Memory loss is the most well known problem associated with Alzheimer’s Disease and other dementias (ADRD). However, the decline in the ability of the brain to process visual information is also profound. Such visual changes are all but unknown to both the general public, as well as to many professional caregivers.
As long as these visual processing changes remain little known — coupled with the decaying judgment and cognitive abilities typical in dementia — navigating ADRD will remain unnecessarily painful and difficult for both care partners and patients alike. However, once understood through the lens of Habilitation Therapy, such knowledge becomes a powerful tool to improve safety, functioning, relationships, and general quality of life for everyone involved with a person with dementia.
Habilitation Therapy (HT) is a comprehensive behavioral approach to caring for people with dementia. It focuses not on what the person has lost due to their illness, but on their remaining abilities. HT creates and maintains positive emotional states in the person with dementia through the course of each day. It is considered by the Alzheimer’s Association to be a best practice for taking care of ADRD patients. (Alzheimer’s Association, 2011) Fairly simple to understand, HT can be profound in its positive impact on dementia patients and their care partners.
HT maintains that people with dementia cannot leave the reality they inhabit — care partners must meet them in that world. (Alzheimer’s Association, n.d., p. 139) This means that family and other caregivers must imagine what it is like to experience visual processing as a person with ADRD does. It is only then that the underlying causes of difficult behaviors can be understood, and methods to prevent or limit them can be developed. For example, these might include providing additional visual cues, or clarifying or eliminating confusing ones.
In general, “less is more” in the space occupied by an ADRD patient, allowing them to function better with less confusion and distraction. Organizing clutter and reducing the number of objects in a room can help them be more independent for longer. Feeling more self-sufficient improves the ADRD patient’s feelings about him- or herself, and makes life easier for care partners, too. (Alzheimer’s Association, 2011)
Changes to the Environment for Someone With Alzheimer’s
While vigilance must be maintained and approaches honed as the disease progresses, simple but vital changes to the dementia patient’s environment can make a real difference in quality of life, safety and ability to function more independently. Applying our understanding of what isn’t working right in the visual cortex of the ADRD brain is central to creating the right interventions.
Here follow some concrete examples.
Wandering. Wandering is when a person with dementia leaves a safe place where they are supposed to be, to strike out for… well, it’s sometimes hard to say where they believe they are going. They can quickly become lost and unable to return to safety; they can even die of dehydration or hypothermia. Due to confusion and panic, they may also assault someone who unwittingly frightens them. Wandering is a problem to be taken very seriously.
Due to their inability to perceive depth or dimensionality, Habilitation Therapy will use this knowledge to reduce or stop wandering behavior. When a large black floor mat is placed in front of every exit accessible to people with ADRD, often their brain interprets the mat as a bottomless pit that must be avoided. Of their own accord, they may lose interest in the doors.
People with dementia need highly contrasting colors to pick out different objects. Painting an exit door, doorknob and its surrounding wall and trim all the same color can make an exit disappear for a person with ADRD. Installing floor-to-doortop drapes on the windows – as well as over an exit door – and keeping the drapes shut can make the door seem like it’s just another window. This, too, can eliminate wandering. (Moore, 2010)
Not using the toilet. There are many reasons a person with dementia may not use the toilet when necessary. If there is a sudden decay in their toileting behavior, they should always be checked medically (for example, for a urinary tract infection). This problem can also arise when they lose the understanding of what mounting sensations to urinate or defecate mean until it is too late.
Another reason can be that they cannot find the toilet when they need to. (Alzheimer’s Association, 2011) Imagine needing to use the toilet in a bathroom with beige floor and wall tiles, and a beige sink, tub and toilet — a common decorating scheme in many homes. A man might under those conditions decide to urinate in a nearby dark brown wastebasket, because he simply cannot figure out where the toilet is. Installing a highly color-contrasting toilet seat and a wastebasket that blends into the walls can help the ADRD patient toilet more successfully and independently.
If the problem is that they can’t remember where the bathroom is, this, too, can be addressed through improved visual cues. In a household with a long hall with several rooms leading off it — including the bathroom — shut all doors except to the bathroom. Keep a bright light on in the bathroom, even during the day. Like a moth to a flame, the person with dementia might be drawn to a well-lit area when they’re wandering around the house looking for the toilet. Consider, too, hanging a sign in a strategic location that says “Mens Room” or “Ladies Room,” with a prominent arrow pointing to the right direction. (Moore, 2010)
Unprovoked assaults. “Out-of-the-blue” assault on a family member, caregiver or another dementia patient is another common issue. This can sometimes be alleviated by understanding the loss of peripheral (or side) vision that ADRD patients undergo. It is the equivalent of “sneaking up on them” to approach dementia patients from the side when they have lost their peripheral vision. Add distorted judgment from dementia, plus maybe an age-related hearing loss, and they may have no idea there is someone else nearby. Tap them on the shoulder and say “hello” to let them know you are there, and they could become so startled that they might just strike out in panic, fear or anger.
Always approach an ADRD patient from the front to get into their field of vision. (Alzheimer’s Association, n.d., p. 163) Before you get close enough to be in their personal space (where, coincidentally, they might be able to reach to hit or kick you), make sure you have their attention. Look them in the eye and greet them by their preferred name, making sure they look back at you before you get any closer. (Snow, n.d.) Remember: moods are contagious, so put a friendly look on your face and make sure you’re showing relaxed, open body language. (Alzheimer’s Association, 2011, Snow, n.d.) If they greet you back with an open and accepting look, then you have permission to stand inside arm’s length. If the person instead looks like he or she wants to hit you, well, you know better than to get any closer just then, right? (Snow, n.d.)
Habilitation Therapy requires creativity to apply to different situations; the above examples are to be considered guidelines. Each person and their environment are unique, and always require a custom approach. (Alzheimer’s Association, 2011) At this point if readers have read through all four articles so far in this series, they possess enough information to start using Habilitation’s principles immediately, if not sooner.
Alzheimer’s Association, Massachusetts/New Hampshire Chapter. (n.d.) Caring for People with Alzheimer’s Disease: A Habilitation Training Curriculum. Watertown, MA: Alzheimer’s Association.
Alzheimer’s Association, Massachusetts/New Hampshire Chapter. (August 2, 2011) Caring for People with Alzheimer’s Disease: A Habilitation Training Curriculum [Training Course]. Lawrence, MA: Alzheimer’s Association.
Alzheimer’s Association. (2011b). 2011 Alzheimer’s Disease Facts and Figures. Alzheimer’s & Dementia, Volume 7, Issue 2.
Moore, B. L. (2009) Matters of the Mind and the Heart: Meeting the Challenges of Alzheimer Care. New York: Strategic Book Publishing.
Moore, B. L. (November 20, 2010) StilMee™ Certification for Professionals: Working respectfully and effectively with people with Memory Loss [Training Course]. Burlington, MA.
Raia, P. (Fall, 2011) Habilitation Therapy in Dementia Care. Age in Action. Vol. 25, No. 4.
Snow, T. (n.d.) The Art of Caregiving. [Video] Florida: Pines Education Institute of Southwest Florida.
Bier, D. (2012). Improving Alzheimer’s and Dementia Care: Environmental Impact. Psych Central. Retrieved on December 10, 2013, from http://psychcentral.com/lib/improving-alzheimers-and-dementia-care-environmental-impact/00013182
Last reviewed: By John M. Grohol, Psy.D. on 30 Jan 2013
Published on PsychCentral.com. All rights reserved.