What are the practical steps for carers when handling patients with Alzheimer's disease who exhibit neuropsychiatric symptoms of dementia?

Practical Guide for Carers Managing Neuropsychiatric Symptoms in Alzheimer's Disease

When caring for someone with Alzheimer's who shows behavioral problems like agitation, aggression, anxiety, or confusion, always start with non-drug approaches first—medications should only be used when these fail or in emergencies when safety is at risk. 1

Understanding the Problem First

Before trying to fix any behavior, you need to understand what's happening:

• Write down exactly what you see: Note when the behavior happens, what was happening just before it started, how long it lasts, and what makes it better or worse 1
• Look for patterns: Does it happen at the same time each day? During certain activities like bathing or eating? When the person is tired or hungry? 1
• Check for physical problems first: Pain, infections (especially urinary tract infections), constipation, or dehydration often cause behavioral changes 2, 3
• Review all medications: Some medicines can make confusion and agitation worse, especially those that affect memory 2

The DICE Approach: Your Step-by-Step Plan

The American Geriatrics Society recommends a structured method called DICE (Describe, Investigate, Create, Evaluate) for managing these symptoms 1, 2:

Step 1: Describe the Behavior

• Keep a diary of when problems occur
• Note what triggers the behavior
• Record how severe it is and how long it lasts 1

Step 2: Investigate Possible Causes

Look for these common triggers:

• Physical discomfort: Pain, hunger, thirst, needing the toilet, being too hot or cold 2, 4
• Medical problems: Infections, medication side effects, constipation 3
• Environmental issues: Too much noise, bright lights, unfamiliar places, clutter 4
• Communication problems: The person may not understand what you're asking or can't express their needs 4

Step 3: Create a Plan

Based on what you found, try these strategies:

Daily Routine Strategies

• Keep a predictable schedule: Same times for waking up, meals, activities, and bedtime every day 2, 3
• Include physical activity: Regular exercise during the day helps with sleep and reduces agitation 3
• Use bright light in the morning: 2 hours of bright light (3,000-5,000 lux) in the morning helps prevent evening confusion and agitation 3
• Reduce stimulation at night: Keep lights dim and noise low in the evening 3

Communication Techniques

• Use a calm, gentle tone of voice 2, 4
• Give one simple instruction at a time: Instead of "Go upstairs, brush your teeth, and get ready for bed," say "Let's go upstairs" first 4
• Avoid asking open-ended questions: Instead of "What do you want to eat?" offer two choices: "Would you like chicken or fish?" 4
• Use gentle touch to reassure: A hand on the shoulder or holding hands can be calming 2, 4
• Never argue or try to reason: The person cannot process complex logic due to brain damage 4

Environmental Changes

• Remove clutter and hazards: Clear walkways, remove throw rugs, install grab bars in bathrooms 4
• Reduce noise and bright lights: Turn off the TV when not watching, use soft lighting 4
• Use memory aids: Large clocks, calendars, labels on doors and drawers with pictures 4
• Create a safe space: A comfortable chair in a quiet area where the person can retreat 4

Activity-Based Approaches

• Match activities to the person's abilities and past interests: If they loved gardening, let them sort seeds or arrange flowers 2, 5
• Break tasks into simple steps: For bathing, do one body part at a time with breaks 1
• Use the "three R's": Repeat instructions calmly, Reassure the person, and Redirect their attention to something pleasant 4

Step 4: Evaluate What Works

• Try each strategy for at least a few days before deciding if it works 1
• Keep notes on what helps and what doesn't 1
• Be flexible: What works today may not work next week as the disease progresses 2

When to Consider Medications

Only consider medications after trying non-drug approaches, or in emergencies when there's immediate danger 1, 2:

• If the person might hurt themselves or others 1
• If non-drug approaches haven't helped after consistent trying 2, 4
• Always discuss risks and benefits with the doctor—all medications for behavioral symptoms have significant side effects 2, 5

If medications are prescribed:

• Check in with the doctor within 30 days to see if they're working 2, 3
• Watch for side effects: Increased confusion, falls, drowsiness, or worsening behavior 2
• Plan to reduce or stop medications after 6 months if symptoms are stable 2, 3

Common Mistakes to Avoid

• Don't rely only on medications: They rarely work well alone and have serious risks 2, 4
• Don't ignore pain: Older adults with dementia often can't tell you they hurt, but pain causes agitation and aggression 2, 4
• Don't use harsh tones or yell: This makes behaviors worse 2, 4
• Don't give complex instructions: The person's brain cannot process multiple steps 4
• Don't assume behaviors are intentional: These are symptoms of brain damage, not deliberate actions 3

Getting Help

• Ask the doctor for referral to a dementia specialist if behaviors don't improve within 30 days of trying these approaches 2, 4
• Seek caregiver support groups: Other carers can share what works for them 1
• Consider respite care: Taking breaks prevents caregiver burnout, which can worsen the person's symptoms 1