Harvard Health Publishing January 2007

Instead of trying to bring people back to reality, caregivers are advised to empathize and establish an emotional connection.

Alzheimer’s disease is usually depicted as mainly a disease that affects memory and thinking, partly because memory lapses are so noticeable during the beginning of the disease. People in the early stages of the disease start to lose things, forget once-familiar faces, and struggle to recall recent events. Other cognitive problems soon develop, including a shortened attention span, difficulties with language, and an inability to think logically. In the later stages, people may completely lose the ability to speak. Eventually, much of what we consider conscious thought disappears.

But emotional aspects of the disease may be just as important, especially to the friends and family who serve as caregivers. On the negative side, Alzheimer’s sufferers may have feelings of anger, anxiety, depression, fear, and loneliness. On the positive side, they may feel serene and joyful, and are especially capable of “living in the moment.” Joanne Koenig Coste, an influential Alzheimer’s disease activist- turned-consultant, believes that wandering, aggression, and other behavioral changes seen in people with Alzheimer’s disease are the direct consequence of feelings that arise because of their cognitive difficulties. In her book Learning to Speak Alzheimer’s, she calls it a “disease of the emotions.”

An emphasis on the emotional life of sufferers is a major theme in the growing number of books directed at caregivers. These advice books still have practical tips on everything from financial planning to meal presentation (use bowls instead of plates) to clothing (no zippers or buttons). But they also have pointers on improving the interpersonal dynamics between caregivers and people with the disease. Coste, for example, refers often to the need for protecting and bolstering self-esteem. Frequently that means being nonjudgmental and devising ways to accommodate cognitive deficits without drawing attention to them. People with the disease seem to have strong emotional memories, even from recent events, long after they’ve lost the ability to form less emotionally charged ones. As a consequence, caregivers are urged to show affection and connect at an emotional level, even if the person can’t remember who you are.

Support for this approach comes mainly from anecdotes, personal experience, and the memoirs of Alzheimer’s patients in the early stages of the disease (they’re usually written with the help of a caregiver). Although behavioral interventions have been tested in clinical trials, there is not much in the way of rigorous scientific evidence to go on. Yet Coste and other authors and advocates are persuasive when they argue that successful navigation of the emotional needs of Alzheimer’s patients is essential to effective, humane care. How could it be otherwise?

Here is some of the advice they give:

Enter their world. People with Alzheimer’s disease sometimes have delusions; challenging these delusions may only make them feel threatened and insecure. Instead, you should acknowledge the underlying emotion and perhaps redirect their thinking. Say a patient falsely accuses someone of stealing a wallet or pocketbook. Paul Raia, director of patient care and family support for the Massachusetts chapter of the Alzheimer’s Association, says you might respond by saying “You must feel terrible that your pocketbook is missing. Let’s go look for it.” If she talks about her dead mother as if she were still alive, rather than disabuse her, you might say, “Your mother sounds like a lovely person. Tell me about her.” Sometimes entering this world means just playing along. In her book, Coste tells a wonderful story about her husband, who developed Alzheimer’s at a relatively young age, feverishly scrubbing the Teflon off a frying pan. Instead of scolding him for ruining it, she congratulated him on a fine cleaning job.

Protect their self-esteem. Caregivers are often told to break down and simplify tasks for Alzheimer’s sufferers. But if you do too much for the person, you may cause anger and frustration by making him feel more helpless and disabled than he really is. You have to consider safety, too; you can’t let him drive just because he wants to. Striking the right balance, helping and protecting without seeming to condescend or belittle, is difficult, especially as the abilities of the person change from day to day while slowly declining.

Books for caregivers

Alzheimer’s Early Stages (Hunter House Inc., 1999, 2003) by Daniel Kuhn

Learning to Speak Alzheimer’s (Houghton Mifflin, 2003) by Joanne Koenig Coste

Talking to Alzheimer’s (New Harbinger Publications, 2001) by Claudia J. Strauss

Take a leadership role. This is one of the central pieces of advice in Daniel Kuhn’s Alzheimer’s Early Stages. Someone has to start making decisions and assuming responsibility for the person with Alzheimer’s disease. Especially if that person is your parent, this change may involve an uncomfortable, volatile reversal of power. It’s yet another difficult balancing act: You must take charge while minimizing people’s disabilities and maximizing their strengths.

Don’t make them wait. A shortened attention span can make waiting even a few minutes trying for people with Alzheimer’s. They become impatient, agitated, even aggressive. Sometimes their problems with bathing, grooming, or eating are the result of waiting for a caregiver to get organized, not the activity itself.

Avoid overstimulation. With the best of intentions, caregivers often want to include loved ones in family gatherings, especially during the holidays. But many people with Alzheimer’s disease are sensitive to sound, especially several sounds at once. A raucous family event can be overwhelming. You might consider a smaller gathering with just one or two people instead. Other strategies include limiting visits to a couple of hours and setting aside time for a nap. Turning off the television and lowering the volume of music while people are talking and eating is another kindness.

Keep the person physically active. People with early disease have said that vigorous exercise seems to sharpen their thinking and settle them down emotionally. Moreover, Alzheimer’s disease and depression often go hand in hand, and numerous studies have shown that exercise is good for depression. In a study published in 2003 in the Journal of the American Medical Association, University of Washington researchers showed that exercise, combined with lessons in behavior management for caregivers, improved physical health and relieved depression in Alzheimer’s sufferers.

Sing a tune. People with Alzheimer’s disease usually remain able to enjoy music even in the later stages of the disease. Studies show that if you sing to them, they respond especially well, becoming more communicative, less aggressive, and less likely to scream. In a study published in 2003, researchers at the Karolinska Institute in Sweden found that both caregiver singing and background music had positive effects on late-stage patients. They sat up straighter, their movements became stronger and more regular, and their awareness improved. Singing by caregivers was especially effective in drawing them out.