He will need help with all his daily activities. At this point, the Alzheimer's individual becomes dependent on help with most everything. It is important at this time to carefully and sensitively adjust social and behavioral expectations downward. Do not place your loved on in situations that could lead to emotional overload. He could overreact in violent and frightening ways. This next section is EXTREMELY IMPORTANT. The thing to remember is this: He is UNABLE to comprehend what behavior is expected of him and may respond inappropriately. This is so very hard for family members to understand of a parent who has been in control of things all his life. I believe if you can fully understand and accept that your loved one truly is unable to comprehend now, things could go much better, feelings can be spared, anger lessened and love preserved as things progress downward.
Some violent behaviors may begin. Much of the violent behavior of persons with Alzheimer's disease is triggered by excessive environmental demands. He is unable to understand what behavior is expected of him and may respond inappropriately. Pressure to respond to situations promptly further accentuates inappropriate responses and behavior. Too many choices or options can precipitate more anxiety and agitation and may lead to further withdrawal or violence.
Bathing problems emerge at this stage. The middle stage of dementia brings on a real fear of bathing. This fear is often misunderstood and is misinterpreted by others as stubbornness and uncooperativeness. Actually this fear of bathing is related to reasonable concern. He has forgotten how to adjust water temperature and how to use the soap and washcloth and so many other things. His impaired coordination creates fear of getting in and out of the tub. He is afraid of falling. He has lost his social importance of personal hygiene. To reduce conflict, towel washing should be done and reduce the frequency of tub bathing. Sometimes a nice hot bath will be accepted when it is combined with a soothing body massage.
He has lost touch with events and experience now. people in middle dementia are generally unaware of their surroundings, the time of year, the year itself, and other indications of time and place. Memory is just fragments. Getting lost is almost inevitable and a very real concern for caregivers. Often, he will not be able to identify the person on whom he is most dependent or his spouse or son or daughter. He will probably know his name but is mostly unaware of all recent events and experiences. For the patient with Alzheimer's, the world has become frightening and largely unmanageable. The loss of cognitive, memory and perceptual abilities prevents him from organizing the pieces of his life into a meaningful whole.
Caregivers become lonelier and more isolated. At this stage of the disease, caregiving takes up most of the day and night. This is an extremely difficult time for caregivers to accept. The greatest isolation of all is created by the inability of the patient to relate to the caregiver. You NEED respite help every few days. You must get out, socialize and put your life in perspective. THIS IS A MUST!
The caregiver must hire help or place the person in a care facility at this point. By this stage, the emotional and physical burdens of care giving are overwhelming and difficult decision about whether to hire in-home help or placing your loved one in a residential care setting must be faced. The primary caregiver must have some relief from the all-consuming tasks of direct care. Even with help, the caregivers role becomes so demanding it overwhelms her life.
Stage V. Late Dementia
This is Alzheimer’s disease’s final stage. It’s been called ‘a long good-bye’ or an ‘unending death’.
All decisions must now be made without the loved one’s input or approval. The caregiver must decide alone what is best or what he would have wanted. It is hard to say good-bye, but one can’t help but hope to see the suffering end. A care facility may be the only realistic alternative now, no matter how much the caregiver wants to keep her loved one at home.
He may still be able to smile and laugh and to appear to enjoy life at times. The emotional experience of life goes on even though the words have been lost for awhile now. Behaviors are generally better and it is as likely for him to be amenable as it is for him to be difficult. The need for tranquilizers lessens because behavior has become more manageable.
His motor abilities continue to decline and eventually his ability to walk, sit, and smile will be lost as well as bladder and bowel functions. Falls are very likely because even though he may still be walking, as he trips he suddenly forgets how to walk or catch himself. Throw rugs and rubber-soled shoes are a hazard. If he has frequent falls, he may require medical attention to ensure that he isn’t having small strokes or transient ischemic attacks (TIA's).
It is important to keep him walking as long as he can . He will not be able to use a walk because of loss of coordination but guardrails and other supports helps. Watch out for loose rugs. Use of confinement devices (like geriatric chairs) should be avoided as they increase agitation and restlessness.
He will eventually lose the ability to chew and swallow and how to eat. He will have to have an almost totally soft diet as he will choke easily. If he refuses to eat, other methods of feeding must be considered.
Stupor occurs in this terminal stage and it leads finally to coma and death. Human contact is very important at this stage, even though the patient seems to be totally unaware of anything. Patience and kindness are necessary, a touch, a loving voice and the presence of a loved one helps keep him physically and emotionally alive, even though he is no longer able to reach out to anyone.
