Alzheimer’s Symptoms and How to Manage Them

Depression and Alzheimer’s Disease

Depression is a common cause of “reversible” dementia in older adults. Depression is four times more likely to strike those over age 65 than younger individuals. It is found in 20 percent of persons with Alzheimer’s disease, in up to 50 percent of Alzheimer caregivers and in 15 percent of adults over age 65. Sadly, most people never get help for this treatable illness.

Those with Alzheimer’s disease commonly exhibit symptoms of depression in the early stages of the disease, while they are still aware. Because depression and dementia share common symptoms, the two are sometimes confused, with the result that depression often goes untreated in persons with Alzheimer’s disease. Alzheimer symptoms, however, are more progressive than the symptoms of depression and include profound memory loss. While their depression can be treated through medications, the cognitive abilities of persons with dementia will continue to decline.

Symptoms of Depression in Alzheimer’s Patients

Persons with depression may lose interest or pleasure in activities that were once fulfilling, have difficulty concentrating or experience feelings of hopelessness and worthlessness. They may exhibit such physical symptoms as changes in appetite, weight, energy and sleeping patterns.

The presence of at least four of the following symptoms over a two-week period may indicate depression:

How Do You Treat Depression in Alzheimer’s Patients?

If symptoms of depression are present, it is important for you to obtain a complete medical evaluation to rule out any other physical causes. Medications or an unrecognized disorder may cause depression. If there are no other underlying causes, consult a psychiatrist to obtain a diagnosis. Geriatric psychiatrists specialize in recognizing and treating depression in older adults.

There is no one test to identify depression. The diagnosis involves an assessment of medical history, interviews with the person with Alzheimer’s and family members and a mental status examination. Treatment for depression can include some combination of medicine, therapy, psychosocial support and activities.

Agitation in Alzheimer’s Patients

The term agitation is used to describe a large group of behaviors associated with Alzheimer’s disease. As the disease progresses, most people with Alzheimer’s experience agitation in addition to memory loss and other thinking symptoms.

Agitated Behaviors

In the early stages of the disease, people with Alzheimer’s may experience personality changes such as irritability, anxiety or depression. As the disease progresses, other symptoms may occur, including sleep disturbances, delusions (firmly held belief in things that are not real), hallucinations (seeing, hearing or feeling things that are not there), pacing, constant movement or restlessness, checking and rechecking door locks or appliances, tearing tissues, general emotional distress and uncharacteristic cursing or threatening language.

What Causes Agitation in Alzheimer’s?

Agitation may be caused by a number of different medical conditions and drug interactions or by any circumstances that worsen the person’s ability to think. Situations that may lead to agitated behavior include moving to a new residence or nursing home, other changes in the environment or caregiver arrangements, misperceived threats, or fear and fatigue resulting from trying to make sense out of a confusing world.

Treating Agitation

A person exhibiting agitated behavior should receive a thorough medical evaluation, especially when agitation comes on suddenly. The treatment of agitation depends on a careful diagnosis, determination of the possible causes and the types of agitated behavior the person is experiencing. With proper treatment and intervention, significant reduction or stabilization of the symptoms can often be achieved.

There are two distinct types of treatments for agitation: behavioral interventions and prescription medications. Behavioral treatments should be tried first. In general, steps to managing agitation include (1) identifying the behavior, (2) understanding its cause and (3) adapting the caregiving environment to remedy the situation.

Preventing Agitation

General caregiving strategies to prevent or reduce agitated behaviors include the following:

• Create a calm environment: remove stressors, triggers or danger; move person to a safer or quieter place; offer rest or privacy; limit caffeine use; provide opportunity for exercise; develop soothing rituals; and use gentle reminders.
• Avoid environmental triggers: noise, glare, insecure space and too much background distraction, including television.
• Monitor personal comfort: check for pain, hunger, thirst, constipation, full bladder, fatigue, infections and skin irritation; ensure a comfortable temperature; be sensitive to fears, misperceived threats and frustration with expressing what is wanted.
• Simplify tasks and routines.
• Allow adequate rest between stimulating events.
• Use lighting to reduce confusion and restlessness at night.

Safety Measures

• Equip doors and gates with safety locks.
• Remove guns and knives from the person’s environment.

Combativeness in Alzheimer’s Patients

When individuals with dementia are frustrated, scared or unable to communicate, they may become aggressive and even combative.

What Causes Combative Behavior in Alzheimer’s?

Combativeness can be caused by many factors including physical discomfort, environmental factors and poor communication. If the person you are caring for is exhibiting combativeness, consider the following:

Caregiving Tips

• Identify signs of frustration. Look for early signs of frustration during activities such as bathing, dressing or eating. Respond in a calm and reassuring tone.
• Don’t take the behavior personally. The person isn’t necessarily angry with you. He or she may have misunderstood the situation or be frustrated with lost abilities caused by the disease.
• Avoid teaching. Avoid elaborate explanations and arguments. Be encouraging and don’t expect the person to do more than he or she can.
• Use distractions. If the person is frustrated because he or she can’t unbutton a shirt, distract the person with another activity. After some time has passed you can return to helping the person unbutton the clothing item.
• Communicate directly with the person. Avoid expressing anger or impatience in your voice or physical action. Instead use positive, accepting expressions, such as “don’t worry” or “thank you.” Also use touch to reassure and comfort the person. For example, put your arm around the person or give him or her a kiss.
• Decrease level of danger. Assess the level of danger — for yourself and the person with Alzheimer’s. You can often avoid harm by simply stepping back and standing away from the person. If the person is headed out of the house and onto the street, be more assertive.
• Avoid using restraint or force. Unless the situation is serious, avoid physically holding or restraining the person. He or she may become more frustrated and cause personal harm.

Hallucinations and Delusions in Alzheimer’s

A hallucination is a false perception of objects or events involving the senses. When individuals Alzheimer’s disease have a hallucination, they see, hear, smell, taste or feel something that isn’t there. The person may see the face of a former friend in a curtain or may hear people talking.

If the hallucination doesn’t cause problems for you, the person or other family members, you may want to ignore it. However, if they happen continuously, consult a physician to determine if there is an underlying physical cause. Also, have the person’s eyesight and hearing checked, and make sure the person wears his or her glasses and hearing aids on a regular basis.

Use Distractions

• Suggest that you take a walk or sit in another room. Frightening hallucinations often subside in well-lit areas where other people are present.
• Try to turn the person’s attention to music, conversation or activities you enjoy together.

Incontinence and Alzheimer’s

Incontinence, a loss of bladder or bowel control, often occurs in people who have Alzheimer’s. Incontinence can be caused by:

• Medical conditions. The person may have a urinary tract infection, constipation or a prostate problem. Other illnesses, such as diabetes and stroke, and medication side effects may also trigger incontinence.
• Fear. The person may fear that an embarrassing accident may occur. This fear may cause him or her to visit the bathroom more times than necessary.
• Abrupt movement. Urine release may be caused by a sneeze, laugh or cough. Weak pelvic muscles in women can also cause uncontrollable loss of urine.
• Dehydration. Withholding fluids when a person starts to lose bladder control may compound the problem. Dehydration can create urinary tract infections that lead to incontinence.
• Diuretics. Certain beverages, such as coffee, cola and tea, may contribute to incontinence.
• Environment. The person may be having trouble finding the bathroom or getting to it in time because it is too far away.
• Clothing. Zippers and buttons on clothing could be making it difficult for the person to undress.

Ways to Help

• Providing visual cues. Signs may assist an individual in finding the bathroom. Placing colored rugs on the bathroom floor and lid covers on the toilet may help the bathroom stand out.
• Avoiding having items nearby that can be mistaken for a toilet, such as a trash can.
• Monitoring incontinence. Identify when accidents occur and plan accordingly. For example, if they happen every two hours, get the person to the bathroom before that time. To help control incontinence at night, limit the intake of liquids after dinner and in the evening.
• Removing obstacles. Make sure clothing is easy for the individual to remove. Clothing with Velcro™ may be easier for the person to remove than clothing with buttons.
• Providing reminders. Because the person with Alzheimer’s may forget to use the bathroom, you may need to remind him or her periodically. Also watch for visible cues such as restlessness or facial expressions that may indicate the person needs to use the bathroom.

Being supportive. Help the person with Alzheimer’s retain a sense of dignity despite incontinence problems. A reassuring attitude will help lessen feelings of embarrassment.

Sleeplessness and Sundowning in Alzheimer’s Patients

Sleeping problems experienced by individuals with Alzheimer’s and caregiver exhaustion are two of the most common reasons people with Alzheimer’s are eventually placed in nursing homes. Some studies indicate that as many as 20 percent of persons with Alzheimer’s will, at some point, experience periods of increased confusion, anxiety, agitation and disorientation beginning at dusk and continuing throughout the night.

While experts are not certain how or why these behaviors occur, many attribute them to late-day confusion, or “sundowning,” caused by the following factors:

To learn more about sundowning, read Caring for Alzheimer’s Patients with Sundowning Symptoms.

Tips for reducing evening agitation and nighttime sleeplessness

• Plan more active days. A person who rests most of the day is likely to be awake at night. Discourage afternoon napping and plan activities, such as taking a walk, throughout the day.
• Monitor diet. Restrict sweets and caffeine consumption to the morning hours. Serve dinner early, and offer only a light meal before bedtime.
• Seek medical advice. Physical ailments, such as bladder or incontinence problems, could be making it difficult to sleep. Your doctor may also be able to prescribe medication to help the person relax at night.
• Change sleeping arrangements. Allow the person to sleep in a different bedroom, in a favorite chair or wherever it’s most comfortable. Also, keep the room partially lit to reduce agitation that occurs when surroundings are dark or unfamiliar.

Nighttime restlessness doesn’t last forever. It typically peaks in the middle stages, then diminishes as the disease progresses. In the meantime, caregivers should make sure their home is safe and secure, especially if the person with Alzheimer’s wanders. Restrict access to certain rooms or levels by closing and locking doors, and install tall safety gates between rooms. Door sensors and motion detectors can be used to alert family members when a person is wandering.

Once the person is awake and upset, experts suggest that caregivers:

Dealing with Unpredictable Situations

People with Alzheimer’s disease can act in different and unpredictable ways. It is important to remember that the person is not acting this way on purpose. Whatever the behavior, try to identify the cause and possible solution.

Managing Wandering Patients With Dementia

An individual with Alzheimer’s disease or a related dementia is likely to become disoriented and wander at some point. Up to 67 percent of those with dementia will wander. Identifying the cause of the behavior can help eliminate or reduce its occurrence. Awareness of the problem can result in reduced injury and death.

What Is Wandering in Dementia?

Persons with dementia have varied movement patterns and trying to identify what qualifies as wandering can be difficult for a caregiver as well as for professionals. Many people with dementia do not fit the textbook definition of wandering, “To move about without a definite destination or purpose.” In fact, persons with dementia may have a definite purpose for their actions.

The working definition that best describes wandering is, “aimless or purposeful motor activity that causes a social problem such as getting lost, leaving a safe environment or intruding in inappropriate places.”