Interventions for Alzheimer's Disease A Caregiver's Complete Reference By Ruth M. Tappen, Ed.D., R.N., F.A.A.N.

Excerpted from Chapter 7: Psychotherapeutic Strategies of Interventions for Alzheimer's Disease: A Caregiver's Complete Reference, by Ruth M. Tappen, Ed.D., R.N., F.A.A.N.

Copyright © 1997 by Health Professions Press. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

Chapter 7
Psychotherapeutic Strategies

Following the discussion in Chapter 6 of the emotional consequences of Alzheimer's disease, this chapter considers a variety of nonpharmacological psychotherapeutic interventions that have been developed or modified for people with Alzheimer's disease. The goals of the various approaches differs substantively. Some focus on control, others on easing the psychological pain, still others on keeping the person constructively occupied. Does this matter? It could matter a great deal. For example, when the goal is control of behaviors that distress others, consideration of the long-term effect on the person with Alzheimer's disease may be lacking. Rather than addressing the discomfort that led to the behavior, the intervention is focused on suppressing or prohibiting it. Consideration of techniques to facilitate communication is the fundamental process through which these interventions are accomplished.

Communication

Being able to share one's thoughts, feelings, and opinions with other people is critical to emotional well-being. This ability slowly but relentlessly declines as Alzheimer's disease progresses. Communication involves both cognitive and motor processes. The motor processes, such as movements of tongue and jaw or of air in and out of the lungs, do not seem to be much affected by Alzheimer's disease. The cognitive processes, in contrast, are profoundly affected by the disease. Supporting and enhancing use of the individual's remaining cognitive capacity and reducing the frustrations engendered by communication failures are the primary goals of the techniques described here.

Communication in the Early Stages of the Disease

Communicative difficulties appear early in the course of Alzheimer's disease, usually after memory deficits have become evident. From reports of family caregivers, the communication problems are first noted in difficulty writing a letter, finding the right word, and naming objects (Bayles & Tomoeda, 1991). Speech errors (e.g., saying "bagoon" instead of "balloon") may worsen the naming problem (Biassou et al., 1995). Production of apparently meaningless sentences (e.g., "So that makes it a make it?") or incomplete sentences, failure to understand what is read, and inability to recognize humor appear in the later stages of the disease.

The decline in ability to communicate is vividly portrayed in the results of a longitudinal (5-year) study of the changes in oral communication that occur over time (Tomoeda & Bayles, 1993). Asked to describe a Norman Rockwell picture (mother and children going off in Easter bonnets while father reads the paper, still in his bathrobe), subjects in the early stages of Alzheimer's disease used more words in their descriptions than did the controls (no cognitive impairment). The conciseness of their responses, however, was a different story. Participants with Alzheimer's disease were less concise, were more repetitive, made more incomplete statements, and conveyed fewer ideas altogether than did the controls.

As the disease progressed, verbal output diminished dramatically in the participants with Alzheimer's disease. People in the middle stages produced more incomplete statements than did those in the early or late stages. In the advanced stages there were few ideas to repeat (Tomoeda & Bayles, 1993). By the fifth year, one of the participants said only "Yeah" and "I like it" when asked to describe the picture (p. 16). In fact, the researchers believed that the participants were approaching muteness by the end of the study.

In the early stages of Alzheimer's disease the primary expressive communication problems are finding the right word and using too many pronouns with vague antecedents. The primary receptive (i.e., comprehension) problems are difficulty understanding long or very complex discussions and difficulty remaining focused on the main points rather than on secondary points. The individual with Alzheimer's disease can do much to facilitate communication. Clark and Witte (1991) suggest the person use the following types of statements to prevent communication failures:

"Would you say that again more slowly?"

"Wait a moment, I'm trying to think of the right word."

"What were we talking about? I've forgotten."

People with these relatively minor communication impairments can (and often do) use their remaining abilities to make up for their deficiencies. The following are some examples adapted from Clark and Witte (1991):

Circumlocutions: Talking around the word the person cannot think of is often sufficient to convey meaning to a perceptive listener. For example, instead of saying, "Would you turn off the television for me?," the person who has forgotten the word television can say, "Would you please turn off that noisy thing over there for me?"

Phonemic cueing: Using another word that sounds like the word needed may also suffice in some instances. For example, if the person wants to ask for a cup but cannot retrieve the word, he or she may say, "May I have that, oh, it sounds like pup, sup ... I've got it — cup." Rhyming may help the person find the word before the caregiver has figured it out.

Life experience strategy: A concrete example from one's life experience may be used to illustrate an abstract idea that the person is having difficulty explaining. For example, in order to explain despair, the person may refer back to the time the family thought their dog had been lost, describing how they missed the dog and thought they would never see it again.

These strategies can be shared with the person with Alzheimer's disease and they can be practiced.