Ask the Nurse who works with Alzheimer's and Related Dementias

To prevent further cross-talk in Blinkie’s thread, and on the request of Olives, Twickster and others… I started my own Ask the…

So a bit of back ground, Im a Registered Nurse (Registered Nerd, as well) and have been for 10 years. Before that, while in nursing school I worked as a home health aide and had some patients with Alzheimer’s Disease. Currently I work in a psychiatric hospital on the Dementia Unit. Most of our patients are too big of behaviour risk to be in regular long term care facilities. (Agression, Noisy, Elopement risks, mainly) I have worked in this position for almost 4 years, and I have also worked on a specialty dementia unit in a long term care facility. I am in Canada, and have worked in three provinces.

So, ask away… If I don’t know the answer I will either try to find it for you or admit it.

Is “elopement risk” a risk of wandering away, or a euphemism for fooling around?

Elopement is leaving, wandering away, which in a patient not dressed for weather, and not oriented to time and place, and possibly person would definitely be a danger.

“Fooling around” does happen, although its mostly “self love” shall we say. And on my floor, no patients are able to give consent, so we try to discourage things. In other situations, if patients are more capable, situations occcur with or without staff intervening.

I know several cases of people whose relatives realized weren’t well enough to care for them at home after they’d been found wandering around town; a recent case involved a man who’d started walking on the train’s tracks - he happened to be on a very long straight part when a train’s driver spotted him. The man in question used to work for the trains, people are guessing the tracks looked familiar.

Another one would mistake his sons for his brothers-in-law and try to kill them.

How often do you get patients after their relatives have had similar scares?

Well most of our patients at one time or other were wanderers. At least 80% of our new patients come to us because the Long Term Care (LTC) facility cannot handle them. Sometimes it is because of wandering/elopement, sometimes it is because of agression or other problems. Of the other 20% probably three quarters of those come from the local accute care hospital. Very few come from home, because to enter our hospital they have to be referred by a geriatric psychiatrist or another doctor. Then our floor doctor has to accept the patient. Usually the referals come through other medical personel, but occasionally we will get a patient who has been looked after at home, and a family doctor starts the process.

The ones that come to us from accute care often come in because families can’t cope any more. The patient may not be eating, may be incontinent, may be wandering.

We are a secure facility, locks on all the doors. We still have patients get out.
(TBContinued in a few minutes)

How do TIA’s relate to dementia?

I imagine as a nurse, you have a pretty good sense of who the good Alzheimers and assisted living facilities are in your area. Any tips on what signs to look for, good or bad, in a facility? (Not a psych facility.)

Thanks for starting this! I’ll be watching with interest. As part of my duties at an assisted living, nursing and rehabilitation facility, I have been assigned to give regular 1/2 hour Spanish lessons to a group of 10 dementia patients. They aren’t actually expected to retain any of the information, but I think it’s just one of those fun activities that might help boost their quality of life.

Tomorrow is my second day on the job and I am clueless. Any suggestions? Do techniques that often work with children also work with people who have dementia, or are there substantial differences? I’m sorry if that sounds really ignorant. I have zero experience.


I’m asking as someone who had a grandmother, gone now, diagnosed with Parkinson’s, in the 70’s, but , I now wonder if she also had Alzheimer’s as well, seems to fit in retrospect. Is there an overlap of the two syndromes?

I’ve gotten this question a few times and found it annoying (I work with autistic children), but: do you find the work sad or depressing? These people are on their way out, no longer have control of themselves or their actions, their personalities have deteriorated…it would strike me as a tough job.

Sorry about that, I ended up picking up overtime this evening!

We have patients that come to us because they keep leaving their nursing homes, the hospital or their own homes. (In fact, on a personal note, two of my Grandparents had dementia, and one grandfather wandered across town the morning before he died) We are better, but not perfect, at keeping them on our unit.

Enomaj, a number of TIAs can eventually lead to something called “Multi Infarct” or "Vascular " Dementia. This is slightly different than Alzhiemers, as the onset is generally more sudden, there tends to develop the following symptoms in a more step like manner than Alzheimer’s disease.
problems with recent memory,
wandering or getting lost in familiar places,
loss of bladder or bowel control (incontinence),
emotional problems such as laughing or crying inappropriately,
difficulty following instructions, and problems handling money.
It is not entirely unlike Alzheimers, but people with Alzheimers have more language problems, earlier, more apathy, short term memory loss and more bizarre behaviours (except emotional outbursts) than MID. But again with MID much depends on where the TIAs occured in the brain.

I can’t find the really good chart on line that shows the differential diagnoses for the different type of dementias.

Teaching techniques? The ones that work with kids work with everybody other than a room full of CPAs (and even with those, if done properly).

Nibblet head,

These are some of the things I suggest when looking for LTC facilities. Except for the first one, which I cannot stess enough, the rest are in no particular order, rank them on what is important to you and what is/was of importance to the family member.

  1. The first thing I would look for is staffing ratios; that is how many patients does the caregiver (Nurse, Registered Practical Nurse, Care Aide, whatever) have on a typical day.
  2. I would look for a specialized dementia unit, and hope the stff there had some training specifically on dementias. I’ve seen really good staff do poorly on a dementia unit, and vice versa.
  3. I would hope the unit is locked, and all the doors to tub rooms, laundry, utility rooms are also locked up, as are knives, shampoos and anything potentially edible. I had one patient who’s daughter could not get it through her head that the pretty little spice bottle glass vases with tissue paper flowers were not appropriate. Her mom, among others would eat them.
  4. I would look for a good recreation program, and one that did not just run 9-3 M-F. Look for recreationists who do more than paper crafts with the more capable. A regular music program is nice, but I only saw that at one private high end facility.
  5. Do the patients look well groomed? Are the men shaved daily? How often are the patients bathed in a tub or shower, besides just the morning wash. If the men often go without a shave it means the staff are busy, and the little things get left.
  6. What provisions exist at the facility for haircuts, nail care, foot care?
  7. What is the food like? Is it made on site or shipped in by a big conglomorate or industrial kitchen. One place served purree foods in sliced pucks from a long pre-prepared logs of extruded puree. Other places cook the regular food and then puree portions for the people who need them.
  8. Location. Sometimes a family member picks a great unit for Mom, but its far from her own friends in the old neighbourhood. Frequent visits mean a lot, a great facility with visitors once a month may not be better than the neighbourhood place where people drop in daily.
  9. The doctor system. Every place has a different way of handling this, make sure you understand what it is.
  10. How do they keep families informed? Are there regular multi disciplinary care conferences, where families can ask questions to the nutritionist, the recreationist, the nurses, and the pharmacist all at once?

Subjective impressions are pretty important. Do the patients look clean, happy and well cared for? My grandmother was in one of the older facilities, inconviniently located, but she had wonderful staff and always looked nice, and Dad and I were kept well informed about Grandma’s progress. I stayed with her in her room the night she died. Pretty surroundings are nice, but I would rather have big hearted staff than big rooms.


Well that sounds like a bizarre kind of recreation for Alzheimers patients, but like anything, its what you make it. I would try to incorporate as many of the senses as you can, maybe camp it up with cheap decorations, sombreros for everyone, try to teach a simple song, preferably something everyone knows the tune (Frere Jacques/Brother John does it have an equivilent?Or head and shoulders knees and toes.) have maracas the patients/clients can shake along to the tune. Serve some kind of snack, also Mexican themed perhaps, pass around some items they can touch, and remember they will fade in/out of the lesson as they are able. Maybe some of the more “with it” ones can talk about vacation memories. I know what I am mentioning requires a budget you probably don’t have but I bet in some cubbyhole the rec staff have at least some of it. Forget anyone learning anything, you can do a repeat after me thing…

Let me know how it goes, I am kind of interested. Sometimes recreation can be great in concept and not so great in the actual action, so I am rather curious about how the whole idea came about. Good luck and have fun, its your enthusiasm and attitude that will make or break the time.

Depending where the patients are in their dementia they very well might be two of age mentally and sinking. Remembering that they may have poor impulse control, need frequent redirection and so forth.

“So we are going to sing a song about … Ginger, no, ok we will take the sombrero back, its not lunch time, and that’s not food. Fred, no the table stays there, please do not move it… can somone show Fred the door. I know you like doggies, Delores, and if we have time after you can tell us about the doggie you used to have… ok lets start the song…”

There is a LOT of overlap between the two. I have several patients that are on anti-parkinsonian drugs (I.e Levodopa-carbidopa, aka sinemet) This may be because of the various medications the patients are on that can cause Parkinsonian-like tremours and symptoms as a side effect, or because what they have is more of a Parkinson-plus disease
From the wiki page on Parkinson’s Disease:

Okay, that along with “it takes a really special person to do what you do” annoy the hell out of me. (I know you are just asking, so no I’m not annoyed at you.)

Depressing, yes at times, but very few people love their job every day. I clean up a lot of feces, and that isn’t fun but I work with good people and we laugh about it.

I get hit, and I hate it. We all get hit, and try not to, but it happens. We have regular discussions about patients, the doctors are quite willing to re adjust medications and doseages if people get violent with staff. We do this every day, so we have a lot of little tricks to stay safe, and we work in teams or even three or four people with very difficult patients. We give them a sedative before we do care, or we wait until late morning if they are feisty early on. We learn what works for our patients to minimize the agression, but it happens.

I find patients who scream all day much more difficult to deal with than any other. I donlt like lots of loud discordant noise and that affects me more than agression or incontinence.

As for is it sad, because they are dying, I happen to like palliative care. Everybody is dying of something, these people are just closer (probably, but who knows?) than I am. These are often members of the greatest generation and I have to respect them for who they were. We often have our patients for months or years and learn things about their lives, and we get attatched, but because they are mentally checked out (mostly, not entirely! never say never!) sometimes saying goodbye to the shell that housed them is a relief.

No it is not an easy job but nothing worthwhile ever is. I am also paid rather well for what I do, and I have an RN job that allows me do do direct patient care with seniors in a non accute setting, which I value very much. But this job isn’t for everyone, and when I see it in a new employee’s face and behaviour I pull them aside and tell them that if they can’t hack it, really and honestly, they probably shouldn’t try. The patients deserved nurses that want to be there.

Hermano Jaime,
Hermano Jaime,
¿duerme usted,
duerme usted?

Suenan las campanas,
suenan las campanas,
din dan don,
din dan don.

I’ve also heard the second verse as “llaman a maitines,” which actually rhymes more properly, but nowadays most people don’t know what does maitines mean so that one is on its way out. It’s the first morning prayer.

We sang “Fray Felipe” in Spanish class, with the lines “¿Duermes tú?” and “Toca la campana.”

Dementia is probably my greatest fear.
So… a potentially uncomfortable question, (sorry):
If you were diagnosed with dementia, would you consider a facility like yours to be the best option?
…or would you take ‘other’ measures?

Well first off, the facility I work at is a Psychiatric Hospital, so it is never a first option. (Our joke is that our floor is for people who “flunk out of” LTC. ) Even Long Term Care is not a first option.There exist mental health teams, geriatric outreach teams, etc, that can be accessed fairly easily with referrals from a number of sources, from family doctors or social workers, other means.

I worked in homecare some 15 years ago, and for me good homecare with strong family supports is always the best, first option. Community Geriatric programs, and things like Alzheimers-Adult daycare can help families who do care for people with dementia to stay at home as long as possible.

Eventually, either problems arise of either a medical or behavioural nature, or the care level becomes to great and or the family supports are not there due to caregiver burnout, changing families or what have you, then longterm care becomes an option, and it very much depends on what is available in the local area. There are such a range of options that I cannot begin to discuss them here. The important thing is to have decent case management from the get-go so that transitioning from one level of care to the next is easier. If you are already in the system with an Alzheimers day care, then referrals become a lot easier.

It is possible to never need institutional care. The key is setting up a system early, with powers of attorney for finance and care, living wills, trusteeships, and a lot of planning. And of course caregivers need to have their needs met as well. More on that later.