Tuesday, 29 October 2013

Dear Caregivers,
This is a very informative video on Dementia and Wandering which every caregiver should watch. 
Most persons with Alzheimer's and other form of dementia wander. Such wandering can traumatize the patient and the family.  This video discusses ways in which families can try to understand what needs or restlessness makes patients wander, how to reduce wandering, and also how to be prepared to get the patients home safe and fast in case they do wander.

Monday, 28 October 2013


We all have minor problems with memory and understanding as we get older.  We forget names or take more time to figure out directions.  These problems are a normal part of aging for everyone. But some older adults develop extreme problems with remembering, understanding, or thinking. For example, they can get lost walking to the bathroom, become confused by simple tasks, forget the names of loved ones, and have trouble speaking in a logical way. These problems can be very difficult to cope with, not only for the person affected, but also for their family, friends, and other caregivers.

Delirium, which is a term meaning “sudden confusion”, refers to an abrupt, rapid change in mental function that goes well beyond the typical forgetfulness of aging.  This syndrome has also been called acute confusional state, toxic psychosis, metabolic encephalopathy, or acute organic brain syndrome.  Delirium is a result of abnormal functioning of the brain.

Many of the characteristics of delirium are the same as those for dementia.  The differences between these two conditions are described more fully later in this chapter. People with dementia are also at high risk of developing delirium, and the two conditions often occur together. Whenever the behavior or thinking of a person with dementia suddenly gets much worse, particularly if the person is sick or in hospital, the cause is likely to be delirium.

A sudden change in mental function in an older person is a serious situation that requires the attention of a healthcare professional.


Delirium usually occurs in two forms: 
  • A hyperactive form, in which patients are agitated or very vigilant, or
  • A hypoactive form in which patients are lethargic, move less than usual, and have little awareness of their surroundings.

Often, doctors and nurses in hospital are not aware that an older patient is suffering from delirium because the patient becomes less active (hypoactive), rather than more restless (hyperactive). Sometimes, the hyperactive and hypoactive forms switch fairly quickly, so that a delirious person cycles between lethargy and agitation within a single day.

Delirium occurs frequently especially in older people.  Hospital records show that one-third of older adults arriving at emergency departments are delirious.  For older people living at home, the risk increases with age.

For older adults in hospital, delirium is one of the most common complications of medical illness or recovery from surgery.  Approximately one-third of patients over age 70 who are admitted to the hospital experience delirium, and about two-thirds of older people experience delirium after surgery.

Delirium is present in half of hospital patients transferred to a nursing home, and about two-thirds of patients who are residents of nursing homes. About 80% of people suffer from delirium at the end of life.

Healthcare professionals still don't completely understand what makes a person delirious, but many factors are probably involved, and some causes are now known.  Generally, people who become delirious already have some type of illness, and are exposed to some additional injury or environmental trigger. For example, if a patient already has dementia, then a relatively minor injury or upset—such as a single dose of a new medication or a change in residence—may bring on delirium.

In fact, dementia is the most common risk factor for delirium, and two-thirds of cases of delirium occur in patients who already have dementia. In other patients who aren’t as vulnerable, delirium may develop only after several factors have occurred together, such as general anesthesia, major surgery, and psychiatric medications.

Addressing just one contributing factor is unlikely to resolve delirium in an older person; they should all be addressed when possible. A key goal for the healthcare professional is to find as many causes as he or she can identify and correct those that are reversible.

Reversible causes of delirium are outlined by the following acronym (DELIRIUM): 
  • Drugs, including any new medications, increased dosages, drug interactions, over-the-counter drugs, alcohol, etc. 
  • Electrolyte disturbances, especially dehydration, and thyroid problems. 
  • Lack of drugs, such as when long-term sedatives (including alcohol and sleeping pills) are stopped, or when pain drugs are not being given adequately. 
  • Infection, especially urinary or respiratory tract infection. 
  • Reduced sensory input, which happens when vision or hearing are poor. 
  • Intracranial (referring to processes within the skull) such as a brain infection, hemorrhage, stroke, or tumor (rare). 
  • Urinary problems or intestinal problems, such as constipation. 
  • Myocardial (heart) and lungs, eg heart attack, problems with heart rhythm (arrhythmia), worsening of heart failure or chronic obstructive lung disease.

Extended biological explanation of delirium:
Side effects of familiar medications or sudden withdrawal from drugs are the most common and most treatable causes of delirium. Since many older people take multiple medications which may interact in harmful ways, you must be sure that the appropriate healthcare professionals are told about every prescription and non-prescription drug in use.

Alcohol abuse is frequently overlooked as a cause of delirium in older adults. Either overuse (intoxication) or a sudden withdrawal from alcohol can cause delirium. Delirium caused by withdrawal of alcohol appears to be as common in older adults with alcoholism as in their younger counterparts, although the death rate after withdrawal is higher in older alcoholics.

Medical Conditions
Virtually any physical illness or condition can bring on delirium, especially when more than one illness is present. Sometimes, delirium is also the first sign of a serious, life-threatening illness such as a heart attack. In hospital, the most common causes are sudden blood loss, dehydration, low blood pressure, fluid retention, infections, low levels of oxygen (hypoxia), kidney or liver failure, high blood sugar (hyperglycemia) or low blood sugar (hypoglycemia) in the blood, intestinal blockage (impaction), sleep deprivation, or inability to urinate. Delirium caused by a sudden change in the nervous system, such as a stroke, brain tumor, or brain infection, is less common.  Immobility, sleep deprivation or fragmented sleep, and pain can all contribute to bringing on delirium.

Environmental Conditions
Delirium can also result from too little stimulation of the senses, especially in people who already have some degree of mental impairment, or who are confined to a featureless hospital or nursing home room. In one study, delirium after an operation occurred twice as often in patients in intensive care units without windows as in patients in similar units with windows. In addition, a form of delirium that occurs in the evening (known as “sundowning”) may be partly due to sensory deprivation. Vision and hearing loss may also make it more difficult for the person to perceive reality and increases the likelihood of delusions or hallucinations.

Delirium after Surgery
Delirium may be the most common complication after surgery in older adults, and leads to longer hospital stays, a higher death rate, and a greater need for nursing-home care afterwards. It may also signal that there will be complications after surgery.

The chance that a patient will become delirious after an operation increases if a patient is an older adult, already has dementia or a physical disability, abuses alcohol, or has very abnormal blood tests. Also, certain types of operations are more frequently associated with delirium. For example, delirium is much more common after hip surgery and heart surgery.

Delirium is recognized by the presence of a number of specific symptoms, but these may change quickly, for example, from lethargy to agitation and then back again. The symptoms also vary quite a bit from one person to the next. Delirium may also come and go within a 24-hour period.

Typical Symptoms of Delirium include: 
  • Sudden onset over hours to days 
  • Slurred speech and language difficulties: talking that doesn’t make sense 
  • Changes in feeling (sensation) and perception 
  • Easily distracted, decreased attention, concentration, and environmental awareness; usually more alert in the morning than at night; in and out of consciousness 
  • Changes in movement (for example, may be slow moving or very restless) 
  • Changes in sleep patterns, such as reversed sleep-wake cycles 
  • Confusion and disorientation: not aware of correct time or place 
  • Memory loss, including decreased short-term memory and recall 
  • Disorganized thinking 
  • Emotional or personality changes, with frequent changes in moods, including anger, agitation, anxiety, apathy, depression, fear, euphoria, irritability, suspicion 
  • Incontinence 
  • Hallucinations (visual, but not auditory) 
  • Signs of medical illness (such as fever, chills, pain, etc) or drug side effects

Healthcare professionals pay special attention to changes from the usual mental state, while taking into consideration any physical problems. For example, when speaking to the patient, they may notice that the patient’s attention wanders, that he or she is restless, distracted easily and unable to follow directions, or that the patient’s speech is disorganized and does not make sense.
A diagnosis of delirium is made on the basis of careful observation and, if necessary, testing. To evaluate thinking, doctors may use a simple set of tests and standardized questions similar to those used to diagnose dementia.

The following tests are typical: 
  • Perform a simple math calculation 
  • Spell a short word backward 
  • Repeat a series of four or five numbers, in order and then in reverse order 
  • Name the days of the week backward.

Other tests to assess cognitive health include the Mini–Mental State Examination (MMSE), the Confusion Assessment Method (CAM), and other similar tests. Since many subtle or hypoactive cases of delirium are missed, healthcare professionals need to check the cognitive health of every older hospitalized patient. If you think that delirium may be present in a family member or someone close to you, you must alert a healthcare professional and have the person evaluated.

When the causes of delirium are not clear, the healthcare professional must take a complete history and physical exam. The history will include a review of all drugs being taken, including over-the-counter medications and herbal remedies. Blood tests and other studies may also be appropriate (see below).

The following tests may be used by healthcare professionals to diagnose delirium: 
  • Neurological exam, including tests of feeling (sensation), thinking (cognitive function), and motor function 
  • Neuropsychological studies 
  • Cognitive testing (such as the Mini-Mental State Examination) 
  • Blood tests (such as a comprehensive metabolic panel or toxicology screen).

Other tests may include:
  • Chest xray
  • Cerebrospinal fluid test
  • Electroencephalogram (EEG)
  • CT or MRI scans of the head
  • Urine analysis.
Slow onset over months to years; remains a long-term condition
Sudden onset over hours to days; lasts a shorter length of time
Normal speech
Slurred speech
Conscious and attentive until late stages; status relatively stable
In and out of consciousness; inattentive, easily distracted; decreased attention and environmental awareness; symptoms variable, disappearing and reappearing rapidly
Hallucinations possible
Hallucinations common (usually visual)
Listless or apathetic mood most common; agitation possible
Can be anxious, fearful, suspicious, agitated, apathetic, disoriented, disorganized thinking, listless, unaware
Often no other sign of physical or medical illness
Other signs of illness are common (fever, chills, pain) or drug side effects
Delirium can be mistaken for dementia or for psychiatric diseases such as schizophrenia. Certain rare forms of epilepsy can also closely resemble delirium. However, in epilepsy there is usually a history of seizures before the episode of sudden confusion.

Delirium and dementia share several characteristics that often make it hard to tell them apart. For example, both syndromes involve memory loss and language difficulties. Also, since dementia greatly increases the risk of delirium, they commonly occur at the same time.

Different Characteristics of Dementia and Delirium:
Delirium occurs very often in older people suffering from dementia, but it is a distinct syndrome requiring medical attention.

Differences between Delirium and Psychiatric Conditions
The best way to differentiate delirium from psychiatric problems is by considering age and how suddenly the symptoms appeared. If an older person's behavior changes suddenly, you should consider delirium as a possibility. Other features that may help separate psychiatric disease from delirium are the types of hallucinations that the person experiences. Psychotic patients typically hear voices or sounds, while people with delirium usually have visual hallucinations, seeing things that aren’t really there. Certain physical characteristics – for example, hand-flapping and EEG changes – are typical of delirium. Sudden underlying medical illness is also unusual in psychiatric disorders.

Delirium is traditionally viewed as a short-term, temporary problem. However, evidence is growing that it may persist for weeks to months in many people, especially in older people. In hospitalized patients, delirium is linked to poor outcomes, such as higher risk of death, complications, long hospital stays, and nursing home care. Poor outcomes are particularly common among older adults whose delirium continues for a long time.

Nevertheless, family members need to understand that, Usually—delirium goes away eventually, although it may take weeks or months. Slow recovery is more common if delirium is severe or if the person already has dementia or is 85 years old or older. Careful supportive care and monitoring of mental status during this period are crucial to recovery.

Family members can play an important role by providing appropriate orientation, support, and assistance. More and more, hospitals are allowing family members to sleep overnight with relatives who are already delirious or at high risk of becoming so. If you are a caregiver, get medical help right away if the patient's mental status worsens suddenly.

You can join Caregiver Support Groups.  Members of these groups obtain support by talking about their experiences, sharing strategies for coping, and informing each other about community resources.

(Source:  Healthinaging.org)

Caring For A Persaon With Severe Alzheimer's Disease

When caring for a person with severe Alzheimer’s disease, these steps can help with eating problems and other end-of-life concerns:
Treat conditions that cause appetite loss, such as constipation, depression, or infection.
Feed by hand. Ask the doctor about the best kinds of foods to offer and the best ways to feed
by hand.
Stop Unneeded Medicines. Some Drugs can make eating problems worse, including:
• antipsychotics such as quetiapine (Seroquel and generic)
• anti-anxiety drugs such as lorazepam (Ativan and generic)
• sleeping pills such as zolpidem (Ambien and generic)
• bladder-control drugs such as oxybutynin (Ditropan and generic)
• alendronate (Fosamax and generic) for osteoporosis
• donepezil (Aricept and generic) for Alzheimer’s disease
Schedule dental care. Badly fitting dentures, sore gums, and toothaches can make eating hard or painful.
Consider hospice care. Many people with advanced Alzheimer’s disease qualify for hospice care if they have difficulty drinking and eating enough to keep their weight up. Hospice eases suffering and pain in the last six months of life. Hospice can be given in the patient’s home.
Plan ahead. Every adult should have an advance directive. It lets you say what kind of care you want and who can make decisions for you if you cannot speak for yourself.
For more information, visit Healthinaging.org and PalliativeDoctors.org.
(Source: The American Geriatrics Society , and American Academy of Hospice & Palliative Medicine) 

Feeding Tubes for People with Alzheimer’s Disease : When You Need Them—And When You Don’t

Most people in the last stage of Alzheimer’s disease have difficulty eating and drinking. At this time, families may wonder if a patient needs a feeding tube. Families want to do everything possible for some-one who is ill. But they often get little information about feeding tubes. And they may feel pressure from doctors or nursing home staff, because feeding is simpler with a feeding tube.

But feeding tubes sometimes do more harm than good. Here’s why:
Feeding tubes usually aren’t helpful for severe Alzheimer’s disease. People with severe Alzheimer’s disease can no longer communicate or do basic things. Chewing and swallowing is often hard. This can cause serious problems, such as weight loss, weakness, and pressure sores. Or food can get into the lungs, and cause pneumonia. So people often need help when eating.  In many cases, a decision is made to use a feeding tube. The tube may be put down the throat. Or it may be put through a small cut in the abdominal wall, into the stomach. The patient is then given liquid nutrition through the tube.

But tube feeding is not better than careful hand feeding —and it may be worse. It does not help people live longer, gain more weight, become stronger, or regain skills. And it may increase the risk of pneumonia and pressure sores. Hand feeding gives human contact and the pleasure of tasting favorite foods.

When death is near and patients can no longer be fed by hand, families often worry that the patient will “starve to death.” In fact, refusing food and water is a natural, non-painful part of the dying process.  There is no good evidence that tube feeding helps these patients live longer.

Feeding tubes can have risks.

Tube feeding has many risks: 
•  It can cause bleeding, infection, skin irritation, or leaking around the tube. 
•  It can cause nausea, vomiting, and diarrhea.
•  The tube can get blocked or fall out, and must be replaced in a hospital. 
•  Many people with Alzheimer’s disease are bothered by the tube and try to pull it out. To prevent
    that, they are often tied down or given drugs. 
•  Tube-fed patients are more likely to get pressure sores. 
•  Tube-fed patients are more likely to spit up food, which may lead to pneumonia. 
•  At the end of life, fluids can fill the patient’s lungs, and cause breathing problems.

Feeding tubes can cost a lot.  Putting in a feeding tube costs about $8,269, according to HealthcareBlueBook.com.

So when are feeding tubes a good idea?
Feeding tubes can be helpful when the main cause of the eating problem is likely to get better. For example, they can help people who are recovering from a stroke, brain injury, or surgery.

The tubes also make sense for people who have problems swallowing and are not in the last stage of an illness that can’t be cured. For example, they can help people with Parkinson’s disease or amyotrophic lateral sclerosis (Lou Gehrig’s disease).

(Source:  The American Geriatrics Society, 17 September 2013)

Monday, 21 October 2013


The human brain contains an estimated 100 billion nerve cells (neurons). All memories are the result of signals that pass through those neurons. But normal aging leads to changes in the brain. Some neurons shrink; others are disabled by damaging molecules called free radicals. Areas of the brain involving memory and learning are particularly affected. Over time, these changes can make it more difficult for an older person to learn new tasks or to retrieve information from memory, such as someone's name. With Alzheimer's disease, the damage is more severe and ultimately affects larger regions of the brain.

The way in which the information that we see, hear and learn each moment is stored in our brains and then made available to be recalled is a complex process. While new theories are still being proposed, the most widely held model proposes that memories are formed in three stages:

Stage 1 : Memory Acquisition
Learning new information activates neurons (nerve cells) in the brain. Communication among these nerve cells encodes the information, creating a temporary neuronal pathway that holds the information as a short-term memory.

If you perceive something visual or spatial, such as a picture, the pathway is created in the right parietal lobe; if you're reading, the pathway forms in the area of the brain that processes language, the left temporal lobe. Focusing attention on new information promotes the encoding process, which then helps it solidify from short- to long-term memory during consolidation. That means that if you have a problem remembering something, maybe you weren't concentrating on it too hard in the first place.

Stage 2 : Memory Consolidation
For information to be retained long term, the neural pathway formed during memory acquisition must be strengthened. The replaying of events in the brain strengthens the pattern of neuronal activity, as more elaborate connections (or synapses) are formed among the neurons.

-  The brain region known as the hippocampus plays a key role in consolidating declarative memories (those related to names, dates, faces, facts and specific events) and is more vulnerable to decline during aging and Alzheimer's disease.

Procedural memories, which deal with skills you acquire (like riding a bicycle), are consolidated throughout the frontal lobes, cerebellum and basal ganglia. These memories hold up better over time and can survive even into dementia.

Stage 3 :  Memory Retrieval
In order to recall something, the brain must reactivate the nerve pathways where the specific memory is stored. Frequently retrieved memories are easier to recall, whereas infrequently retrieved information often takes longer to emerge and may require a prompt of some kind, such as a related piece of information.

(Source:  John Hopkins Health Alert, posted 21 October 2013)

Thursday, 17 October 2013

An Exercise RX to Ward Off Cognitive Decline

In the not too distant past, doctors knew little about the value of exercise for the heart. But beginning in the 1950s, findings from a number of important studies began to demonstrate that not only was a lack of physical activity harmful to the heart, but increased physical activity was good for it.

In much the same way, researchers are in the early stages of discovering the impact of physical activity, or lack thereof, on cognitive function. Much of the evidence to date suggests that physical activity does indeed offer some protection against cognitive decline.

Still, plenty of questions remain, and among those yet to be answered: How much physical activity is enough to help? And can any amount of physical activity reverse or slow the rate of decline in those with or at risk for cognitive impairment or Alzheimer's disease?

How much physical activity is enough? Results from several studies have provided intriguing clues about the amount of physical activity needed to slow the rate of cognitive decline. For example, findings from nearly 17,000 participants in the Nurses' Health Study demonstrated that women aged 70 years and older who walked at an easy pace for at least 90 minutes per week had higher cognitive scores than those who walked less than 40 minutes per week.

The results, which were reported in the Journal of the American Medical Association, also demonstrated that women who reported the highest rates of physical activity showed significantly less cognitive decline than women who reported the lowest rates of physical activity. Perhaps most striking: The apparent cognitive benefits of greater physical activity were similar in extent to being about three years younger.

What you can do now. Clearly, there's no specific exercise prescription for preventing or reversing cognitive decline. But given the evidence that physical activity is beneficial to the brain - as well as to your heart, lungs and bones -- it's a good idea to get moving.

The American Heart Association recommendation of 150 minutes of moderate exercise per week is a reasonable goal for many people. However, if you or a family member with mild cognitive impairment has been sedentary or has other medical conditions, get the OK from the doctor before you start.

Even if you or your family member is not up to 30 minutes five days a week, any physical activity you enjoy, such as gardening, is likely to be a boon to your overall well-being.

If a family member has more advanced Alzheimer's disease, keep in mind that he or she may be able to derive benefit from some type of physical activity until the final stages. For example, simple gentle stretching exercises can help reduce muscle and joint pain and help increase and maintain flexibility. Again, be sure to consult with the doctor to determine what type of activity is safe, realistic and helpful.

(Source:  John Hopkins Health Alert, posted in Memory, 14 October 2013)

Tuesday, 15 October 2013

SAT/9NOV13 ADFM Public Seminar Titled "DEMENTIA CARE" for Caregivers for Persons with Alzheimer's and Dementia

Dear Caregivers,

ADFM is holding a Public Seminar, Titled “DEMENTIA CARE” for Caregivers for Persons with Alzheimer’s and other form of Dementia. 

Caregivers and their families are specially invited to this Caregiver Seminar to meet with Ms Lynda McNab from UK, a Clinical Nurse Specialist in specialist care services for people with dementia and with very extensive experience in older adults mental health.


SPEAKER:  Ms Lynda McNab, Specialist Dementia Nurse, UK  

DATE:  Saturday, 9 November 2013

TIME:  9.00AM – 1.00PM (8.00AM Registration of Attendance)

VENUE:  Hall 3, Graduate Centre, Ground Floor, Sunway University, No. 5 Jalan Universiti, Bandar Sunway, 46150 Petaling Jaya


08.00am     Registration of Attendance  

09.00am      Welcome Address by Mr Ong Eng Joo, Vice Chairman, ADFM Exco

09.05am      "Overview of Dementia" by Dr Lu Ann Chong, Consultant Psychogeriatrician

09.40am      "Living Well with Dementia" by Lynda McNab, Specialist Dementia Nurse, UK

10.30am      REFRESHMENT

10.45am      “Behaviour That Challenges” by Ms Lynda McNab

12.00pm      Questions and Answers

01.00pm      End

Who Should Attend?

Caregivers for Persons with Alzheimer’s and other form of Dementia 

REGISTRATION FEE:  RM10 Per Person (for refreshments).

Compulsory Registration (On First-Come, First-Served Basis)

1.  Register now, click on ->  Registration Form
2.  Email to:  jenny@adfm.org.my  OR Fax to 03 7960 8482

Further details, call Jenny at 03 7931 5850 / 016 608 2513 / 7956 2008

Please do not miss this caregiver seminar specially arranged for all of you and your families.  Kindly help circulate this information to all concerned who is a Caregiver, who have no access to email and internet, and help them to register.    

A Community Project sponsored by CIMB Foundation, organized by Alzheimer's Disease Foundation Malaysia (ADFM) and supported by Sunway University

See all of you on 9 November !!!

Thank you,
ADFM National Caregivers Network
(A FREE Online support and discussion forum platform which provides resource and support for the caregivers community in Malaysia, to learn how to understand, cope and communicate with a person living with Alzheimer’s and other form of Dementia)

Monday, 14 October 2013

A Community Project  sponsored by CIMB Foundation, organized by Alzaheimer’s Disease Foundation Malaysia (ADFM) and supported by Sunway University


Organizing A Public Seminar For Healthcare Professional/Workers On

Speaker - Ms Lynda McNab, Specialist Dementia Nurse, UK

Date:  Saturday, 26 October 2013

Time: 9.00a.m. to 1.00 p.m.

Venue:  Hall 3, Graduate Centre, Ground Floor, Sunway University
 No. 5 Jalan Universiti, BandarSunway, 46150 Petaling Jaya


08.00am    Registration of Attendance  

09.00am    Welcome Address by Mr Ong Eng Joo, Vice Chairman, ADFM Exco

09.05am    "Overview of Dementia" by Dr Lu Ann Chong, Consultant Psychogeriatrician

09.40am    "Living Well with Dementia" by Lynda McNab, Specialist Dementia Nurse, UK

10.30am    REFRESHMENT

10.45am    “Behaviour That Challenges” by Lynda McNab

12.00pm    Questions and Answers

01.00pm    End

Who Should Attend?
Healthcare Professional / Workers from Healthcare Sector. 

Note: If you are unable to attend the 26 October Seminar, you can register for the 23 November which will be held at the same venue.


A Separate Public Seminar on “Dementia Care” is specially organized for you which will be held on the 9 NOVEMBER 13 and is open for registration now. The Program is the same.  A separate announcement will be broadcast to all Homecaregivers.  

REGISTRATION FEE:  RM15 per person (for refreshments)

COMPULSORY REGISTRATION (On A First-Come, First-Served Basis)

1.   Register online now ->  Registration Form
2.   Email: jenny@adfm.org.my  OR  Fax:  03 7960 8482

Further details, contact Jenny at 03 7931 5850 (DL) / 016 608 2513 / 03 7956 2008.

Thank you and See You There !!!

NOTE:   Attention All Caregivers for Persons with Alzheimer's and Other Form of
Dementia, a separate Seminar on Dementia Care will be held on 9 November at the same venue and time. Registration is open now to all caregivers. Please register early as places are limited.

Are you a Caregiver?  Join the ADFM National Caregivers Network
(An Online support and discussion forum platform which provides resource and support for the caregivers community in Malaysia, to learn how to understand, cope and communicate with a person living with Alzheimer’s and other form of Dementia)