# Presentation: 431258

## Levels of Personal Awareness and Alzheimer’s Disease

- Role of denial
- No awareness
- Partial awareness
- Much awareness

**Notes:**
Slide 1 - Levels of Personal Awareness and Alzheimer’s Disease— Role of denial - Denial is a term familiar to most of us. It refers to the human tendency to deny that a painful reality is occurring and act as if all is well in the face of adversity. Denial is a common psychological defense mechanism. It seems reasonable to assume that a person with Alzheimer’s disease (AD) would deny the presence or the severity of his or her symptoms. As we increase our understanding about the subjective experience of AD, we begin to know that denial is less of an issue than we might expect. Instead of denying the presence or severity of symptoms, persons with AD have varying degrees of insight into or awareness of their disease. The damage to the brain itself may be responsible for these varying degrees of awareness. Each person may experience his or her disease in ways contrary to popular thinking. Some people with AD have little or no awareness, while others may have much awareness, and still others may have awareness now and then but do not dwell upon the implications of their disease. Neuropsychologists are just beginning to understand how damage to the frontal lobe of the brain is associated with decreased personal awareness.
— No awareness - Some persons with AD seem to always forget that they are forgetful.  They have no appreciation of their limitations. They reject offers of help by others since they do not perceive any need. Getting their cooperation with respect to any need for care or oversight is virtually impossible in light of their resistance. They are not really in a state of “denial.” They simply lack insight due to impairment or damage in the brain.
— Partial awareness - Most people with AD have some awareness of their deficits, especially when they are put in situations that highlight their problems with memory and thinking. On the other hand, they may not dwell on their problems. The experience of “living in the moment” typifies their outlook. — Much awareness - Those who have a high degree of awareness about their disease appear to be the ones most prone to reactive depression. They may grieve over their past losses and worry about the future in ways that most of us can understand. Fortunately, a minority of people with AD seem acutely aware of the true nature of their cognitive impairments. 

## What’s the Fuss Over Autonomy?

- Power or right to make one’s own decisions & choose personal preferences
- Recognition of one’s values, history, personhood
- Loss of autonomy threatens well-being

**Notes:**
Slide 2 - What’s the Fuss Over Autonomy?— Power or right to make one’s own decisions and choose personal preferences - Autonomy is something that every adult is expected to exercise but AD changes one’s ability to make sound decisions independently. — Recognition of one’s values, history, personhood - Autonomy means making personal choices based on preferences made over the course of one’s life experience. — Loss of autonomy threatens well-being - To take away autonomy or have it taken away is an assault on one’s self-esteem.

## Decision-Making

- Competence is presumed unless there is evidence of inability to care for oneself or manage one’s own affairs
- Voluntary & involuntary means of ceding power
- Capacity depends on a clinical judgment
- Full versus partial capacity; not “all or nothing”
- Standards of capacity differ with associated risks

**Notes:**
Slide 3 - Decision-Making and Alzheimer’s Disease—Competence is presumed - Everyone is entitled to make decisions for oneself unless that power is voluntarily given away or if that power is taken away by court action. Competence is presumed unless there is evidence of inability to care for oneself or manage one’s own affairs.—Capacity depends on a clinical judgment - Personal ability to make sound decisions is compromised by AD but capacity is not an all or nothing proposition.
—Full versus partial capacity - Some brain functions may be impaired while others may be preserved, especially in the early stage of the disease. The capacity to comprehend, communicate, form and express a preference changes over the course of the disease.
—Standards of capacity differ with associated risks - The ability to choose between two items on a menu carries little risk compared to choosing how to make a series of financial investments. Therefore, standards of capacity must be weighed against the types of decisions being made. 

## Legal Tools to Preserve Autonomy

- Wills
- Living Wills
- Durable Powers of Attorney for Health Care & Property
- Living Trusts

**Notes:**
Slide 4 - Legal Tools to Preserve Autonomy
Several legal documents are intended to give voice to one’s wishes. These include:
—Wills - Of course, wills apply to matters after one’s death, usually in relation to distribution of one’s assets. Wills have no influence over decisions in one’s lifetime.
—Living Wills - Living wills typically apply to end-of-life decisions only and are invoked when a person has less than a six month lifespan. Living wills direct a surrogate decision maker to make certain choices about life sustaining medical decisions, except that living wills often omit language pertaining to artificial nutrition and hydration. Thus, living wills have limited use during one’s lifetime.  
—Durable Powers of Attorney for Health Care and Property - Durable powers are intended to serve the interests of a disabled person who can no longer make decisions regarding heath care and financial affairs. In advance of incapacity, one may designate an agent to make these decisions later on in the event of incapacity. Due to their broad application, Powers of Attorney are recommended over living wills. Forms are typically available in office supply stores. 
—Living Trusts - Living trusts are planning tools that aim to plan for incapacity by naming a designated agent or “trustee” to address one’s health care and financial decisions. There are tax advantages to a living trust that make it an attractive tool, especially for someone with substantial assets. 

## Telling the Diagnosis to the Person The pro side

- The right to know the truth
- Opportunity to choose/reject participation in research
- Discuss advance directives & other plans
- Explain symptoms as part of a disease
- Enable help to be solicited by the person
- Enable others to offer help

**Notes:**
Slide 5 - Telling the Diagnosis to the Person - The pro side
Decisions affecting personal autonomy are played out in a number of ways beginning with the matter of disclosing the diagnosis to the person with AD. Controversy over disclosure occasionally arises within families although the law is clear about every person’s right to access his or her confidential medical records. Arguments favoring disclosure of the diagnosis include:
—The right to know the truth—Opportunity to choose or reject participation in research — Discuss advance directives and other plans— Explain symptoms as part of a disease— Enable help to be solicited by the person— Enable others to offer help

## Telling the Diagnosis to the Person The con side

- Diagnosis imperfect & prognosis uncertain
- Treatment options are limited at present
- May lead to hopelessness, depression, or suicide
- Limited capacity to understand meaning

**Notes:**
Slide 6 - Telling the Diagnosis to the Person - The con side
On the other hand, there are some arguments for not disclosing the diagnosis to the person with AD. Although these carry some emotional weight, there is a well established consensus within the medical community and the Alzheimer’s Association that the person with AD should be told his or her diagnosis despite these potential drawbacks. The issue of disclosure is discussed in detail by ethicist Stephen Post, Ph.D., in his book, The Moral Challenge of Alzheimer’s Disease.—Diagnosis imperfect and prognosis uncertain—Treatment options are limited at present—May lead to hopelessness, depression, or suicide—Limited capacity to understand meaning

## Telling the Diagnosis to Others The pro side

- Educate others about the nature of disease, needs of person & family
- Create opportunities for others to offer help or be asked for help
- Put everyone concerned at ease in discussing the situation

**Notes:**
Slide 7 - Telling the Diagnosis to Others - The pro side
Another way that autonomy is affected relates to the issue of disclosing the diagnosis of AD to other people. This is a highly personal decision but certainly one that others may need to know eventually as symptoms of the disease become more obvious over time. However, in the early stage, there may be a desire to keep the news private. Some good reasons for sharing the news  include these possibilities:—Educate others about the nature of disease, needs of person and family—Create opportunities for others to offer help or be asked for help—Put everyone concerned at ease in discussing the situation

## Telling the Diagnosis to Others The con side

- “What they don’t know won’t hurt them”
- Negative stereotypes associated with the disease
- Risk of social isolation & other dehumanizing consequences

**Notes:**
Slide 8 - Telling the Diagnosis to Others - The con side—“What they don’t know won’t hurt them”—Negative stereotypes associated with the disease—Risk of social isolation and other dehumanizing consequences

## Driving a Car:Continue, Restrict or Stop?

- Mixed results of research studies thus far
- No clear markers for risks
- No specific public policy in most states
- Personal freedom vs. public safety
- Voluntary vs. involuntary means

**Notes:**
Slide 9 - Driving a Car : Continue, Restrict or Stop?
Driving a car is not only a practical means of getting around but a symbol of personal independence. AD often impairs brain functions that affect driving ability but sometimes those functions are spared so that driving may continue without difficulty for awhile.   
—Mixed results of research studies thus far - Results of research on the effects of AD on driving performance are not completely clear. However, virtually all studies conclude that severity of symptoms correlates with increased risk for traffic accidents. Every driver’s ability to drive safely should be assessed on an individualized basis.—No clear markers for risks - There is no definitive cognitive test or driving test yet available to accurately measure one’s risk of impaired driving ability. —No specific public policy in most states - In the state of California, every person who drives a car who is diagnosed with AD must be reported by the diagnosing physician to the state for a reassessment of driving skills. Drivers in California who reach the middle or late stage of the disease are not allowed to have their licenses renewed. In most other states, there is no specific public policy governing AD and driving. Most states address the issue of medical problems that may impair driving ability in order to protect personal and public safety. Physicians and other authorities are usually entitled under state laws to take action if there is a question about a driver’s ability to safely operate a motor vehicle.—Personal freedom vs. public safety - Weighing one’s desire to drive a motor vehicle against the public’s need for safe drivers appears to be the crux of the issue. How this dilemma is resolved remains a private matter in most states. —Voluntary vs. involuntary means - Most people with AD discontinue driving on their own for the sake of safety or will bend to the wishes of others to voluntarily quit driving. By all means, a physician should take the lead in addressing this issue in order to spare the family the hassles that often ensue. After all, the decisions to stop driving stems from the medical problem of AD and the physician is best suited to address the practical implications of the disease including driving. If persuasion alone is insufficient to keep an unsafe driver off the road, then taking action through the state department of motor vehicles to revoke one’s license may be the only alternative. Another undesirable option is to get rid of the car. 

## Handling Health Care & Financial Decisions

- Personal freedom vs. risks of exploitation & self-neglect
- Mismanagement of finances & medical compliance
- No clear markers of incapacity
- Capacity exists unless ceded voluntarily or involuntarily to another

**Notes:**
Slide 10 - Handling Health Care and Financial Decisions
Making personal decisions over one’s health and financial affairs is a personal right that is threatened by AD. Assessing when and how to intervene is difficult unless the person with AD cedes this authority on a voluntary basis. As the disease progresses, the risks of continuing to manage one’s own affairs will become more obvious to others, but in the early stage there may legitimate differences of opinion about the person’s ability to handle these affairs alone. Nevertheless, due to the person’s impaired memory and judgment, someone else must be in a position of monitoring risks and benefits. —Personal freedom vs. risks of exploitation and self-neglect—Mismanagement of finances and medical compliance—No clear markers of incapacity—Capacity exists unless ceded voluntarily or involuntarily to another

## Living Alone versus Relocation?

- Potential risks: burnt food & fire, poor diet, medication compliance, financial exploitation, neglect of hygiene, disorientation, & paranoia
- Vs. fear & upset about moving elsewhere
- Others must weigh risks & benefits
- What are the options?
- Negotiated risk

**Notes:**
Slide 11 - Living Alone vs. Relocation?
Again, the symptoms of AD may cause undue harm to the person with AD to the extent that he or she may no longer safely live alone. Potential risks include:—Burnt food and fire, poor diet, medication compliance, financial exploitation, neglect of hygiene, disorientation, and paranoia—No longer feeling secure in familiar surroundings and routine

Persons with AD typically avoid change, including relocation since this would involve a degree of planning and organization no longer permitted by the disease itself. There may be a deep fear about moving elsewhere since one’s home may seem like a comfortable and safe place.
—Others must weigh risks vs. benefits - Nevertheless, someone with AD may not fully be capable of assessing the risks and benefits of living alone versus relocation. This decision cannot be left entirely to the person with AD. Otherwise, the risks may increase and a decision may not happen until one is forced by a crisis.—What are the options? - In weighing the options regarding the living situation, issues like personal preferences, financial costs, and the commitment of other family members to provide care must be considered by the person who has taken charge in behalf of the person with AD.—Negotiated risk - The concept of “negotiated risk” refers to weighing the pros and cons of a decision and then arriving at a compromise that takes into accounts any inherent risks. For example, it is impossible to guarantee that a person with AD living alone can be safe at all times. However, if certain supports are agreed to that help minimize the dangers of living alone, then the arrangement is considered a “negotiated risk.” 

## The Basics of Good Communication

- Rules of communication between two cognitively intact persons (a 2-way street)
- When one person has AD there is no longer an even exchange
- Setting the right tone

**Notes:**
Slide 12 - The Basics of Good Communication —Communication between two cognitively intact peopleWhen two people communicate with each other, both persons share responsibility for the communication to be successful. In a sense, communication is expected to be a two-way street. Information is shared by one person, while the other person must receive the information and communicate understanding. Both people have responsibility in making sure the message is sent and understood by the other. Both exchange roles of sender and receiver. Such communication is typically done without much conscious thought by either person.
Rau (1997) states, "Communication is a broad term that includes all of the ways in which people send and receive messages. Speaking, listening, reading, writing, and gesturing or pantomime are all forms of communication. Drawing, sign language, facial expression, and body postures are other forms of communication between and among people." (p. 2). When people are cognitively intact, they can use all of these forms to communicate effectively. If one form is not working well, then a switch can be made to another form. For example, if a person is not conveying a message while speaking, then writing, pantomiming, or rephrasing might help.
The main goal of communication between two cognitively intact people is to share information through both thoughts and feelings. Content, facts, ideas, and words are all very important. In this framework of communication, much emphasis is placed on accuracy, being able to state something right the first time.
—Communication when one party has ADA person with AD has an increasingly difficult time communicating on a verbal level. With this increasing difficulty, the person with AD can no longer have an equal responsibility in how well the communication succeeds. The person with AD cannot consistently convey a message, evaluate whether a message is received, or understand the message of another person. The roles of sender and receiver can no longer be easily switched. Thus, the two-way street becomes more like a one-way street. The person who does not have AD must assume responsibility for making communication successful with a person who has AD. This calls for some creative means of listening to and talking with someone with the disease and setting aside customary means of communication.
—Setting the right toneBeing able to communicate with others is an important part of daily life. Sharing thoughts and ideas and enjoying the company of others are activities often taken for granted. These are events that bring individuals together. Such interactions give a chance to feel good about oneself and provide support to others. These interactions help to define who we are as people in relation to others and to the environment. People with AD often lose the opportunity for pleasant social interactions. Cohen and Eisdorfer (1989) state: “What becomes destructive to the patient’s relationships with other people is the inability to articulate thoughts and feelings and to be understood by others. Communication disorders. . .will significantly decrease the patient’s quality of life as they struggle unsuccessfully to interact with family and friend. Listening, talking, and watching are the primary ways in which people maintain contact with their environment.” (p. 152).

## Communication Changes over the Course of the Disease

- Early stage: Difficulty finding the right word, repetitiveness & keeping pace with others
- Middle stage: Increased difficulty with speaking correctly & comprehending language of others
- Late stage: Vocabulary reduced to a few words or phrases; increased need for nonverbal cues
- Terminal stage: Mute or occasional word/phrase

**Notes:**
Slide 13 - Communication Changes over the Course of the Disease
As AD worsens and the affected person suffers more brain damage, ability to communicate becomes increasingly impaired. Engaging in conversation, which might have been a simple task before the onset of the disease, now requires more effort. AD affects one's ability to understand and use words (aphasia). As the disease progresses, one’s vocabulary becomes more limited. The ability to process what is said also takes longer periods of time. Others must assume a more active role in compensating for such difficulties. The following is an overview of some communication challenges across the early, middle, late, and terminal stages of AD:
—Early Stage
Even in the early stages of the illness, a person with AD begins to have problems with communication. Expressive aphasia is exhibited at this stage as seen in difficulty finding a specific word, often a noun. An item may be described instead of actually using a specific word. For example, when trying to think of the word “chair,” the person might say, "I sit there, I eat my meal there, or I read there." Because of the decreased ability to think of nouns, the person might use generic words that do not carry much meaning. Words like “things” or “stuff” might be used more frequently instead of words specifying an exact idea.
The person may also begin to have difficulty with receptive aphasia. Though concrete thinking and understanding are still often intact, one might have difficulty with abstract thought. For example, the ability to understand proverbs or figures of speech might be impaired. A phrase such as "An apple a day keeps the doctor away" might prove terribly confusing. The literal meaning of words and phrases may make more sense than their figurative meaning.
Also, the memory problem may cause the person to unknowingly repeat statements or questions. Losing track of conversations may also be noticeable. Robert Davis (1989), a minister with AD writes about his communication problems early in the course of his AD:
	“In my present condition (just seven months since diagnosis) there are times when I feel normal. At other 	times I cannot follow what is going on around me; as the conversation whips too 	fast from person to person 	and before I have processed one comment, the thread has moved to another person or another topic, and I am 	lost isolated from the action—alone in a crowd. If I  press myself with greatest concentration to try to keep up, 	I  feel as though something short  circuits in my brain. At this point I become disoriented, have difficulty with 	my balance if I am  standing, my speech becomes slow, or I cannot find the right words to express myself.“	 (pp. 85-86).
—Middle Stage
By the middle stage of the disease, one's inability to communicate effectively becomes more obvious. The person might forget what he or she was talking about in the middle of a conversation. Repetitious questions and statements tend to become more frequent. On the other hand, the person may refrain from talking much out of worry or embarrassment. Initiating a conversation may be too taxing but responding to specific questions might also be limited. At this stage, the person is not always able to process strands of conversation. The person might wish to express a thought but choose the wrong words. At this stage, a person might avoid social situations. Mixing up words and thoughts is common. This "word salad" occurs as aphasia worsens. It becomes more difficult to understand what the person with AD is trying to say.
—Late Stage
In the late stage of the disease, vocabulary is often reduced to a few words or phrases. Repetition may be evident but just a few words or phrases may be repeated. A person might also repeat back what is said or echo another’s words. Comprehension decreases significantly. Nonverbal communication becomes more important, even a necessity at this point.
—Terminal Stage
In the terminal stage, the person is often mute or utters a few incomprehensible sounds. The ability to follow a simple, two-step command may be lost. When communication skills are severely impaired, it should be assumed that the person with AD can still experience emotion. Nonverbal means are perhaps the only means to connect with someone at this final stage. 

##     How is the person with dementia understanding the world?

**Notes:**
Slide 14 - How Is the Person with Dementia Understanding the World?
We are influenced by how we see and understand the world around us. How we understand ourselves, other people, and the environment also influence how we are able to communicate with others. The person with AD often has difficulty understanding and interpreting events and actions. This can greatly influence the ability to communicate with others. Several factors can influence how a person with AD communicates with others, including problems within the person, other people, and the environment.

## A Behavioral Profile

- Trigger Event
- Behavior Seen
- Interventions

- What Happened?
- How is Person Responding?
- What Can You Do?

**Notes:**
Slide 15 - A Behavioral Profile 
Trigger Event------>	What Happened?
Behavior Seen----->	How is the Person Responding?
           Interventions------>   	What Can You Do?

There is a strong link between impaired communication skills due to AD and the anxiety and agitation sometimes expressed by persons with AD. Understanding the importance of communication is the foundation for all interactions with people who have AD. The behaviors of people with AD tell us much about how they feel about themselves, how comfortable they are in a situation and environment, and how comfortable they are with others. When the person with AD displays increased anxiety or agitation, it is crucial that we look at the verbal and nonverbal messages he or she is sending. What are the behaviors telling us? 

Consider “behavior profiling” as a method to systematically identify the causes of challenging behavior. Once the causes are identified we are in a much better position to consider our approaches and responses. When assessing the behavior of someone with AD, it is important to ask several basic questions: What is the behavior? Where it is taking place? What is the time of day? Is the social situation or environment creating confusion? After this information has been collected, the final question of what communication approaches to take should be considered.

## Approaches of Others

- Unrealistic expectations
- Communication is key
-     - verbal means
-     - nonverbal means

**Notes:**
Slide 16 - The Approaches of Others—Unrealistic expectations - How you and other people approach and relate to the person with AD will influence interactions. If someone acts hurried or angry, the person with AD will notice, and it will cause a negative response. People with AD can often detect a mood or body language more quickly than they understand verbal communication. If you are acting rushed, the person with AD may sense this mood and become anxious.
Communication is key: Verbal and non-verbal means

## Emotional Stressors

- Diminished self-esteem
- Fear
- Low frustration tolerance

**Notes:**
Slide 17 - Emotional Stressors
—Diminished self-esteem - The person with dementia is often in the position of wondering where exactly he or she is, who are these other people, what can he or she do to make things turn out? It seems that some of the anxiety seen in persons with dementia is the result of not knowing how to make things come together. It seems logical that if we don’t feel mastery or a sense of control over our immediate lives that it would contribute to diminished self-esteem.
—Fear - Throughout the disease process, fear can be a strong element in the person'semotions. This fear can influence both communication and behaviors of the person with AD. A person might be afraid for many reasons: fear of not recognizing others, that nothing looks familiar, that something is awry, or that one can no longer communicate in a “normal” way. Others must constantly work to make the person with AD feel comfortable and safe. Use of hugs, hand holding, reassurance, and praise will help to calm the person and help to increase the ability to communicate. Diana Friel McGowin (1993) writes about fear based on her personal experience with AD:

“One day I stood in front of the enormous mirrored closet doors that covered one entire 	wall of my bedroom. I studied my reflection closely. I looked perfect. I looked untouched. No one could tell just by looking at me that I wasn't perfect any more. Suddenly a spasm went through me. I clasped my hands tightly over my mouth to stifle the scream that was rising from my throat and trying to spill out into the quiet room” (p. 74).

—Low frustration tolerance - The person with AD may respond with frustration or
abruptness to a new situation or when there are competing stimuli. The individual may be having problems perceiving what is going on and integrating complex information. This confusion can result in an anxious and even angry reaction. The person may not feel in control and not know how to regain it without the help of others.

## Medical Stressors

- Medications
- Pain
- Insomnia/fatigue
- Infections/illness

- Dehydration and malnutrition
- Constipation
- Poor vision
- and hearing

**Notes:**
Slide 18 - Medical Stressors
—Medications - Polypharmacy or taking many different medications can commonly be the cause of unplanned cognitive side effects. An important aspect of assessing the person with AD is to know what prescription and over-the-counter medications he or she is currently taking. Is he or she accurately following the medication regimen? What are the potential side-effects?
—Pain - Pain can go unreported because of the person's inability to communicate exactly what he or she is feeling. Discomfort, headaches, tooth decay, or joint pain can greatly affect the ability to positively interact. It is good practice to ask about the presence of pain and give Tylenol or another analgesic if there is any sign of discomfort. Decreasing pain will help the person to be more successful during interactions. You and others need to be diligent about monitoring for signs of pain and treating it right away.
—Insomnia/Fatigue - Sleep patterns of persons with AD can be highly irregular. Some people may sleep for periods of day and night. Others may sleep for short periods during the day and be awake for most of the night. The goal is to promote good sleep rituals to enable the person to sleep as normally as possible. A good balance of physical activity during daytime hours, including walking, exercise, and dancing will promote sleep throughout the night. It is also important to be exposed to adequate amounts of light during the day and then darkness at the time of sleep. Avoid encouraging persons to lay down and begin sleep early in the evening. If the sleep cycle starts later in the evening, there is less likelihood of wakefulness during the night.  Sedatives for short-term use may be helpful, but these medications are often ineffective after a month or two.
—Infections/Intercurrent Illness - If the person with AD is not feeling well from an infection or illness, interactions with others will be affected. The person could also be having difficulty with bowel and bladder, the flu, or a urinary tract infection. Also, falls, bumps, and bruises may occur yet go undetected since the person may not report an injury. Monitoring for infection or injury is a good idea, especially if there has been a sudden change in behavior. Keeping the person as healthy as possible will enhance well-being and improve interactions with others.
—Dehydration and Malnutrition - For someone with AD, sufficient intake of fluids can be poor and dehydration may occur, especially during hot weather. The person with AD may be unaware of the sensation of thirst although he or she will drink liquids if reminded or offered. Also, meal preparation may become problematic and food intake might not be adequate. A person might forget to eat or be unable to locate food and liquid. Poor intake of food and liquid will influence bowel and bladder habits. Monitoring intake of food and fluids is essential for maintaining good health.
—Constipation - If a person is constipated or if bowels become impacted, mood and behavior will be altered. Increased confusion, hallucinations, and delusions may occur. The person may feel and act uncomfortable without being able to state why. Bowel habits require close monitoring.
—Poor Vision or Hearing - It is important to make sure that the person is wearing appropriate eyeglasses and hearing aids. If the person seems to have a hearing or visual deficit despite wearing glasses and/or hearing aids, a re-evaluation for updating of prescriptions may be indicated. Persons with sensory deficits can easily misinterpret words or actions and appear more confused than usual. Routine eye and ear exams are called for to evaluate and treat any deficits. 

## Environmental Stressors

- Stimulation - too much or too little
- Physical design - helps and hindrances
- Familiarity- cues & labels

**Notes:**
Slide 19 - Environmental Stressors
—Stimulation - too much or too little—Physical design - helps and hindrances—Familiarity - cues and labels

The physical environment can often influence how the person with AD is thinking, feeling, and interacting with others. Too much or too little stimulation can have profound effects on the well-being of someone with AD. For example, if a room is crowed or noisy, anxiety and agitation may arise from the overstimulating sights and sounds. If a room is too quiet or too dark, similar responses may be seen. 

Robinson and colleagues (1988) observed that, “As people become more cognitively impaired they encounter increasing problems with negotiating the environment.” People with AD need a supportive environment. They may get lost trying to find their way to the bathroom because all the doors in the hallway look the same. Some people may be able to read and understand signs, while others may have lost that ability. It may be necessary to provide the information in different ways.” 

It is important to know what type of environment works best for each person. Some people enjoy a high level of stimulation, while others need peace and quiet. Visual cues will be increasingly important to a person prone to disorientation. Signs and labels may help the person with AD to retain a sense of connection with his or her surroundings.

## Things to Think About When You Speak   

- Make the setting free of distractions
- Gain attention, make eye contact, be aware of body language
- Provide orienting information

**Notes:**
Slide 20 - Things To Think About When You Speak
—Make the setting free of distractions - First, try to pick a setting that is free of environmental distractions. Background noise like music, a television, or loud conversations can inhibit the person with AD from focusing on what you are saying. Individuals with AD typically have difficulty sorting out competing stimuli, so decreasing distractions will facilitate communication.
—Gain attention, make eye contact and consider body position - First, set the stage for good communication. Before starting a conversation, make sure that the person with AD knows you are in the room and that you can be easily seen and heard. Use your body posture and language in intentional ways. Establish and maintain eye contact. Establishing eye contact before beginning to speak will set the mood for the conversation and will help the person to focus on the conversation. Nonverbal communication becomes more important than spoken language as AD progresses. A person with AD receives cues from the tone of your voice and body language. If you appear stressed or hurried, the person with AD will pick up on these feelings and the essence of the conversation may be lost.
—Provide orienting information - If you do not have a very close relationship with someone with AD, you probably need to re-introduce yourself at each encounter. A good introduction involves stating your name and the purpose of your encounter. This orienting information provides a context for and prepares the way for a successful interaction. It is also important to address the person by a preferred name or title. Whether to use just first name, both first and last name, or a surname will be an individual decision. If the person had a title used in earlier years (e.g., Doctor or Officer), it might be wise to use that official name. Simply ask the person about his or her preference.

People with AD often respond to the mood of a situation more than actual spoken words. For example, if you use  precise words but sound hurried or disinterested, your mood will be communicated rather than the intended message. Since it is very important to set a proper tone, you need to first convey calmness. It takes practice to sound relaxed when other things may be on your mind, but this is a necessary skill. It is also important to use humor. Smiling at and laughing with a person can set a relaxed tone. Humor that is abstract, such as sarcasm, should not be used since it may not be understood.

## Language that Works:Techniques to enhance communication

- Use short, simple sentences
- Use familiar and concrete words
- Break down tasks  into steps
- Avoid open-ended questions
- Help reduce choices

**Notes:**
Slide 21 - Language that Works - Techniques to Enhance Communication
—Use short, simple sentences - We must also think carefully about the words and structure of the sentences used in conversation. A person with AD can easily get lost if you use long sentences. As few words as possible should be used to convey a thought. There is always the risk of outpacing the person’s ability to keep up with a conversation. Be aware of the speed of your speech. Avoid using abstract thoughts as the person often understands concrete thoughts better than something that must be interpreted. Use simple words that convey as much meaning as possible, and speak in short sentences. The challenge is to simplify your ideas without talking down to the person. 
—Break down tasks - If the person with AD appears to be having trouble completing a task, try breaking the task down into a few steps. Talking someone through the steps of a task is preferred over taking over the task completely. Feeling successful and semi-independent is clearly more desirable to the person with AD than feeling helpless or dependent on others.
—Avoid open-ended questions and reduce choices - Questions that offer innumerable choices are often quite confusing to the person with AD. However, by narrowing the number of choices or possible responses to a question, the person with AD is more likely to be responsive. For example, instead of asking an open-ended question such as, “What would you like to do today?” it is best to offer a couple of specific options. 

## When You Are Having                                      Trouble Understanding

- Active listening
- Focus on word or phrase that may have meaning
- Respond to the emotional tone
- Try to stay calm and be patient
- Ask family members for clues

**Notes:**
Slide 22 - When You Are Having Trouble Understanding
—Active listening
—Focus on a word or phrase that may have meaning
—Respond to the tone
—Stay calm and be patient
—Ask family members for clues

Communication difficulties may arise when the person with AD struggles to communicate a thought or idea but the words are not easily understood by others. First, take a deep breath and give the individual your full attention. In this way, you assume the role of an active listener.  Focus on a specific word or phrase that seems to have particular meaning. You may be able to best understand the person with AD by being open to hearing the emotional tone of the communication. This may prove to be a better means of communication than the actual words being spoken.

## When You Are Having Trouble Being Understood

- Allow enough time
- Give a visual demonstration
- Evaluate complexity of task
- Change the subject if necessary

**Notes:**
Slide 23 - When You Are Having Trouble Being Understood
—Allow enough time
—Give a visual demonstration
—Evaluate the complexity of task
—Change the subject

You may wish to communicate a thought, idea, or emotion, but the person with AD may have difficulty grasping your message. The pace of the words and sentences may be too rapid. Most of us probably talk too quickly for persons with dementia, jumping from one idea to the next. One simple strategy is to slow down your pace. Another strategy is to point to the subject at hand or visually demonstrate an activity being discussed. Most tasks involve a series of steps. For example, preparing a meal involves dozens of small steps. It cannot be assumed that someone with AD can still do this task to completion. Consider breaking tasks and conversations into simpler steps, thus making the entire activity more attainable.

## Things to Avoid

- Don’t argue
- Don’t give strict orders
- Don’t be condescending
- Don’t ask questions requiring detailed responses
- Don’t talk about people in front of them
- Don’t bother asking, “Do you remember?”          in regard to recent events

**Notes:**
Slide 24 - Things To Avoid
—Don't argue - Arguing only makes a situation worse. Someone with AD no longer has the ability to be rational or logical to the same extent as in the past. Arguing is bound to lead to frustration for both parties. Do not allow yourself to get caught in an argument.
—Don’t give strict orders - Few of us like to be bossed around, and the person with AD is no exception. Gentle persuasion and limiting choices are much better ways of getting something done. State directions positively. Instead of saying "You can't go outside now," try an alternative such as, "Let's sit down here, I really could use your help right now."
—Don’t be condescending - It is a challenge to speaking slowly and in short sentences without using a condescending tone of voice. Also, an adult tone of voice and respectful words are needed. There is the risk of triggering anger if the person with AD feels that he or she is being treated like a child.
—Don’t ask questions requiring detailed responses - Answers to direct questions often require a good memory. Someone with AD may feel embarrassed or humiliated if asked questions that cannot be answered correctly. Try rephrasing questions to be more concrete and specific. For example, instead of saying "Who are the people in this photo?" say, "This must be your family." This approach allows the person to reply gracefully and without undue pressure.
—Don't talk about people in from of them - It is easy to fall into the habit of talking
about people in front of them when they can no longer communicate well. It is difficult to know how much someone with AD understands, so it is best to assume that everything can be understood.
—Don’t bother asking, “Do you remember?” - Although it certainly is useful to tap into the preserved, long-term memory of someone with AD through reminiscence, it is not worthwhile to ask questions about recent events that cannot be recalled. What is the point of testing a person’s faulty recent memory?