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Coping with Senile Dementia

Coping with Senile Dementia

Better Nursing Care through Understanding the World of the Demented Elderly

Takahiro Sugiyama
Director of Kawasaki Saiwai Clinic
President of Kanagawa Chapter
Alzheimer’s Association Japan

Contents

  • Four psychological stages that family caring for persons with senile dementia experience
  • Table 1 Four psychological stages that family caring for persons with senile dementia experience
  • Stage 1 Bewilderment and denial
  • Stage 2 Confusion, anger and rejection
  • Stage 3 Reconciliation or giving a definite solution to the problem
  • Stage 4 Acceptance
  • Psychological stages and understanding of senile dementia
  • The law of senile dementia
    • Law 1 The law about the disorder of memory
      • (1) Deterioration of the ability to memorize
      • (2) Impediment in recalling of the entire memory stock
      • (3) Reversed memory loss
    • Law 2 The law about the appearance intensity of the symptom
    • Law 3 The law about making oneself favorable
    • Law 4 The law about the spotted symptoms of dementia
    • Law 5 The law of emotional afterimage
    • Law 6 The law of stickling
    • Law 7 The law about the comprehension possibility of dementia

symptoms

Law 8 The law about the progress of the weakness
The principle about nursing care
Table 2 Eight Laws and One Principle for Better Understanding of senile dementia

Four psychological stages that family caring for persons with senile dementia experience

“When my mother began to show the symptom of senile dementia, I earnestly tried to teach her what, or what not to do, and sometimes I even scolded her. The more I tried to do so, the more I got confused about nursing care. At the same time she seemed to have a scared look on her face.


I didn’t want to believe that such a surefooted mother had become senile. Moreover, my husband blamed me for being a bad caregiver. I felt like I was a lot of trouble without receiving help. I felt that I wanted to die with my mother.


After I joined the Association of Families for the Demented Elderly (Alzheimer’s Association Japan), I found many others who are having similar problems. I learned the basic knowledge of nursing care from public health nurses and other supporting staff. This experience changed my mind about taking care of my mother.


When I desperately tried to correct each of my mother’s unusual speech and behavior, I felt like I was at battle with her. However, after I read “The rules for better understanding of senile dementia”, written by Dr. Sugiyama, I felt like I could understand my mother’s feelings better, and I started to apply the basic rules of nursing care while taking care of my mother.


I slowly felt more relaxed and I was able to concentrate more on taking care of her. What a wonder! Although my mother’s condition didn’t improve, I began to feel at ease in coping with the problem. As if my feelings were reflected in a mirror, her conditions admirably improved as well. Even though there are still many problems, my mother now shows a happy expression on her face, which resembles a baby or Buddha.

I hope she lives as long as possible.”

This is the story I heard from the daughter who is taking care of her mother wonderfully.

I realized from my experience of more than twenty years that people coping with senile dementia meet four psychological stages (Table 1). They eventually become veteran caregivers, while continuing daily nursing care: yet, they continually face problems such as being at the mercy of symptoms of the demented elderly. This makes the caregivers feel confused, exhausted, and hopeless.

I would like to explain four psychological stages that all caregivers will unavoidably experience.
For caregivers, looking back at their past experience objectively and also looking ahead and planning into the future will certainly be helpful for understanding where they stand now as a caretaker.
With this understanding, the supporting staff will also be able to better clarify their support to the caregiver. This will enable both parties to construct a mutually effective support system.

Table 1 Four psychological stages that family caring for

persons with senile dementia experience

Stage 1- Bewilderment and denial

At this stage, the family is bewildered by the unusual speech and behavior of the member with senile dementia and they try to deny it.
The family is not able to discuss this problem with other relatives due to embarrassment. Thus, the family struggles to find a solution to the problem and cope with their distress in isolation.

Stage 2- Confusion, anger and rejection

Since the family lacks the adequate understanding of senile dementia, they have difficulty dealing with the problem.
Consequently, they feel confused and angry, which leads them to reproach the senile family member. Due to their psychological and physical exhaustion, the family members may even reject the senile person. This is the most difficult stage for the family members. In order to overcome this stage properly, the family should actively seek the use of medical treatment or social welfare services.

Stage 3- Reconciliation

The family eventually comes to terms with the understanding that feeling irritated and getting angry at the situation is not helpful.
As a result, the family members reach a new phase of reconciliation with their own feelings.
Problems of nursing care can be mitigated at this stage even when the symptoms of the senile person have not improved.

Stage 4- Acceptance

The family’s understanding of the nature of senile dementia deepens at this stage. The family can emphasize with the senile person’s psychology and fully accept them as a natural family member..

Stage 1- Bewilderment and denial

If a parent or a grandparent of a family who has led a normal life suddenly becomes increasingly forgetful, repeats the same action, suspects wrongly of the family members, or is enable to carry out tasks that s/he could have done easily before, then the family members might become afraid of her/him with the following question in mind:
“What is happening? Is s/he going senile?”
However, if this family member has always displayed proper behavior until this point, and the other family members respected them as parents ( or grandparents), then the family members may think in the following manner:
“S/he must be in a bad mood today.”
“S/he is still healthy, so it cannot be senility. I want to deny
that s/he is becoming senile.”
“S/he is naturally obstinate. It’s just his/her idiosyncrasies that are standing out more as s/he is getting older.”
Eventually, the family members will come to a conclusion of denial that the family member is displaying symptoms of senile dementia. This period is the stage of bewilderment and denial.
In this period, it is not easy for the family to ask someone else about:
“My father is behaving a little strange. What should we do for him?”
They can visit the public health center or the Association of Families Caring for the Demented Elderly to discuss their problems. However, in many cases the family thinks that the problems will escalate as they become open about the situation. Thus, due to various hesitations at this stage, the family worries about the situation in isolation.

Stage 2- Confusion, anger and rejection

When the condition of the family member with dementia does not improve and the process of nursing care becomes more difficult for the family members, the situation will exceed the stage of bewilderment and denial. The symptoms of a dementia person will put the family into confusion because they are not certain whether the sudden outrageous speech and behavior are based on senile dementia, or whether they are carried out on purpose.
The family members’ careful explanation to make the senile member understand will have no effect. S/he will still repeat the same behavior: such as making noise all night long that will hinder other family members to sleep.
When it comes to this stage, even a kindhearted family memb e r may develop a feeling of frustration and anger and say that, “Stop it! I told you not to do it only a few minutes ago!”
Furthermore, the main care giving family will feel more isolated as s/he has to continue taking care of the senile member without witnessing any improvements. This caregiver will feel physically and mentally burned out and begin to reject the senile member:
“ I can’t take care of my mother any more. Both my family and I will break down with the way things are going.”
“Things would be so easy only if my mother weren’t here!”
This is the second stage where the family members feel confusion, anger and rejection.
At this stage the caregiver’s distress reaches its peak. It becomes the most difficult time for the family members. In addition to the daily pains, the anxieties about the future long-lasting nursing care will heavily burden the family. .
The characteristic of this second phase is that the caregivers will eventually worsen the senile person’s symptoms due to the lack of knowledge of senile dementia and the lack of assistance by other family members or community.
Even in the cases of caregivers who displayed great nursing care abilities confess that they had lapsed into the abysmal state of mind during the stage. They remember the severity of this period:
“I wanted to kill both him and myself. If it weren’t for him, my family wouldn’t have been so confused.”
Various forms of social assistance, proper understanding of senile dementia and the knowledge to cope with it, and words of gratitude and encouragement by friends and relatives are all helpful in relieving the mental stress of the caregiver.
It is also important to make various supportive circles for caregivers.

Stage 3-Reconciliation or giving a definite solution to the problem

As the plight of confusion or anger at the second stage repeats, the caregivers will get the knack of nursing care and can alleviate the confusion caused from it: though symptoms of the senile person may remain much the same:
“No matter how much I scold him, he forgets everything instantly. My words have no effect. Since there is no use of getting tired, I leave things untouched.”
“My Grandfather will calmed down more if I try to hear what he says without denial. I’ve been taking care of him as much as possible because I worry about his condition, but I feel more confused. I decided to find a definite solution to this.”
The state of things mentioned above can be applied to the third stage of reconciliation or giving a definite solution to the problem.
I make it a rule to tell the caregivers as follows:
“Put a mirror between you and the old person and see yourself in the mirror. Your state of mind or feelings is that of the old person’s. If you feel irritated, so does the old person. You should reconcile with yourself and the situation to make the burdening feeling lighter. The old person will calm down as well as you do so.”
At the same time, the caregivers will learn various techniques on nursing care by coping with the problems of the demented elderly. They can also get information through books, newspapers, care lectures given by public health centers, and at the Association of Families Caring for Demented Elderly meetings. Moreover, services and medication provided through social welfare and social institutions will motivate the caregiver to take care of the demented elderly at home instead
of placing them under the care of a hospital or an institution.
At the same time, the symptoms of senile dementia will make progress and take on diverse conditions at this stage. We often see that the caregivers relapse into a second phase of confusion, anger and rejection because of the new symptoms that surface among the senile dementia patients: though they may also feel relieved that the demented elderly no longer display their unusual behavior. After a while, the caregivers advance to the third stage again. In other words, the caregivers experience a repetitive cycle of the second and third stage. Although it depends on the symptom or duration of the senile dementia, the transition between the two stages gets better as the cycle repeats.

Stage 4-Acceptance

“I didn’t expect that my mother who had cursed at me with a stern look and shouted “Murder! Demon!” would become so meek. Now she’s becoming slow in her motion and isn’t able to swallow food. She even stopped talking. When the doctor said “she will become better tomorrow,” I couldn’t believe it.
But now I understand. She looks like a Buddha. Come to think of it, she is my mother. She raised us with difficulty. I do take care of her at home continuously as a member of the family. I’d like to attend to her until her last days, as long as I could get a visit to the doctor and nurse. I would please like to continue receiving your service.”

As the caregiver mentions above, the fourth ”Acceptance stage is where the caregivers deepen their understanding of senile dementia and learn to emphasize with the senile person’s state of mind. At the same time, they can accept the senile person as a natural member of the family. We can also call this stage “the state that accomplishes growth as a human being through hard nursing care”
At the first or second stage, the caregivers’ point of view about the demented elderly only tends to focus on their unusual behavior or the things they should not be doing. But at the fourth stage, the focus shifts to recognizing the positive capability left in the demented elderly, such as their gentle facial expressions and so on. When the caregivers come to this stage, they will notice the following:
“Nursing care for the demented elderly is akin to child care.
We are used to being exaggeratedly pleased with a baby’s smile or when they learn to do things. I really agree with the fact that the demented elderly return to being a child.”

Psychological stages and understanding of senile dementia

If the feature of the four stages is considered from a viewpoint to better understand senile dementia, qualitative changes in each stage can be seen.
The symptoms of the demented elderly can be considered the following manner:
1. The first stage – it is strange, mysterious and a far removed thing.
2. The second stage– it is the continuation of unusual and embarrassing behavior.
3. The third stage – “reconciliation or giving a definite solution to the problem” stage. This stage can be thought of as the unavoidable phenomena for having
grown old.
4. The fourth stage – “acceptance” stage. The caregivers become humane and understandable.
“I can understand the feelings of the old person who shows various symptoms. I could become senile someday, so when I think about the future, I want to take care of him with all my strength.”
The deeper the understanding of dementia, the more quality change occurs between the caregiver’s relationship with the demented elderly.
I think many people consider that relationship between a demented person and a caregiver is fixed, or the difficulty of nursing care is proportionate to the drop in the intellectual functioning indicated on the dementia scale. However, I do not think this is correct. I think that the weight of a family’s confusion caused by the condition of dementia can change according to the position of psychological stages that the caregivers experience while being influenced by a better understanding of dementia and the supportive circles of assistance. Would you not agree?
I think the basic idea of social assistance for the families coping with senile dementia should be realized in the following manner: to assist the families in passing through the first and second stage as fast as possible with the least amount of confusion, and to guide them to the third ”reconciliation” stage and finally the fourth “acceptance” stage.

The law of senile dementia

If one of the family members grows severely forgetful and repeats the same action, and is not able to recognize the family members’ faces or even his/her own house, the family members are thrown into serious confusion, because they do not understand what is happening and know how to cope with the situation. I have come to think that the symptoms of senile dementia that appear strange can be understood naturally as the speech and behavior of an old person with lower intellectual functions of memorization, comprehension, judgment, and reasoning.
To make everybody better understand, I have summarized “The Eight Major Laws and One Principle for Better Understanding of Senile Dementia”

Law 1. The law about the disorder of memory

The disorder of memory is a basic symptom of senile dementia and has three major aspects:

(1) Deterioration of the ability to memorize
(2) Impediment in recalling of the entire memory stock
(3) Reversed memory loss

If you keep these aspects in mind, you can clearly understand a great portion of senile dementia Incidentally, the first thing we have to bear in mind is that nothing can be a ”fact” if it does not remain in our memory. Even if something is true for the surrounding people, it is not true for the demented person because of their memory loss. It is important to understand that this situation can easily occur in the world of the demented elderly.

(1) Deterioration of the ability to memorize(severe forgetfulness)

The ability to instantly remember what one has seen, heard or experienced is called ‘the ability to memorize.’ If senile dementia happens to an old person, first comes the deterioration of the ability to memorize. Severe forgetfulness takes place.
Although an old person with senile dementia repeats the same thing over hundreds of times, s/he will forget it as soon as the action completed. So s/he will repeat the action to other people as if it is the first time. Even if you give them careful instructions and they reply, “Okay, I understand”, you will not feel easy. The senile person will carry out the same action again, because s/he forgets what was taught at the moment s/he replied. Your repetitive instruction is not only ineffective
but also negatively taken as, “this person is a nagging and fussy.” Preferably it is better that you do not instruct the senile demented.
Additionally, the senile person is not the only one who repeats the same actions because of forgetfulness. Have you ever worried about whether you turned off the gas, or unplugged the iron after leaving your house? You would probably return to your home to check. It is important not to think that the senile demented are abnormal, because it is natural for people to repeat their actions when they forget and worry about things.

(2) Impediment in recalling of the entire memory stock

This is the situation where the senile demented completely forgets what happened. Our memory is transitory and we forget most of the detailed things. On the other hand, big events or things considered important remain in our memory.
But if the senile dementia happens to be an old person, s/he will forget about the whole incident after experiencing it. If one of the family members asks the senile person who has come back from day care about there whereabouts, s/he might reply with a serious face, “I’ve been in the house all day long without going out.” This kind of incidents always happens because s/he loses the entire memory of participating in day care.
Soon after a meal, we often hear an old person say, “ I haven’t eaten yet. Give me some food,” or “Are you going to kill me by not making me a meal?”
Law 1 is applicable in this case. A dementia old person may show an unusual appetite during a certain period. Even if s/he just ate a meal, the feeling of hunger still remains.
Besides, s/he will forget not only the detailed contents of the meal but also the fact that s/he ate it; thus, the aforementioned reaction by the senile person. In this case it is not effective to respond, “You just ate and must not to eat anymore.
It will hurt your stomach.” The following response will be more effective: “I’m preparing a meal for you now. Please wait for a while.” or “I know you are hungry. Here’s a rice ball.”

(3) Reversed memory loss

“Reversed memory loss” means the phenomenon of losing all the accumulated old memories from the past to present.
However, the “present” of a person is a point in time of the latest remaining memory. By knowing this peculiarity, you will be able to grasp the world in which the senile person exists in and understand how to deal with it.
If a senile person reaches the stage where s/he does not recognize even the family’s member’s face anymore, the family will feel embarrassed, lamented, and finally fall into confusion and strive to call back his/her memory. But just think of a demented husband, his wife is a young woman of some thirty years old and his son is a schoolchild. So he will not accept the old woman and the grown-up son in front of him as the family members.
You can think of it like the following: Suppose that you have been sent to dozens of years into the future by a time machine, and there comes your grown-up son and he tells you that he is your son. Would you believe it? The demented person feels like this and refuses to admit the present world. Those who persistently try to persuade him/her might be considered as enemies trying to play tricks on them.
We often see that an old person with dementia becomes restless, then packs his/her belongings and leaves the house after politely saying the family, “I really appreciated your kindness. I have to go back home.” It mostly happens during the time of twilight, thus we call it the “twilight syndrome.”
You may be able to better understand the problem by thinking in the following manner: For the old person with dementia who returns to the world of thirty to forty yeas ago, the house in which s/he lives in now is somebody else’s house, because it has quite a different atmosphere compared to the old one s/he used to live in. This causes the demented person to feel like s/he has to go back to his/her own house in the evening. To such a senile person, it doesn’t work when you say, “This is your house.” It is understandable to see such a senile person go on a wild rampage if you try to stop them leave the house by locking the front door. S/he feels like, “I’ve been locked up in someone else’s house.” An important thing is to accept the feelings of the dementia old person in such a condition for a
while, and to think of the various ways to cope with the situation by saying, “Tea is ready, please have it,” “I’ve cooked the dinner, please have it,” or “ Then, I need to see you off half way.”
If you consider the psychiatric symptom called hallucination or illusion as part of the world that reflects part of the dementia old person’s experience or thinking, you may no longer view it as unusual.
By understanding this principle, you will not feel that a dementia old person’s anomalous sexual behavior is unusual either. How about giving a second thought that it is not an action of a 80- 90 year-old-man, but of a sexually active 40- 50 year-old-man?
As mentioned above, “reversed memory loss” has wide application and is indispensable in understanding the feelings of the demented elderly, and the world they live in.

Law 2. The law about the appearance intensity of the symptom

This law applies to the phase that the symptom of senile dementia appears more strongly to the people who are familiar to the dementia old person.
While a dementia old person troubles the caregiver with a severe condition of dementia, s/he may respond correctly to some cases. Therefore, a big difference arises in the understanding of senile dementia symptoms between the caregiver and the surrounding people. The senile dementia problems have occurred in many families, but only the caregivers complain and have a laborious feeling: “Although I am caring for him as hard as possible, he doesn’t thank me. He even says cruel things like, ‘you stole my things’ or ‘you do nothing for me.’ Besides, far from appreciating my efforts, the other family members rather criticize me by saying ‘you are too exaggerated.’”
We tend to judge that the symptoms of a person with dementia are not so serious, because they can respond properly during the dementia consultation or at the time they meet the visiting examiner.
The family members fall into despair and distrust because they think that even a specialist cannot recognize the real condition of senile dementia.
Why does a senile person display such nasty behaviors? I presume it as followed:
An infant nestles up to his/her mother and puts her in trouble by behaving selfish towards her, but shows more respectful and stable behavior towards his/her father or other people.
Since infants trust their mothers absolutely, they can behave selfish towards her. I suppose that dementia old persons show their symptoms more strongly to the caregivers, because they rely on the caregivers most. Am I assuming too much?
We also deal with things differently according to whether we are in our house or in front of others. We work on how to appear to others. So wouldn’t you think that it is rather unusual to think that a dementia old person’s proper behavior in front of others is unusual? I presume that you can become kind to the dementia old person when you understand that both you and they are in the same position.

Law 3.The law about making oneself favorable

This law means that the senile people do not admit being disadvantageous for themselves.
“My valuables are missing!” A person with dementia sometimes makes a fuss and shouts like this.
As the family members search all over the house together with the senile member, they finally find the item in the drawer that the senile member uses.
In this case, if the family says, “Take a look! You forgot keeping it here.
Nobody keeps it here except you!”” the senile member will surely reply, “I couldn’t have put it away in such a place.
Someone has kept it there.” The surrounding people cannot see that the elder member is suffering from senile dementia, because s/he retorts too quickly and uses difficult proverbs, etc.
However, clear errors or inconsistencies are included in the contents of the excuses, which makes the family consider the senile person as, “a person who says whatever is convenient for himself or herself.” or ”a liar.” Therefore, the family considers him/her as a person with low character and many families seem to lower the quality of care giving after this.
There must be an instinctive mechanism of self-preservation working in such a speech and action of the demented elderly.
It is natural that people try not to admit the decline or loss of one’s capability to live properly.
So do the demented elderly.
Adapting oneself to social life exactly means to control the instinct by intellectual functions such as the power of reasoning and judging.
But as for the demented elderly, their instinctive actions easily appear on the surface due to the decline of their intellectual functioning.
If you understand “the law about making oneself favorable”, you will not repeat the meaningless exchange of the conversations, or rather detrimental disputes, and you can settle the confusion sooner.
I recommend that the families who are confused by daily care, look back at the situation by asking themselves, “aren’t we caught up in the symptoms explained in this law?”

Law 4.Tbhe law aout the spotted symptoms of dementia

Even if an old woman slips into senile dementia, she does not always show unusual behavior.
“The law about the spotted symptoms of senile dementia” means the condition of senile dementia mixed with normal conditions.
Since the old person also has a very sound behavior, the family cannot easily take him/her as a dementia old person.
So the family carelessly scolds or tries to pound him/her by saying, ”why can’t you get such a thing?” How can we recognize that the speech and actions made by an old person are symptoms of senile dementia or not? One of the causes that bring about the biggest confusion to the caregivers is that they cannot distinguish the symptoms well and are caught into it.
If the family understands the symptoms of senile dementia, and copes with it properly, the confusion due to the senile dementia will almost disappear.
When the old person is showing unusual speech and behavior that are not performed by a person with common sense and is causing confusion to the surrounding people, it can be thought that the problem of dementia has started.
And to get a knack of finding a definite solution is to think that the problematic unusual speech and behavior are symptoms of senile dementia.
Just think about the illusion that things were stolen, such as ”you must have stolen my precious money.
Thief!“ The caregiver’s confusion completely differs by whether they have heard these words from a bedridden person or a person whose appearance looks normal.
But since it is unusual to cry “Thief!” towards a family member, it is a symptom of senile dementia.
By the way, the spotted symptom of senility sometimes happens to an ordinary person with no senility.
We often encounter scenes where we think, ”why on earth did that person do something so silly? Or a person who is efficient at work and shows a wonderful judgment and planning ability in the company can be treated and rejected as a “bulky burden” when at home.
As I mentioned above, if we can understand that it is not only the senile person who shows “the spotted symptoms”, but also normal people may do things similar in their daily lives, we may be able to deal with the senile person with a more open mind.

Law 5 The law of emotional afterimage

As it is shown in the first law about the disorder of memory, the demented elderly easily forgets what they have talked about, heard or done.
But their emotional world is firmly left and the emotions they feel will last long as a light reflected on their eyes remain as afterimages.
This phenomenon is called the law of emotional afterimage.
Though the facts of what is happening can not be grasped, they are left as waves of emotions.
When a family notices the symptoms of an old person and a doctor diagnoses them as dementia, the family tries teaching them using various methods, explaining in details, and admonishing and scolding them in hopes to diminish their symptoms.
But in most cases, such efforts don’t have an effect and it will even make the senility symptoms worse.
The senile elderly will forget instantly what was repeatedly explained to them (especially those from the person earnestly caring for them), and will think of the explanation as noisy, unpleasant, and dreadful.
In other words, the senile elderly does not take the caregiver as a person who is caring and worried about them.
How should we understand this? We can think that due to the decline of intellectual ability such as memory, the senile person has escaped the world in which common sense exists, and instead lives in the world that is controlled by emotions.
The animal world has a similar aspect.
Animals live in the world of the survival of the fittest, judge the object promptly whether it is an enemy or an ally, whether it can feel at ease without anxiety, and express their feelings as is.
In fact, a dementia old person is in the same state of mind.
The old person who got out of the safe and friendly world is placed in the world where s/he cannot but sharpen his/her feelings in order to live well.
The surrounding people need to handle the senile person with heartfelt sympathy in order to calm him/her down, in other words, sympathy beats persuasion in caring for the demented elderly.
Although feelings remain in the senile elderly, bad feelings are not necessarily the only emotions that remain.
It is important to take care of the old person in a way that leaves good feelings.
The old person will be able to have moderate contact with people who are kind and accepting to him/her.
At first, it might be difficult for a caregiver to say, “Thank you very much.
You are helpful.” “I know, that is so difficult.” or “That is good.” When a caregiver can say such things, we can presume that s/he is surely taking good care of the senile elderly.
Suppose that you find your old mother trying to take in wet laundry, there can be two ways to handle this.
“They haven’t dried yet! Mom, why can’t you understand? You did such an unnecessary thing!” or “Oh, Mom, thank you for your help.
I’ll do the rest.
Take a rest over there.” Your manner of speech will greatly affect the easing of nursing care.

Law 6 The law of stickling

This law represents the following features: “When a dementia old person concentrates on one thing, s/he cannot get out from it.
The more the surrounding people try to persuade them, the more they keep sticking to it.” If there is a conflict with others, we generally try to resolve it by persuasion, explanation, and sometimes ordering.
However, this way of problem solving has no effect in the world of demented elderly.
The basic means to deal with the stickling of the demented elderly are: if we know the cause of the person’s stickling, we should try to remove it: if we think that it doesn’t matter, we should allow the situation as it is: have a third person get in between for reducing the person’s adherence: think about the development to another scene: since a senile person’s life experience in the past often leads to the stickling, we can cope with it well by learning about his/her life experience.
When it comes to the attachment to money and embarrassing behavior, the family thinks that they cannot tell about it to others and get confused without knowing how to handle it.
In my experience, the demented elderly with strong attachment to money often had economically severe experiences in the past.
The following may be examples: a woman who brought up her child alone: a person who went bankrupt, or was swindled: a person who had lived alone for a long time.
Every person mentioned in the examples above has a right reason to have attachment to money or things that are indispensable for living.
A senile person who picks up anything lying on the road and brings it home based on the feeling that it should not be wasted could be thought more normal than a person who mindlessly throws away precious resources, though it may be unbearable that the house becomes a mountain full of garbage.
Let me offer some concrete examples: When I was doing the dementia consultation at the health center, which I am taking charge of (the mental health consultation for old people), a woman past middle age came for the following consultation: “When I get home, my husband comes to me and always ask me, ’where have you been till now? Did you meet a man?’ The other day, when I got home together with my son, my husband even said that I had sexual contact with my son.
I felt so ashamed.
What should I do?” I heard her talk further and realized that she had decided to keep the seal and the passbook and not give them to her husband even if he asked.
This is because his forgetfulness has become severe about a year before and he has come to lose things.
I advised her as followed: “He thought that you had taken his valuables and suspected you.
You should return the passbook and the seal to him if he asks.
Suppose he loses it, then all you need to do is get it issued again or report the change-of -seals.” She came for the dementia consultation the following month and said, “I did what you told me.
His delusion that I was having an affair completely disappeared.
Did he really have dementia?” To a dementia old person who keeps stickling, we may often need to give a temporary solution to get them out of a difficult situation or to satisfy them with false words.
As I mentioned in the second law, that is, “The law about the appearance intensity of the symptom”, a senile person shows a stable attitude to other people.
We often see that a senile person’s adherence becomes lighter when a third person is concerned.
A senile person tends to trust the people of high reliable social standing such as policemen, officials, staff members of post offices and banks, and doctors.
When a senile person keeps insisting that, “ My daughter- inlaw has drawn my pension out without permission,” the family will try to persuade him by showing the passbook and say, ”Have a look, not even a yen has been drawn out.” But the senile person will not accept it.
On the other hand, if s/he is told by a post office clerk, “Sir/Madam, the pension has been transferred rightly into your account.
Please feel relieved.” S/he will believe it without doubt and show a sign of relief.
Regrettably, although s/he feels relieved for a while, s/he will begin to worry again and go to the office because of memory loss (terrible forgetfulness).
I hope the post office clerk will give him the similar casual words so s/he can feel relieved again.
In the future aging society, dealing with senile people well should be added to the work of policemen, post office clerks, bank clerks, and medical institution staff.
It heavily burdens the family when they interrupt the action of the dementia old person who is trying to call a police or leave the house.
But if the society as a whole understands the dementia problem and learns to cope with the senile persons’ adherence, it will evidently lessen the problem of the serious dementia.
An old person’s stickling can often be dissolved by changing the scene.
Leading a topic to an old story, especially when it is about a meal or tea, may frequently work well.
Why don’t you try it? Here is a report from a family: a 92-year-old man who was taking house calls used to make noises at midnight without sleeping.
The family started to serve him light meals and he came to sleep well.
A caregiver gets exhausted by trying to manage everything.
Just change a point of view.
Leaving things as they are without coping with them can relieve nursing care.
For example, when an old person has taken out kimonos from the wardrobe and spreads them all over the room, the family will put them back into the wardrobe.
However, the senile person will immediately take them out and scatter them around again.
It will be easy to consider the situation as followed: “That’s because she couldn’t see her important kimonos, she must have been worried that they were lost.
I will leave her to do what she likes.” In some cases, an old person’s attachment to things last long, but in general, the symptom of one’s adherence continues only half a year or one year.
It might be good to think that it is a matter of patience for one year.
We tend to understand that a clean and organized environment and a well-regulated life are desirable for anyone, but for the senile persons who have become free to the restraints of social norms by the decline of the intellectual function, it must be nothing but an uncomfortable and rigid situation.
Leaving things as they are and making a habit of thinking about better nursing care will alleviate the family’s worrying.

Law 7.The law about the comprehension possibility of dementia symptoms

This law means that most of the symptoms of the demented elderly can be understood, if we stand in their shoes, thinking about the characteristics of the decline of intellectual functioning (the third stage) and the combined symptoms of senile dementia from the first to sixth law.
When night comes, a senile person may wake up and call out a family member’s name, especially that of the caregiver’s and awake them.
This is called night insomnia and it causes great trouble to the family.
Let’s try to think why such a thing happens: when dementia begins, “impaired orientation” appears and causes the senile person to lose the concept of time and place, which is one of the aspects of the declining of intellectual function.
If this happens, the senile person cannot understand where s/he is sleeping at the moment.
If at the time s/he wakes up, and everything is black, silent, and nobody is around, s/he cannot comprehend where s/he is and feels fearful.
Just imagine a scene where we are staying at a hotel and wake up in the middle of the night.
Everyone feels worried for a moment, because the surrounding atmosphere is different from our own rooms.
But after a moment, we remember staying at a hotel and feel at ease and then fall asleep again as nothing has happened.
What if, no matter how much we think, we cannot understand why we are there?: “Why on earth am I here in such a strange place?” “Has my family left me here and went elsewhere?” “Did anyone kidnap me while I was sleeping, and lock me up here?” Various ideas will come into our mind one after another and then, after several minutes we will be seized by terrifying fear.
What will we do in such a case? If nobody is there, we will probably call the name of the most reliable person and continue doing it until the person shows up.
If we are able to walk freely, we might look into all the rooms to find somebody familiar, namely, husband, wife, or children.
It is not so unusual if the persons with dementia also display the same behaviors in the condition above.
Thus, what we should do to restrain the senile person’s night wanderings will become clear by putting ourselves in their shoes.
The point is to get the dementia old persons understand that the room belongs to them and relieve their fear.
I would like to offer some tips on this as followed: keep the room and passage bright: keep the wardrobe and clothing that the senile person uses easily accessible when s/he wakes up: keep a radio or television on with suitable volume even during midnight: play a tape with the family’s voice or the person’s favorite song recorded so that s/he can listen to the various sounds..
The goal is how we can eliminate the senile person’s feelings of fear.
A well-experienced caregiver in Association of Families Caring for Demented Elderly (Alzheimer’s Association) told me that she had done the following when she had been in trouble with a senile elderly: she used to lie down next to the senile person, and held his hands while saying “Don’t worry”; by doing this, he slept without making much noise and she herself was able to take a rest too.
It is good to remember that our mothers slept with us for years when we were kids.
Just keep in mind that in order to understand the speech and behavior of the demented elderly, the experience in the past has deep relations to the present symptoms of dementia The surrounding people of the dementia old person should try to grab his/her feelings by learning about his/her life and job history.

Law 8 The law about the progress of the weakness

This law represents that the speed of aging of a dementia old person is very rapid and advances about three times faster than that of an old person without dementia.
According to the studies that followed annual mortality rate of the demented elderly group and that of the non-demented elderly group for five years (by Dr.
Kazuo Hasegawa, Director General of St.
Marianna University School of Medicine), the mortality rate of the demented elderly is 83.2 percent and is three times higher when compared with the 28.4 percent of the normal elderly.
Therefore, to the family who worries about caring for a senile dementia person over dozens of years, I explain the following: “Let’s think that a dementia old person’s aging advances by about three times faster than that of a normal old person of the same age.
If a dementia old person lives for two years, s/he will be in the same condition of having lived for six years.
About 60 percent of people have died within four years after dementia comes out.
The period of nursing care is limited.” The principle about nursing care “Understanding and respecting the world that senile persons form and trying not to make them feel the gap between their world and the actual world is the principle for nursing care.
I make it a rule to tell the caregivers who take care of the demented elderly the following: “Try to accept a senile person’s emotion, speech and action first, and then, be a great actor who can make and perform the scenario suitable for it.
This is the best way for both you and the senile person.
And a great actor sometimes has to play the villain.” Taking care of a senile person involves many difficulties and troubles at times.
A caregiver will be burdened with various troubles occurred by the family members, or social and economical matters.
To imagine yourself as an actor in such a case will at least relieve your emotional burden.
Handling a senile person in a way that s/he can feel being recognized by the surrounding people and feel secured in his/her living place will make the daily care the easiest and most skillful.
As I mentioned in “ The law of emotional afterimage”, feelings that once obtained will remain for a long time like an afterimage.
Therefore, trying to make a senile person have good feelings is the key for nursing care.
Table 2 Eight Rules and One Principle for Better Understanding of Senile Dementia Law 1- The law about the disorder of memory ・ Deterioration of the ability to memorize: severe forgetfulness such as forgetting immediately what they were told, saw, or did.
The same thing is repeated after forgetting each time.
・ Impediment in recalling of entire memory stock: forgetting the whole thing that one experienced like having eaten a meal.
・ Reversed loss of memory: to lose the accumulated memories going back to the past from present.
Law 2- The law about the appearance intensity of the symptom ・ A senility symptom comes out more strongly to the senile elderly’s more familiar person.
Law 3- The law about making oneself favorable ・ Not admitting being disadvantageous for oneself Law 4- The law about the spotted symptoms of senility ・ The symptoms that should be understood as senility is mixed with the normal behaviors.
This can be seen through from the early stages of senility to the last stage.
When an old person is doing an unusual speech or behavior that will not be done by a person with the common sense and giving the neighboring people confusion, the problem of senility is happening.
The speech and behavior that caused the confusion should be considered as the symptom of senility.
Law 5- The law of emotional afterimage ・ Although what one said, heard or carried out are instantly forgotten (deterioration of the ability to memorize), the emotion remains like an afterimage.
From the world of reason to the world of emotion.
a.
praise and appreciation b.
sympathy and sharing their feelings c.
apologizing and accepting the situation even if it is not a fact Law 6- The law of stickling ・ Adhere to one thing for a long time.
Persuasion and denial only strengthen the adherence.
・ Making a caregiver feel easy is important.
a.
keeping things as they are b.
having a third person show up c.
changing the scene d.
getting the cooperation and understanding of the community e.
taking the initiative f.
knowing the old person’s past g.
giving a definite solution to the problem by not thinking that it will last long Law 7- The law about the comprehension possibility of senile symptoms ・ All symptoms of senility can be understood and explained by the feature of the decline of the intellectual function of old age.
Law 8- The law about advance of debility ・ A person with dementia ages very rapidly and the speed of aging advances by about three times faster than that of an old person without dementia The mortality rate after four years of the normal old people is 28.4 percent, whereas that of the demented elderly reaches 83.2 percent (from the report of Emeritus Professor Hasegawa, St.
Marianna University School of Medicine).
The principle about nursing care ・ Understanding and respecting the world that the demented elderly form.
・ Try not to make them feel the gap between their world and the actual world.

Coping with Senile Dementia -Better Nursing Care through Understanding the World of the Demented Elderly- The Date of Issue: The first edition December 15, 2003 Author: Takahiro Sugiyama Publisher: Alzheimer’s Association Japan Kanagawa Chapter President: Takahiro Sugiyama Location: 〒212-0016 Grace Kawasaki 203 1-31 Minami Saiwai-cho Saiwai-ku Kawasaki-shi Japan Tel・Fax 044-522-6801 Translation from Japanese: Tatsuo Ushigome Proofreader: Kukhee Choo