or consult with a religious advisor or therapist.

Remember, that as a caregiver, you are not required to devote every ounce of energy to your loved one. It is essential to maintain your balance and minimize your stress level. It is OK to get angry sometimes (but not to get violent). Your emotions are natural, but the challenge is to address the in a healthy manner and grow from the experience.

Rediscovering Loving Relationships A couple’s role and intimacy will undergo change (all relationships do over time). Even with the onset of dementia, there are still facets of your relationship that you can nurture. However strained and limited, you can still focus on these positive aspects of a relationship: singing and music reviewing photo albums talking about the past taking walks or rides visiting with animals or children engaging in simple projects such as gardening or painting assisting with personal care such as shaving, manicures or hair-setting exercising and dancing However you cope with the changes in your loving relationship, you may be able to find additional emotional support and relationships in friends and family, children, pets, and coworkers/volunteers. The Power of Touch All individuals, regardless of age or abilities, have the need for touch and love and the desire for companionship. Touch is a human need and personalizes caregiving. People respond to touch depending upon their upbringing and self-image. A touch can convey compassion, not just sexual interest. It can convey reassurance (as a gentle stroking of the forearm), safety (as an arm around the shoulder) or relaxation (as a shoulder massage) among other feelings. So often we rely on the "miracles of modern medicine" and technological solutions to the stresses of aging and physical illness (and even spiritual/emotional losses). Most religions have traditions of the healing and curative powers of touch. These traditions can be interpreted as myth or fact. Yet even modern science recognizes the importance of human interaction and physical contact. Touching or massage can promote physiological responses such as decreased nervous tension, decreased muscle contractions, increased circulation, and decreased heart rate and blood pressure. Ten years ago as I watched a good friend of mine die of AIDS. As David’s disease progressed he suffered from terribly disfiguring Kaposi’s sarcoma. People avoided him on the street and averted their eyes. In the days before he died, I made a conscious effort to face him as I spoke and rest my hand on his knee or shoulder when we sat together. At times this was not easy for me. I did not – could not – cure his disease. But I know that I made a difference in his frame of mind, especially given his own perception of himself as "untouchable." When I volunteered as a Long-Term Care Ombudsman at a nursing home, I frequently found myself sitting and talking with residents. THEY reached out to touch me – grasping my arm (sometimes bone-crunching!), tapping my knee and even kissing my hand. People in residential settings are not solely "patients" – they need attention and affection more than ever before. Caregivers have a great opportunity to enhance the well-being of their loved ones by being more conscious of the power that they hold in the fingertips. I have included a few additional examples: Encourage family members and guests to face their elder when talking to him/her. This is an essential skill for hearing-impaired or demented elderly. Gently massage some lightly scented lotion on your loved one’s hands and feet. Yeah, old people’s feet get gnarly, because/so they don’t get touched often. Have a podiatrist take care of nail clipping and necessary medical procedures. Whenever you sit or stand with your loved one, retain physical contact by holding his/her hand or arm. This also can help to orient a demented or sight-impaired person. Avoid signs and actions that show your discomfort or repulsion to your loved one’s ailment(s). People are very conscious of the way that other people perceive them and take on negative frames of mind.

It's helpful to know where your Alzheimer's patient falls in the stages of the disease in order have some sense of what to expect and how to plan. There are several different lists of stages of Alzheimer's that can be found all over the Internet, but the one I've chosen is the one posted in the Alzheimer's FAQ at the Washington University at St. Louis Alzheimer Page. (The list on that site was adapted from Reisberg, B., Ferris, S.H., Leon, J.J. & Crook, T. "The global deterioration scale for the assessment of primary degenerative dementia." American Journal of Psychiatry, 1982.)

Stage 1 - "No cognitive decline." No memory deficit is evident any clinical interview used for testing the presence of Alzheimer's.

Stage 2 - "Very mild cognitive decline (Forgetfulness)." Some complaints of memory problems. Mostly the patient is forgetful in areas of where an item has been placed, such as car keys, and in forgetting people's names.

Stage 3 - "Mild cognitive decline (Early Confusional)." This is the stage at which there begins to be some memory loss evident in a clinical interview. The problem will affect the person in one or more of these areas: 1) getting lost while traveling, 2) lowered performance at work may be noticed, 3) increased difficulty in finding the needed words or remembering names, 4) reading retention lowered, 5) losing objects of value. The patient may experience both anxiety and denial along with these symptoms.

Stage 4 - "Moderate cognitive decline (Late Confusional)" At this stage there is clearly some memory loss evident in a clinical interview. The problem will be seen in one or more of the following areas: 1) Decreased knowledge of current events, 2) may begin to lose some personal history, 3) inability to concentrate, and 4) inability to travel, handle finances, etc. The person may also begin to be unable to recognize familiar people and may lose orientation to time or place as well as being unable to perform complex tasks. Denial is evidental, and withdrawal from challenging tasks becomes a defense mechanism.

Stage 5 - "Moderately severe cognitive decline (Early Dementia)" The patient needs assistance in daily living in order to survive. Though the person may require no assistance with toileting and eating, they may need help choosing clothes. They may not be able to recall in a clinical interview important information relavant to their lives as address or telephone number they've had for years, the names of family members, or the high school they attended. Stage 6 - "Severe cognitive decline (Middle Dementia)." The patient may occasionally forget their spouse's name, and they may be largely unaware of much of their own history as well as of recent events. They may retain some knowledge of their past lives, but this is sketchy. During this stage personality changes may occur, and the person may become obscessive or delusional and may begin having hallucinations. They may begin to have some incontinence as well. Stage 7 - "Very severe cognitive decline (Late Dementia)" All verbal ability is lost, the person is incontinent, and needs assistance with eating. The person may also lose the ability to walk, and eventually to sit and head control as well. Looking at the early stages, it is easy to see how a person with Alzheimer's can function for years without others being aware that there is a problem. Some of us might even wonder if we're not in stage one or two ourselves. Looking back, I think I can safely say that my mother was in stage four before her diagnosis (1993), and in stage five when my sister was her caregiver (1993-1994), stage six when I became her caregiver (1994-1995), and stage seven soon after she entered the nursing home (Jan.-Apr. 1996). Although she was unable to walk or to eat without assistance near the end, and she did pretty much lose her ability to talk, she didn't become unable to sit or to control her head. I hope this list of stages will be helpful to you who have loved ones with Alzheimer's. The diagnosis isn't the end of the world. If it is caught early, as it often is these days, there can be years of functionality, especially with the aid of new medications that may delay the more advanced symptoms for a long time. There is so much research going on, and perhaps there might even be a cure found before your loved one reaches those advanced stages. There is always that hope!

This article is about Alzheimer's disease and other types of dementia. It presents information for patients, family members, and other caregivers. It talks about the effects Alzheimer's disease can have on you, your family members, and your friends. This article describes the early signs and symptoms of Alzheimer's disease. This article is not about treating Alzheimer's disease, nor should it be construed as medical advice. Consult your physician or other medical professional immediately if you suspect that you or a loved one has Alzheimer's Disease.

Terms You Need to Know

Dementia is a medical condition that interferes with the way the brain works. Symptoms include anxiety, paranoia, personality changes, lack of initiative, and difficulty acquiring new skills. Besides Alzheimer's disease, some other types or causes of dementia include: alcoholic dementia, depression, delirium, HIV/AIDS-related dementia, Huntington's disease (a disorder of the nervous system), inflammatory disease (for example, syphilis), vascular dementia (blood vessel disease in the brain), tumors and Parkinson's disease.

Alzheimer's disease is the most common form of dementia. It proceeds in stages over months or years and gradually destroys memory, reason, judgment, language and eventually the ability to carry out even simple tasks.

Delirium is a state of temporary but acute mental confusion that comes on suddenly. Symptoms may include anxiety, disorientation, tremors, hallucinations, delusions, and incoherence. Delirium can occur in older persons who have short-term illnesses, heart or lung disease, long-term infections, poor nutrition, or hormone disorders. Alcohol or drugs (including medications) also may cause confusion. Delirium may be life-threatening and requires immediate medical attention.

Depression can occur in older persons, especially those with physical problems. Symptoms include sadness, inactivity, difficulty thinking and concentrating, and feelings of despair. Depressed persons often have trouble sleeping, changes in appetite, fatigue, and agitation. Depression usually can be treated successfully.

What Is Alzheimer's Disease?

In Alzheimer's disease and other dementias, problems with memory, judgment, and thought processes make it hard for a person to work and take part in day-to-day family and social life. Changes in mood and personality also may occur. These changes can result in loss of self-control and other problems. Some 2 to 4 million persons have dementia associated with aging. Of these individuals, as many as two-thirds have Alzheimer's disease.

Although there is no cure for Alzheimer's disease at this time, it may be possible to relieve some of the symptoms, such as wandering and incontinence. The earlier the diagnosis, the more likely your symptoms will respond to treatment. Talk to your doctor as soon as possible if you think you or a family member may have signs of Alzheimer's disease. Research is under way to find better ways to treat Alzheimer's disease. Ask your doctor if there are any new developments that might help you.

Who Is Affected?

The chances of getting Alzheimer's Disease increase with age. It usually occurs after age 65. Most people are not affected even at advanced ages. There are only two definite factors that increase the risk for Alzheimer's Disease: a family history of dementia and Down Syndrome.

Family History of Dementia: Some forms of Alzheimer's Disease are inherited. If Alzheimer's Disease has occurred in your family members, other members are more likely to develop it. Discuss and family history of dementia with your family doctor.

Down Syndrome: Persons with Down syndrome have a higher chance of getting Alzheimer's Disease. Close relatives of persons with Down syndrome also may be at risk.

What Are the Signs of Alzheimer's Disease?

The classic sign of early Alzheimer's Disease is gradual loss of short-term memory. Other signs include:

Problems finding or speaking the right word.
Inability to recognize objects.
Forgetting how to use simple, ordinary things, such as a pencil.
Forgetting to turn off the stove, close windows, or lock doors.

Mood and personality changes also may occur. Agitation, problems with memory, and poor judgment may cause unusual behavior. These symptoms vary from one person to the next.

Symptoms appear gradually in persons with Alzheimer's disease but may progress more slowly in some persons than in others. In other forms of dementia, symptoms may appear suddenly or may come and go.

If you have some of these signs, this does not mean you have Alzheimer's disease. Anyone can have a lapse of memory or show poor judgment now and then. When such lapses become frequent or dangerous, however, you should tell your doctor about them immediately.

Possible Signs of Alzheimer's Disease

Do you or your elder have problems with any of these activities:

Learning and remembering new information. Do you repeat things that you say or do? Forget conversations or appointments? Forget where you put things?

Handling complex tasks. Do you have trouble performing tasks that require many steps such as balancing a checkbook or cooking a meal?

Reasoning ability. Do you have trouble solving everyday problems at work or home, such as knowing what to do if the bathroom is flooded?

Spatial ability and orientation. Do you have trouble driving or finding your way around familiar places?

Language. Do you have trouble finding the words to express what you want to say?

Behavior. Do you have trouble paying attention? Are you more irritable or less trusting than usual?

Remember, everyone has occasional memory lapses. Just because you can't recall where you put the car keys doesn't mean you have Alzheimer's disease.

Consulting the Doctor Identifying mild cases of Alzheimer's disease can be very difficult. Your doctor will review your health and mental status, both past and present. Changes from your previous, usual mental and physical functioning are especially important. Persons with Alzheimer's disease may not realize the severity of their condition. Your doctor will probably want to talk with family members or a close friend about their impressions of your condition. The doctor’s first assessment for Alzheimer's disease should include a focused history, a physical examination, a functional status assessment, and a mental status assessment. Medical and Family History: Questions your doctor may ask in taking your history include: How and when did problems begin? Have the symptoms progressed in steps or worsened steadily? Do they vary from day to day? How long have they lasted? Your doctor will ask about past and current medical problems and whether other family members have had Alzheimer's disease or another form of dementia. Education and other cultural factors can make a difference in how you will do on mental ability tests. Language problems (for example, difficulty speaking English) can cause misunderstanding. Be sure to tell the doctor about any language problems that could affect your test results. It is important to tell the doctor about all the drugs you take and how long you have been taking them. Drug reactions can cause dementia. Bring all medication bottles and pills to the appointment with your doctor. Do you take any medications? Even over-the-counter drugs, eye drops, and alcohol can cause a decline in mental ability. Tell your doctor about all the drugs you take. Ask if the drugs are safe when taken together. Physical Examination: A physical examination can determine whether medical problems may be causing symptoms of dementia. This is important because prompt treatment may relieve some symptoms. Functional Status Assessment: The doctor may ask you questions about your ability to live alone. Sometimes, a family memberor close friend may be asked how well you can do activities like these: Write checks, pay bills, or balance a checkbook. Shop alone for clothing, food, and household needs. Play a game of skill or work on a hobby. Heat water, make coffee, and turn off stove. Pay attention to, understand, and discuss a TV show, book, or magazine. Remember appointments, family occasions, holidays, and medications. Travel out of the neighborhood, drive, or use public transportation. Sometimes a family member or friend is not available to answer such questions. Then, the doctor may ask you to perform a series of tasks ("performance testing"). Mental Status Assessment: Several other tests may be used to assess your mental status. These tests usually have only a few simple questions. They test mental functioning, including orientation, attention, memory and language skills. Age, educational level and cultural influences may affect how you perform on mental status tests. Your doctor will consider these factors in interpreting test results. Alzheimer's disease affects two major types of abilities: The ability to carry out everyday activities such as bathing, dressing, using the toilet, eating and walking. The ability to perform more complex tasks such as using the telephone, managing finances, driving a car, planning meals and working in a job. When a person has Alzheimer's disease, problems with complex tasks appear first and over time progress to more simple activities. Treatable Causes of Dementia Sometimes the physical examination reveals a condition that can be treated. Symptoms may respond to early treatment when they are caused by: Medication (including over-the-counter drugs) Alcohol Delirium Depression Tumors Problems with the heart, lungs, or blood vessels Metabolic disorders (such as thyroid problems) Head injury Infection Vision or hearing problems Drug reactions are the most common cause of treatable symptoms. Older persons may have reactions when they take certain medications. Some medications should not be taken together. Sometimes, adjusting the dose can improve symptoms. Delirium and depression may be mistaken for or occur with Alzheimer's disease. These conditions require prompt treatment. See the inside front cover of this booklet for more information on delirium and depression. Special Tests Gathering as much information as possible will help your doctor diagnose early Alzheimer's disease while the condition is mild. You may be referred to other specialists for further testing. Some special tests can show a persons mental strengths and weaknesses and detect differences between mild, moderate, and severe impairment. Tests also can tell the difference between changes due to normal aging and those caused by Alzheimer's disease. If you go to a special doctor for these tests, he or she should return all test results to your regular family doctor. The results will help your doctor track the progress of your condition, prescribe treatment, and monitor treatment effects. Getting the Right Care When the diagnosis is Alzheimer's disease, you and your family members have serious issues to consider. Talk with your doctor about what to expect in the near future and later on, as your condition progresses. Getting help early will help ensure that you get the care that is best for you. When tests do not indicate Alzheimer's disease, but your symptoms continue or worsen, check back with your doctor. More tests may be needed. If you still have concerns, even though your doctor says you do not have Alzheimer's disease, you may want to get a second opinion. Whatever the diagnosis, followup is important Report any changes in your symptoms. Ask the doctor what followup is right for you. Your doctor should keep the results of the first round of tests for later use. After treatment of other health problems, new tests may show a change in your condition. Recognizing Alzheimer's disease in its early stages, when treatment may relieve mild symptoms, gives you time to adjust. During this time, you and your family can make financial, legal, and medical plans for the future. Coordinating Care Your health care team may include your family doctor and medical specialists such as psychiatrists or neurologists, psychologists, therapists, nurses, social workers, and counselors. They can work together to help you understand your condition, suggest memory aids, and tell you and your family about ways you can stay independent as long as possible. Talk with your doctors about activities that could be dangerous for you or others, such as driving or cooking. Explore different ways to do things. Telling Family and Friends Ask your doctor for help in telling people who need to know that you have Alzheimer's Disease members of your family, friends, and coworkers, for example. Alzheimer's Disease is stressful for you and your family. You and your caregiver will need support from others. Working together eases the stress on everyone.

BILL: This is Bill Hammond. I'm the president and founder of The Elder & Disability Law Firm in Overland Park, Kansas, and I'm here today with Peggy Tener. Peggy, we're going to talk about how to find the right nursing home and how to get good care there. Before we begin, Peggy, I'd like to have you give us a little bit of your background.

PEGGY: Okay. Well, I'm a Social Worker, and I'm a licensed Nursing Home Administrator, and I've worked for the past twelve years in the areas of acute care and primarily, long-term care, including adult day care and nursing home care.

BILL: Okay. Peggy, let's say that I've just been told that a loved one of mine needs nursing home care. Where should I begin to look? How do I even start?

PEGGY: Well, I think that the first thing is, if you're in a crisis situation when this happens, I think the best thing to do first is to rely on the professionals who are available to you. For example, discharge planners, Social Workers in the hospitals. They are there to help guide you in making these kinds of plans and arrangements. If you are not in a crisis situation, and you have some time, I would first start off with deciding what is important to you and your loved one. I would look at - is the geographic location the most important? Is there an importance in the type of unit that your loved one needs to be on; for example, an Alzheimer's unit? I would start there, deciding what you want. Then I would gather information from the resources that are available in the community. For example, through the Area Agency on Aging, the Alzheimer's Association, and other organizations such as that who would have listings of nursing homes.

BILL: Okay. If I can go back a second, Peggy, to the crisis situation, I know the folks that you mentioned - the Social Workers, discharge planners, and folks like that. I know they must be just incredibly busy. What can you reasonably expect them to do? I know they're very knowledgeable. How much time will they have, and how can you help them help you find the right place?

PEGGY: Right. You're absolutely right. Discharge planners in hospitals, especially in the way today's health care is set up, are very busy, because length of stay is so short in a hospital now. I think it is reasonable to expect them to discuss with you the options for care, primarily in the geographic area that you're looking at, and to guide you as to which of those facilities might best meet your needs. They will not go out with you and look for a nursing home, but they will guide you and even call and set up tours.

BILL: Will they tend to have to have things like listings of various facilities?

PEGGY: Yes. They will have lists, and many times, will highlight for you facilities that they have worked with and have had good contact with.

BILL: And by "good contact" you mean that they typically have had a pretty good relationship or they've had positive feedback?

PEGGY: Both. They've had positive feedback, and also have had a smooth working relationship with transfers to and from the facility.

BILL: Okay. Let's say, then, that you've got a list, and you've got maybe three or four different places on it, and it's kind of a crisis situation, once again. You don't have a lot of time. You've got this list in front of you and it's got the name and phone number of facilities that you probably know little or nothing about. What do you do?

PEGGY: I would first call and speak with the Admission Director to find out, first of all, if they have bed availability, if they have a place for your loved one. More than likely, before they answer that question, they will call themselves the nurses on the nursing station, and probably talk with the Social Worker to get information, to make sure they can meet your loved one's needs. Then they will tell you if they have availability. At that time, those facilities that you have talked to, you'll want to go tour that facility, and initially I would recommend you tour during a weekday, while the administrative staff is there, because they're the ones that can answer a lot of your questions. I also do recommend, if time permits, to go for a second tour during an off time, either an evening or a weekend, just to walk around and see how things seem to be going. Do they look smooth? Do the residents look like their needs are being met? Are they clean and well kept? Are the staff getting along and paying attention to the needs of the residents? That kind of thing - just more of an observation, because it is telling of what's going on while the boss is not there.

BILL: So you're saying that you would go out and take a business hours tour and actually have facility folks show you around and give you the overall tour, but with the understanding that there's always PR involved. So what you're saying is go back and go to the same facility - obviously the ones that you are considering - but walk in unannounced. Is that what you're saying?

PEGGY: Yes, I would.

BILL: What's a good time to do that?

PEGGY: I would say that dinner time is a good time. I think meal times tend to be one of the more hectic times at a nursing facility, so if you go in and things seem to be running relatively smoothly and people seem to be being cared for properly, at that time, I would think it would be safe to assume that at most times, people are getting their needs met.

BILL: Now, Peggy, I know that when people are dating, sometimes they can't see the flaws in each other, and then all of the sudden, you make a decision, and you start to see some things that maybe you didn't see before. Let's say that we have a situation where you've selected the nursing home, you like it. It's a nice facility, it's clean, it's odor-free, it's all those things that you talked about, and yet, inevitably, some problems might come to the fore. How do you, first of all, try to head those off to begin with. Let's start there. What do you do first to make sure your loved one gets good care?

PEGGY: I think first of all, assume when you go in that the goal of the facility is to provide great care, and that you are going to work as their partner to help them do that. So I think the first thing is to realize that they don't know your loved one. They don't know their likes and dislikes, they don't know their typical day - how they do things, and most facilities want to do a good job and want to meet your loved ones' individual preferences. I think the first thing is to get to know the staff and educate them about your loved one. Let them know what your mom likes to be called. Let them know what kind of food she likes and dislikes. What is her typical day like? If your mother, for the past forty years, has never gotten up before 10:00, they'll understand that when they go in to wake her up at 6:30, why she is not happy about it.

BILL: And in your example, is it okay for my mother to sleep in?

PEGGY: Absolutely! There is no reason, as a matter of fact, it's a goal of long-term care, in most states, to have individualized care, and to try to make a facility as home-like as possible. There are some things, obviously, you are working with a system, and to make things go smoothly in providing care for let's say, 120 people, you obviously have to have some systems in place. So for example, there might be some things with bathing days, where you get two full baths a week. However, if your mother has been an insomniac and has taken her bath at 2:00 in the morning her whole life, there really is no reason why she shouldn't be able to have her bath in the middle of the night if that's been her routine. And it will take some adjustment for the facility to adjust to that, but there's really no reason why they can't.

BILL: And you said to be sure and talk to the people. Who exactly should I be talking to? When I go to the facility, there are so many people. I don't know who to deal with.

PEGGY: I think you will get to know the administrative staff through the admission process. Definitely, you will get to know the Social Worker and Admission Coordinator. Sometimes, that's the same person. Sometimes there's two different people. You will probably also meet the Director of Nursing, and probably the Administrator through that process. When I'm talking about getting with staff and letting them know about your mom's specific preferences, I mean those people as well as the Charge Nurses, who are in charge of your mom's care during the day, evening, and night shifts. Get to know the Certified Nursing Assistants who are there five days a week during the day shift. Get to know those individuals who are spending the most time with your mom.

BILL: It seems to me that if we have gone through that process - I've taken the steps that you said - I've informed them of what Mom was like, and what-not. Is there some kind of a formal process that is supposed to put this all into play?

PEGGY: Absolutely. And that is through what is called "Care Planning." In the long-term care industry, anywhere you go, a document called a "Care Plan" is what drives the whole process of caring for your loved one. This is where a facility states what they feel your mother's needs are, what their goal is in meeting those needs, and then how they're going to meet them. The Care Plan is done initially upon admission, and then it's revised or reviewed and revised every 90 days, unless there's a change in your mom's condition, and then it's again reviewed then. But on a regular basis, assuming there's no acute incident with her health care or anything else, it would be every 90 days. At that time, the staff is required to invite the resident and/or their family members or their next of kin to participate in the care planning.

BILL: Is it important for me to be there, then, as a family member?

PEGGY: I think it's vital, because I think this is the time when you can sit with all the staff members that are involved in overseeing your mom's care. By staff members, I mean dietary, therapy, nursing, social service, activity. You can talk about all aspects of your mom's care, not just her nursing care. You can talk about any concerns that you have. You can also help guide them in deciding what interventions might work to help solve a problem, if a problem can be solved. BILL: Okay. Let's say that I've gone through this process, and I've given them the information and by the way - should I write it down? Is that helpful? PEGGY: I would keep notes of a Care Plan meeting, as to the things that were discussed, and solutions that you came up with. BILL: Okay. Let's say I've gone through and done all that, and for some reason, it doesn't seem to be working out. Who do I talk to? Where do I go? PEGGY: I think first, I would go to the department head of whatever department it is you're dealing with. If it's an issue with food and the dietary, I would go to the dietitian or the dietary manager. I would first talk to them. If that does not work, I would then follow the formal grievance process that is in place and that is explained to you upon admission. It is a required element of the admission process that the grievance procedure be explained to you upon admission so that you know, from day one, how you would go about letting the staff know of problems, and how you'd go about getting them solved. BILL: Okay. I'm sure that may vary from facility to facility, exactly how they do it, but can you give me an idea of what a typical grievance process might be? PEGGY: It would probably be involved with a meeting, initially, with the Social Worker, where they would document your grievance. I, though, would recommend putting it writing, as well as meeting with them in person. Then they have a set amount of time for them to investigate your grievance and to get back to you as to what they can do to solve the problem. If that is not satisfactory, you can go to the Administrator, or even if this is a facility with a large company overseeing it, you can go to a regional director. If that does not seem to work, I would recommend then you contact the Division of Aging in Missouri, or the Department on Aging in Kansas, and speak with them about your concerns. There are different ways to do it. The easiest way is usually to call. There's a 1-800 number in each state to call and to list a complaint regarding a facility. BILL: And then what happens at that point? Does the state actually come in and review the complaint? PEGGY: Yes, they do. They are required to come in and review the complaint. The timeliness of them going in depends on the type of complaint. If this is a complaint where someone is in immediate direct danger, or immediate neglect, then they go in right away, and they do follow up with you in writing as to the outcome of their investigation. They will not be specific in that follow up, but they will let you know if your complaint was founded or not. BILL: And would this be through the Ombudsman Program or is that a different deal? PEGGY: That's a different deal. The Ombudsman Program - there is actually an Ombudsman who can act as a liaison for you between the facility and you in working out an issue. BILL: Have you found that to be helpful in your experience? PEGGY: Yes. I have in Missouri, primarily because there is one Ombudsman to work the entire Kansas City area, and she's a very dedicated person. So it has been successful. It's one of those things where the program is as good as the person doing it. But yes, she is very helpful. However, she is one person, so many times, going through the state may be your best option. BILL: Okay, good. We spent quite a bit of time on the crisis situation, and you gave us some good advice there. Talk a little bit more about a situation where perhaps we have a progressive disease or something, and we know that nursing home placement is going to be likely, but we've got say, 6 months to look. And I'm assuming that everything else you talked about regarding the care still all remains the same, once the person is placed. PEGGY: Absolutely. BILL: So how do find a place when we've got several months to look? PEGGY: Well, it's kind of the ideal situation where you, at that time, have the time to really do some investigation, and this would be things, for example, like I said, getting lists from multiple places like the Area Agency on Aging, the Alzheimer's Association, and many other special service agencies. You then can be collecting packets of information from the facilities before you decide who you will go tour. At that time, you would tour the facilities, and then also, I would recommend, if your loved one is able, that they go in and spend a little time there. For example, maybe go in and have lunch or participate in an activity and see how they seem to like it. That's not always possible, and it's sometimes not always the best option because of the trauma of changing your living situation and having to go into a care facility. But if it is possible, and they are part of the decision-making process, I would recommend that. BILL: Peggy, you hit on something that I frequently hear, and that is complaints about the food - that it's bland. Tell us why that's often the case, and tell us if there's anything that a resident can do about that. PEGGY: Yes. Sure. I think the thing to remember is that meals are being cooked for sometimes 120 to 200 people, all with very different dietary needs, and different obvious preferences. Most meals that are made in facilities are made low sodium and they are, I would be safe to say, sometimes bland. I think the thing to remember are two things: number one is that as we get older, our taste buds lose their ability, so many times, older people tend to season their food quite a bit more than they had when they were younger. So that's one thing to remember, is that it takes more seasoning for them to taste it now. I think the other thing to remember is that if you don't have any dietary restrictions, you can have your own condiments at a facility. For example, I used to work in some facilities down in Louisiana where half the people would bring their own bottle of hot sauce to the dining room, which is not unusual down in Louisiana. But I think that you can, as long as your meeting your dietary restrictions that the doctor has put in place for you. BILL: So it's okay to have, literally, a condiment basket, that you take out and season however you want, as long as the doctor doesn't have any problem with it. PEGGY: Absolutely, and many facilities will even provide those for you. Some facilities will put condiments on each person's tray that will meet their dietary needs, so that, for example, there's not a shaker of salt sitting on a table where someone who's on a limited salt diet would use it. BILL: Right. But again, I think what you're telling me is that this is a case where if you don't feel like your needs are being met individually, you have options through the care planning process, and even speaking with the physicians. PEGGY: Absolutely, and the thing to remember, too, is that the biggest complaint is usually about texture of food. It's too soft, and that is one thing that can be dealt with at the facility level, because the food should not be overcooked. BILL: Okay. What if I have someone who's frequently losing laundry, and I think that's the other major complaint that I hear. Number one, the food is bland, and number two, my stuff keeps getting lost. How do we fix that? PEGGY: Right. Well, I think there's a couple of preventative things you can do first. Number one is that ever item, no matter what size it is, that you take into a facility, mark it with a permanent laundry marker. That is usually the biggest thing that happens, especially when someone is in a facility around a holiday or birthday time, is they will get gifts without their being marked. And again, if you think about every resident - 120 people, all with 50 items of clothing, which includes socks and underwear, that's an awful lot of laundry to go through a system in a day, or in a week, and the best way to make sure your clothes remain your clothes is to have them clearly marked with your name. If you have a common last name, put a first initial. I think the second thing is that, if family wants to, they can do the resident's laundry. It doesn't have to be done at the facility. So if the family wants to and has the ability, they can do the laundry. You just need to make sure you post a sign wherever the dirty clothes are put, usually in a closet in a hamper, that says, "Family will do laundry." BILL: Peggy, what if we have a special situation. Let's say that we have, and I'm shifting gears here, let's say that we've got someone with a progressive disease - Parkinson's, Alzheimer's, something like that - let's say, Alzheimer's because we see a lot of that in our practice. I know that all the things that we have talked about apply. Are there some special things in addition that folks with a loved one who's suffering from Alzheimer's should be looking at in trying to find the right facility? PEGGY: Absolutely. I think, first of all, they need to make sure that what their loved one has is Alzheimer's. If they haven't been through a formal diagnostic process, I would recommend doing that first, because it's vital to not assume that because Mom is forgetful or seems to be acting a little strange, that it's just Alzheimer's. There can be a number of other things going on that can be treated. So that's first. Second is, in going through that process, working with the doctor and talking about if he feels a special care unit is required, and would be beneficial. When I say a special care unit, I'd like to make sure that people who are looking for a nursing home know what really makes a special care unit. Many facilities have put doorways at the end of the hall that are locked and call it an Alzheimer's special care unit, and it's not. It's a secured unit, which is beneficial to people who may wander or leave the building, but it's not an Alzheimer's special care unit. What you want to look for is a couple of things. Number one - have they taken advantage of the education that's out there about environmental factors for Alzheimer's? Colors that they seem to respond to better. Pattern of paint on the wall, because when someone has Alzheimer's, their perception is off, and many time, they can't tell where a doorway ends and where the wall begins. So a facility might do things like paint the trim around a door a darker color than the walls so they can see. I think the second thing is that they have staff on the unit who have had special training in how to work with people with Alzheimer's, and that they have a specialized activity program going on that meets the needs of people with Alzheimer's. What I am looking for are things like very short intervals of different activities with breaks in between. Do they meet the areas of getting physical exercise, enhancing motor skills? Those are the things that are lost when you have Alzheimer's because they quit using them. Are they doing activities that are adult and age specific? We're not doing childish things. Those are the kind of things you want to look at. Are you meeting the needs of people with Alzheimer's who, for example, won't sit down? There are things you can do for people who wander all the time. For example, I had many clients who would never sit down to eat, so what I did was have the dietary department prepare meals that could be eaten while walking - finger foods, that kind of thing. I think the main philosophy you want to look at on an Alzheimer's unit is are they able to adapt their system to meet everybody's needs? Or the reverse of that, which I find very frustrating, is are they trying to force people with Alzheimer's to try to behave a certain way that fits into their system? If that's the case, then they're really not doing a good job. BILL: Okay, thanks, Peggy. One last question, and then we'll kind of wrap up here. We've gone through this process, we've talked about how to find the right facility. We've talked about how to get good care there. We've talked about dietary issues and laundry and all those types of things. The thing that I see in my practice probably more often than anything else, as an elder law attorney, and I try to counsel people on this, but I'm not sure exactly how to do it. How do you help people deal with the incredible grief and guilt that they feel at this time? PEGGY: Gosh, that is so hard to do, and many times, unfortunately, there's not a whole lot you can do other than just support them as they go through it. It's a natural thing for them to go through. I know we have worked with families where they have promised Mom and Dad they would never put them in a nursing home, and here they are faced with that, or a spouse. It's heartbreaking to sit with families and their loved one and help them do this. But I think the thing that you need to remember in working with them is to support that desire for Mom, Dad, their husband, their wife, or whoever it is, that they first of all, get the best care they need. And many times, if they need a high level of care, being at home is not getting the best care they need. I think then, also, give them permission to do what is required, and many times that's really all that's needed, is to say, "It's okay to do this because..." and lay out the facts. Mom can't get out of bed by herself any more. You have to work full time. You don't have the ability to private pay for someone to be in the home 24 hours a day. It's really just not feasible, but you can find a good place that provides good care that you're secure with, and know that Mom's being taken care of, I'm not making myself sick, and neglecting my family, which many times we see. Maybe a daughter, who is married with children at home, who works full time, and where Mom now needs 24 hour care, and she's trying to do it all and it's not working. Nobody is getting what they need then. Just let them know that you're going to be able to find a way to meet everybody's needs and to do it in a good way. BILL: Sometimes, of course, you know, professional counseling is called for. PEGGY: Absolutely. If going through the grief process really is not happening, or it's taking a long time, or they just can't get out of the guilt associated with it, I do recommend that they go see a professional to work through these issues so that they can feel secure and because the other thing to remember is that as involved family members, my personal feeling is that we are obligated to see that our family members are cared for. BILL: Great, Peggy. Thank you. I appreciate it. I'm going to stop right there. Do you have any closing comments for us? PEGGY: No. I think just the one thing is to trust your gut instinct. If you feel something is going wrong, it probably is, even though a facility or other people might be telling you, "Oh, no. This is the way we do it." If you feel it's wrong, then address it. BILL: Thank you very much. If you'd like to obtain an additional copy of this interview, or a written transcript, please call The Elder & Disability Law Firm at (913) 338-5713. Again, that's (913) 338-5713. Thank you very much.

Naomi was hopelessly lost. As she drove, absolutely nothing looked familiar. She noticed a fluttering in her stomach. She had to admit that she was in a lovely area, with large shade trees and a lovely lawn, but there were no houses where she could stop to ask directions. And the road seemed so narrow. She was starting to feel confused again. And there was nowhere to turn around. So she stopped the car and placed the gearshift into park.

Some time passed before a groundskeeper noticed the car on the golf course cart path. He called the police. A patrolman checked Naomi's identification and called her husband. The police officer then notified the state driver's licensing authority that Naomi should be retested.

Knowing when and how to take away the keys to the car is one of the most troublesome issues facing families who have a loved one with the illness. As we age, our eyesight and hearing may worsen. Depth perception plays tricks. Our reaction time slows. These elements of normal aging may interfere with our ability to drive a motor vehicle safely. For someone with Alzheimer's disease, these normal processes are complicated by additional symptoms related to the disease's effect on the brain. In fact, studies show that a person with Alzheimer's disease has twice the chance of being involved in a motor vehicle accident as a driver of the same age without the illness.

While a person in early stages of Alzheimer's disease may retain the ability to drive a motor vehicle, as the disease progresses, the time is likely to come when he or she is no longer safe behind the wheel. At the same time, the person with Alzheimer's disease will cling to whatever sense of independence he or she can.

The American Psychiatric Association says that some Alzheimer's patients with moderate impairment and all severely impaired patients pose unacceptable risks to themselves and others behind the wheel of a motor vehicle. Even those in early stages of the disease may be unable to drive even short distances safely. Depending on the individual, family members and others have a responsibility to assess the situation and, when necessary, step in and take away the keys.

Warning Signs

How do you know when to restrict driving privileges in a person with Alzheimer's disease? Trust your instincts. If you feel uncomfortable riding with him or her-or letting your children ride along-you may have unconsciously decided that the time has come. Another indicator is the person's inability to follow a recipe or perform simple household tasks. These types of activities require some of the same mental abilities necessary for safely operating a motor vehicle.

Deterioration in the ability to concentrate, as well as impairment of judgment seen in people who have Alzheimer's disease, add to the concern about such patients driving motor vehicles. According to the Alzheimer's Association, some things to watch for include the following:

1. Getting lost.

Anyone can get lost in an unfamiliar area. Those with Alzheimer's disease may become disoriented and be unable to find his or her way in familiar locales.

2. Ignoring traffic signals.

Failure to notice or obey stop signs, traffic lights or other highway markers may mean the driver didn't notice them. In addition, the driver may have lost the ability to associate the sign with its meaning. He or she may see the sign, but not know what it means.

3. Lack of judgment.

Inability to estimate the speed of oncoming traffic, deciding whether to stop for a yellow light or slide through the intersection, or becoming confused at a four-way stop sign are some examples of poor judgment while driving. Being slow to make decisions-or making poor ones-when driving can result in accidents that can harm the driver, as well as others on the road.

4. Driving too fast or too slowly.

Erratic driving at inappropriate speeds can indicate a lack of concentration, as well as poor physical coordination. It may also indicate poor judgment.

5. Anger and confusion.

You don't have to have Alzheimer's disease to experience road rage. Frustration during driving can make anyone flustered or angry. If the driver has Alzheimer's disease, however, watch for frequent occurrences of anger or confusion, as well as inappropriate or exaggerated reactions, while driving.

Taking Away the Car Keys

If your family member's ability to drive is impaired, you have a moral responsibility to take action to keep him or her off the road. However, accomplishing this goal may not be easy. Any suggestion that car keys be relinquished could be met with resistance, frustration, anger, or hostility-especially when it comes from a family member who may already be providing care by assisting with activities of daily living like bathing, dressing, and meal preparation.

Ask the Doctor

Many Alzheimer's families turn to the loved one's physician for help with the issue. Your loved one may more easily accept advice not to drive from a health care professional he or she has an established trust relationship with. For one thing, a doctor is often seen as an authority figure. For another, such a third party can discuss the situation objectively and dispassionately with less chance of offending your loved one on a personal level. Many doctors understand the need for this intervention and will be willing to comply with requests of this nature from family members. In some cases, doctors will write the words "Do Not Drive" on a prescription slip. In others, you may need to ask the doctor to file a request for re-examination of your loved one's driving abilities by the state driver's licensing authority.

Contact the State Licensing Authority

All states have a system in place to require retesting of persons with mental or physical impairments. However, state laws and re-examination processes vary. They may include medical evaluation, as well as written and road tests. Laws also vary concerning who is authorized to request re-examination. They may include police officers, judges, state's attorneys, physicians, family members, neighbors, friends, or other drivers. In some states, all older drivers must take driving tests for annual renewals. Check with your state's driver's licensing authority to see what rules and procedures exist for revoking driver's licenses for impaired drivers.

If your loved one's driver's license is ultimately revoked, he or she should get a state issued photo identification card to use for check cashing, air travel, and other uses.

Protecting Insurance Coverage

Even with a doctor's advice not to drive, or a driver's license revocation, a person with Alzheimer's may still get behind the wheel. He or she may forget that driving is no longer allowed. Or, stubbornness, anger, or frustration may encourage him or her to grab the keys and hit the road. If that happens and an accident occurs, serious consequences-beyond the risk of personal injury or death to the driver, passengers, or others-may result.

For example, although some state laws require insurance companies to honor claims involving insured motor vehicles, even if driven by an unlicensed driver, an insurance claim can be challenged. Insurance coverage may be cancelled. And future applications for motor vehicle insurance can be denied. In some states, insurance companies can cancel policies if a driver's license is revoked, regardless of whether an accident has happened or not. Should a driver without coverage become involved in a motor vehicle accident, his or her assets will be at risk from claims by accident victims for property damage or personal injury.

These issues are particularly important for an unimpaired spouse of a person with Alzheimer's disease. Insurance cancellation will jeopardize the spouse's insurability. Acceptance under a new policy may be difficult because of the spouse's older age. And the new policy may cost much more than the previous one. State insurance laws vary, and some states have regulations pertaining to such situations.

One option is for the impaired driver to exclude himself or herself from the policy, enabling the unimpaired spouse to continue insurance coverage. But if the excluded driver drives anyway, a claim for personal injury or property damage to the driver's car may not be honored to the full extent of the policy's limits. (Liability claims by others would likely be paid, however.) If that happened, the policy would most likely be canceled.

Action Steps for Family Members

Depending upon your loved one's abilities and desire to drive, regardless of driver's license status or doctor's orders, family members can take steps to prevent an impaired driver from operating the car. Here are six steps you can take: 1. Sell the car. If the car won't be driven, it makes sense to sell it. However, Americans love their cars. Some even name them the way they would name a pet dog or cat. If your loved one is attached to his or her motor vehicle, your suggestion to sell it may meet strong objection, even if the impaired driver seems to understand that driving is no longer allowed. If the loved one wants to keep the car, or is comforted by seeing it in the garage or driveway, you can disable the car so it can't be driven. 2. Hide the car keys. If the car remains in the family, someone must control access to all copies of the keys. Lock them in a safe place unknown to the impaired driver. 3. Replace the car key. If the impaired driver resists or refuses to hand over his or her set of keys, quietly replace the car key with one that looks like it, but that doesn't work in the vehicle. 4. Remove the tires. Removing the tires will disable the vehicle, but in some residential areas, parking a car on blocks is not allowed, except-perhaps-in an enclosed garage. Check with your local jurisdiction before taking this step. 5. Disable the vehicle. Ask a mechanic to show you how to disconnect the car's battery or how to disconnect the coil wire between the coil and distributor. If a spouse or other household member needs to use the car, reconnecting them is relatively easy. 6. Park the car elsewhere. Park the car down the street, around the corner, or out of sight in a neighbor's garage to make it inaccessible.

Look for Alternatives A person who has been driving for decades and who takes pride in his or her independence will likely resist attempts to restrict driving privileges. That independence is difficult to give up, especially in neighborhoods without good public transportation systems. The person may not want to burden friends or family to get where he or she wants to go. In modern American culture, driving is important. For many, it involves self-esteem and status as well as mobility. For these reasons, those who have Alzheimer's disease are unlikely to admit difficulties they are experiencing when driving. So, family members and physicians must balance the person's convenience with the safety of the driver, as well as passengers and other drivers on the road. When restricting driving privileges becomes an issue, you can ease the transition by investigating alternative methods of getting from place to place. Here are some choices you can make available to your loved one in place of a personal motor vehicle. 1. Friends and family. Are you willing to provide all or part of your loved one's transportation needs? What about other family members? If friends say, "let me know if I can do anything to help," suggest they give your loved one a ride to the grocery store, hairdresser, or doctor's appointment. You can also ask for volunteers at your place of worship. 2. Public Transportation. Gather information about bus routes, train schedules, and taxi services. See whether they offer discounts for older individuals or those with disabilities. Calculate round-trip fares from your loved one's home to frequently visited locations, such as the grocery store, doctor's office, barber shop, or library. 3. Government -funded transportation. Investigate availability of government-funded transportation for people with disabilities. Inquire about how to qualify for such programs. 4. Delivery Services. To reduce the need for trips outside the home, look for pharmacies, office supply stores, restaurants, and other businesses and organizations that deliver goods and services to the home. Find a courier service that operates in your area, or see whether a taxi service will perform that function. Look into the Meals on Wheels program in your area.

Much of the frustration and anger a person with Alzheimer's disease feels stems from difficulty with communication. Many times they can no longer express what they would like, such as needs or feelings and cannot receive or interpret information as they once could. When communicating with your loved one, allow them a significant amount of time to process the information and then time to respond to the information. We may think the person is having difficulty hearing, when in fact, they are processing the information more slowly and may need adequate time to respond.

One very successful form of communicating with a person with Alzheimer's disease is through validation. All people want their feelings validated, the person with AD is no different. Actually, they need more due to their memory loss and feelings of insecurity. Feelings are very real to them and if they are shunned and not validated, it can lead to frustration, anger and possible outbursts. Validation lets a person know they are being heard, hopefully reducing episodes of frustration and anger.

Validating someone's feelings does not necessarily mean you agree with them, it means you have heard and acknowledged what they are feeling.

For example, your loved one is asking for their parents who have been deceased for many years. You need to try to look beyond the question and determine what they are feeling; lonely, sad, abandoned or are they grieving because they miss them?

A good general response would be, "I have always loved your parents, what is your favorite memory of them? Or "Remember the great pot roast your mom cooked?"

This validates they are thinking about their parents and allows them the opportunity to reminisce. Reminiscing is very calming to them and helps with feeling secure about "who" they are. It also aides in the transition from the intense feelings to feeling more at ease. Another example: "I'm so stupid, I just can't think like I used to." Answer: "Honey, I know you are feeling angry and frustrated. I get frustrated too when I forget things. We're going to have to help each other." You have validated the feeling and at the same time have calmed them by acknowledging the feeling, and then offered support. Validating their feelings is crucial to their self-esteem!

The idea of validation of feelings deals with the feeling(s) at that moment. With short term memory loss, we have to focus on the moment at hand. The old school of thought was "reality orientation" or always bringing them back to the present. This concept can still apply depending on the individual person and their level of orientation and memory. For instance, if your loved one was asking about their parents and you responded "Oh honey, you know they have been dead now for over 20 years, they're buried in St. Andrews cemetery just outside of your hometown." This one statement could bring up many questions such as "My parents are dead?" "How did they die?" "Why can't I remember they died?" "Aren't we still living in my hometown?" In turn that can lead to feelings such as abandonment, anger, frustration, loneliness, sadness, and so on. As you can see, this response can cause anxiety and maybe even panic. Allowing them to stay in the moment and not orienting them to reality, is not only okay but almost necessary for their emotional well-being. Many times trying to orient them to reality will cause confrontation, making them defensive and wanting to "lash out." As they say, "Just go with the flow." As a caregiver, your goal is to communicate in a way that will not upset or cause your loved one to become anxious or agitated. You want them to feel as safe and secure with this situation as possible. Good communication will not only help your loved one, but may make your role as caregiver less stressful and more rewarding.

First of all, remember that it is extremely important for your loved one to take his/her prescribed medications. Not doing so could cause both physical and mental problems and could lead to the emergency room. How best to manage medication will depend on how much medication she takes, how many times a day she takes it and her ability to manage it.

If your loved one is capable of taking her medication and just needs reminders, you can purchase some devices. One of them from ALR Technologies, www.alrt.com, is inexpensive and the size of your palm. It is called the Med Reminder. It uses a beeping sound and a visual signal as a reminder to take the medication at the prescribed time, day and night.

You will find instructions on how to operate this device on the above website.

If on the other hand, your loved one is in a stage where she cannot remember to take medication, then you, or someone else, for example a nurse or family member, will need to intervene and give it to her. In the mid to later stages of Alzheimer's, you need to observe her taking medication. You should also watch her when eating, as people with Alzheimer’s disease begin to have difficulty swallowing as the disease progresses. This is a real concern for those caring for them, as caregivers need to be constantly on alert to intervene if needed. If your loved one is in a nursing home and you see that the medication is affecting her in a negative way, you may ask the nursing home to change the medication. You may need to make an appointment and let the administrator know that you observed some changes since your loved one started her medication. You can also ask to attend the next planning meeting for your loved one. By law, family members are to be informed and invited to the meetings. If the staff still doesn’t want to deal with this issue, you can call the long-term care ombudsman in your state. Ombudsmen are volunteers who have been trained to advocate for and on behalf of the residents of nursing homes. They will try to mediate between you and the facility. And remember, you know your loved one best. So trust your feelings and work with the caregivers when managing medication for your Alzheimer's patient.

Adult Day Care provides comfort, support, care, companionship and counseling for elderly or Alzheimer’s patients who require supervision during daytime hours. It offers patients the opportunity to socialize and to receive health and social services in a stimulating and supportive environment.

When you have chosen your Day Care, make sure that their license is current and do not hesitate to ask questions. Among others,

• Ask to see results of their state inspections and if there were any deficiencies, ask if they have been corrected.

• Observe if the patients are involved in activities.

• Does the staff encourage the participants to be as independent as possible?

• Ask about the staff to client ratio. For Alzheimer’s patients, the ratio should be at least one staff member for every eight patients.

• Meet the director and the staff.

• Is there a lot of staff turnover?

• What are the emergency procedures?

• Do they serve meals and how are they prepared? Do they offer food for patients of special dietary needs?

• Is there a secure outdoor area sufficient for walking and spending time outside? It can be vital for an Alzheimer’s patient to spend time outdoors in order to have a good quality of life.

• What are the hours of operation?

• How do they handle participants who wander?

• How often must the participant attend and for how long?

• How involved can I be as a family member?