I recently began working with a client family of a woman in her 90s who had been living independently. Following a health care crisis, she had to move in with her daughter and son-in-law. Although the couple cared very deeply for this woman, living together in the same home and addressing all her physical and psychological needs was not a tenable long-term solution.
In this case — and it’s something we experience often with our client families — while the signs of cognitive impairment had been evident for quite some time, they had never before been addressed head-on. The crisis forced the family to quickly develop both short- and long-term plans, as well as learn how to communicate differently with her and manage her problematic behaviors.
What is “Cognitive Impairment?”
Cognitive impairment is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life. When defined as “mild,” it is considered an intermediate clinical state —between normal cognition and Dementia.
Many people immediately label all types of cognitive impairment as Alzheimer’s Disease. That is sometimes the case, but certainly not always.
Alzheimer’s Disease is the most common form of Dementia, accounting for 60-80% of cases. But Dementia is a more global term, one that describes a group of symptoms affecting memory, thinking, and social abilities severely enough to interfere with daily life. It isn’t a specific disease; several different diseases may cause Dementia.
In all situations, an appropriate diagnosis — and an appreciation of the differences among them — is helpful with overall management and with preparation for continued decline. Depending on the cause, some Dementia-like symptoms may be reversible.
Whatever the specifics, the day-to-day interactions with someone experiencing cognitive impairment can be incredibly frustrating, particularly when a loved one resists doing something that they never had a problem with before. In these cases, we encourage our caregiver clients to focus on the one thing they have control over — their approach to managing behavior.
For example, many of those with cognitive impairment resist taking their prescribed medications. This can be very serious, leading to a medical crisis such as a fall, an event that may in turn lead to hospitalization, surgery, confusion, additional medication, and a downward spiral from which a loved one may never fully recover.
Here are some recommendations for managing problematic behaviors you may experience…
#1. Simplify everything.
In the case of medications, are all of them necessary? A review of the medication panel with your loved one’s primary care physician can help with this assessment.
Would prearranging medications in a daily AM/PM pill box help, so that taking them out of individual bottles every day is not necessary?
Would a reminder system, such as leaving the medications on the dining room table or a daily call, be helpful?
#2. Develop purposeful activities and participate together in social engagements.
A loved one who previously enjoyed cooking may have stopped because alterations in their executive function skills now prohibit the planning and sequencing necessary. You can help by participating in the planning and using simple questions to limit decision making.
“Let’s have pasta and meatballs tonight for dinner. I’ll get the recipe to see what we need. Let’s go to the market together to get the items on the list. It looks like we have all we need, let’s get started. How about if you open the packages of meat and I’ll crush the garlic.”
#3. Validate the emotions you hear.
Individuals with cognitive impairment often retain memories of life events that resulted in powerful emotions. They may perseverate on an experience and bring it up repeatedly.
Instead of saying that you know all about it and have heard the story many times before, validate the emotion: provide reassurance while distracting them toward a more positive conversation.
“I know it hurt when your sister stopped talking to you for a while and that it continues to make you sad. You also have lots of fun stories about when you and your sister were little. Tell me about the mischief you used to get into.”
#4. Create predictable routines and offer choices (but only two at a time).
Establishing routines, even ones that are new, can be incredibly helpful for those with cognitive impairment.
For example, if your loved one needs assistance with dressing, he/she may be overwhelmed by the available choices in their closet. So, try selecting two outfits that are clearly segregated from the rest and suggesting that they chose between them. Ask, never command:
“We need to get going so we can get to the market before it’s too crowded. You look great in both this red and this blue outfit. Which would you like to wear?”
In all cases, remember that the way you communicate can be as important as the words themselves. For example, instead of saying, “Why didn’t you take your medication today?”, you could say, “I see your medications are still in the box for this morning. Let’s take them now. I’ll get a cup of your favorite juice.”
The journey of caring for a loved one with cognitive impairment is not an easy one. If you notice subtle changes in behavior and mood, share your observations with them. Beginning a dialogue about the topic can lead to an appropriate evaluation, diagnosis, and treatment.
Simultaneously, focus on day-to-day management and practice changing how you react and interact with your loved one. Most important, remember to laugh — often and together.