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MedicineNet: Alzheimer's Disease



Alzheimer's Disease



What is dementia?

Dementia is a syndrome characterized by:
1.     impairment in memory,


2.     impairment in another area of thinking such as the ability to organize thoughts and reason, the ability to use language, or the ability to see accurately the visual world (not because of eye disease), and


3.     these impairments are severe enough to cause a decline in the patient's usual level of functioning.
Although some kinds of memory loss are normal parts of aging, the changes due to aging are not severe enough to interfere with the level of function. 

Many different diseases can cause dementia, but Alzheimer's disease is by far the most common cause for dementia in the United States and in most countries in the world.


What is Alzheimer's disease?

Alzheimer's disease (AD) is a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception






Many scientists believe that Alzheimer's disease results from an increase in the production or accumulation of a specific protein (beta-amyloid protein) in the brain that leads to nerve cell death.
The likelihood of having Alzheimer's disease increases substantially after the age of 70 and may affect around 50% of persons over the age of 85

Nonetheless, Alzheimer's disease is not a normal part of aging and is not something that inevitably happens in later life. For example, many people live to over 100 years of age and never develop Alzheimer's disease.


Who develops Alzheimer's disease?

The main risk factor for Alzheimer's disease is increased age

As a population ages, the frequency of Alzheimer's disease continues to increase. 

Ten percent of people over 65 years of age and 50% of those over 85 years of age have Alzheimer's disease. 

Unless new treatments are developed to decrease the likelihood of developing Alzheimer's disease, the number of individuals with Alzheimer's disease in the United States is expected to be 14 million by the year 2050.
There are also genetic risk factors for Alzheimer's disease. 


Most patients develop Alzheimer's disease after age 70

However, 2%-5% of patients develop the disease in the fourth or fifth decade of life (40s or 50s)

At least half of these early onset patients have inherited gene mutations associated with their Alzheimer's disease. 

Moreover, the children of a patient with early onset Alzheimer's disease who has one of these gene mutations has a 50% risk of developing Alzheimer's disease.
There is also a genetic risk for late onset cases

A relatively common form of a gene located on chromosome 19 is associated with late onset Alzheimer's disease. In the majority of Alzheimer's disease cases, however, no specific genetic risks have yet been identified.

Other risk factors for Alzheimer's disease include 

  • high blood pressure (hypertension), 
  • coronary artery disease
  • diabetes, and possibly 
  • elevated blood cholesterol


Individuals who have completed less than eight years of education also have an increased risk for Alzheimer's disease. 

These factors increase the risk of Alzheimer's disease, but by no means do they mean that Alzheimer's disease is inevitable in persons with these factors.
All patients with Down syndrome will develop the brain changes of Alzheimer's disease by 40 years of age

This fact was also a clue to the "amyloid hypothesis of Alzheimer's disease" (see section later in this article).

What are the symptoms of Alzheimer's disease?

The onset of Alzheimer's disease is usually gradual, and it is slowly progressive

Memory problems that family members initially dismiss as "a normal part of aging" are in retrospect noted by the family to be the first stages of Alzheimer's disease. 



When memory and other problems with thinking start to consistently affect the usual level of functioning; families begin to suspect that something more than "normal aging" is going on.
Problems of memory, particularly for recent events (short-term memory) are common early in the course of Alzheimer's disease. For example, the individual may, on repeated occasions, forget to turn off an iron or fail to recall which of the morning's medicines were taken



Mild personality changes, such as less spontaneity, apathy, and a tendency to withdraw from social interactions, may occur early in the illness.
As the disease progresses, problems in abstract thinking and in other intellectual functions develop. 

The person may begin to have trouble with figures when working on bills, with understanding what is being read, or with organizing the day's work

Further disturbances in behavior and appearance may also be seen at this point, such as agitation, irritability, quarrelsomeness, and a diminishing ability to dress appropriately.

Later in the course of the disorder, affected individuals may become confused or disoriented about what month or year it is, be unable to describe accurately where they live, or be unable to name a place being visited. 

Eventually, patients may wander, be unable to engage in conversation, erratic in mood, uncooperative, and lose bladder and bowel control

In late stages of the disease, persons may become totally incapable of caring for themselves

Death can then follow, perhaps from pneumonia or some other problem that occurs in severely deteriorated states of health. 

Those who develop the disorder later in life more often die from other illnesses (such as heart disease) rather than as a consequence of Alzheimer's disease.

Ten warning signs of Alzheimer's disease

The Alzheimer's Association has developed the following list of warning signs that include common symptoms of Alzheimer's disease. 

Individuals who exhibit several of these symptoms should see a physician for a complete evaluation.
1.     Memory loss
2.     Difficulty performing familiar tasks
3.     Problems with language
4.     Disorientation to time and place
5.     Poor or decreased judgment
6.     Problems with abstract thinking
7.     Misplacing things
8.     Changes in mood or behavior
9.     Changes in personality
10.   Loss of initiative
It is normal for certain kinds of memory, such as the ability to remember lists of words, to decline with normal aging. 

In fact, normal individuals 50 years of age will recall only about 60% as many items on some kinds of memory tests as individuals 20 years of age. 

Furthermore, everyone forgets, and every 20 year old is well aware of multiple times he or she couldn't think of an answer on a test that he or she once knew.

Almost no 20 year old worries when he/she forgets something, that he/she has the 'early stages of Alzheimer's disease,' whereas an individual 50 or 60 years of age with a few memory lapses may worry that they have the 'early stages of Alzheimer's disease.'

Mild cognitive impairment

The criteria for dementia are conservative meaning that a patient must have had considerable decline in the ability to think before a diagnosis of dementia is appropriate. 

The progression of Alzheimer's disease is so insidious and slow that patients go through a period of decline where their memory is clearly worse than its baseline, yet they still do not meet criteria for dementia. 

This transitional syndrome is called Mild Cognitive Impairment (MCI). Individuals affected with MCI have cognitive impairment that is demonstrated on formal neuropsychological testing but are still able to function well. 

Formal neuropsychological testing usually means that the patient is administered a battery of standardized tests of memory and thinking. 


Some of these tests are something like the IQ tests we may have taken in school. When these tests were developed they were administered to hundreds or thousands of people so that statistics are available to say how a person's score compares to a sample of healthy persons of the same age. 

If a person scores in the top 50%, it means that he or she did better than at least 50% of other normal people who took the test. Persons with lower scores - often in the bottom 7% - are considered to have MCI.

There are several forms of MCI. Perhaps the most common is associated with impairment in memory but not in the ability to plan and reason. 

Persons with this type called "amnestic MCI" (amnestic comes from "amnesia" and means no memory) have a high risk of developing Alzheimer's disease over the next few years. 


Persons with preserved memory but impaired reasoning or impaired judgment (call non-amnestic MCI) have a lower risk of developing Alzheimer's disease.
As treatments are developed that decrease the risk of developing Alzheimer's disease or slow its rate of progression (as of June 2007, no such medication has been approved by the FDA), recognition of amnestic MCI will be increasingly important. 
It is hoped that medications will be developed that will slow the rate of progression of MCI to Alzheimer's disease or completely prevent the development of Alzheimer's disease

What are causes of Alzheimer's disease?

The cause(s) of Alzheimer's disease is (are) not known

The "amyloid cascade hypothesis" is the most widely discussed and researched hypothesis about the cause of Alzheimer's disease. 

The strongest data supporting the amyloid cascade hypothesis comes from the study of early-onset inherited (genetic) Alzheimer's disease. 

Mutations associated with Alzheimer's disease have been found in about half of the patients with early-onset disease. 

In all of these patients, the mutation leads to excess production in the brain of a specific form of a small protein fragment called ABeta (Aβ)


Many scientists believe that in the majority of sporadic (for example, non-inherited) cases of Alzheimer's disease (these make up the vast majority of all cases of Alzheimer's disease) there is too little removal of this Aβ protein rather than too much production. 

In any case, much of the research in finding ways to prevent or slow down Alzheimer's disease has focused on ways to decrease the amount of Aβ in the brain.

What are risk factors for Alzheimer's disease?

The biggest risk factor for Alzheimer's disease is increased age

The likelihood of developing Alzheimer's disease doubles every 5.5 years from 65 to 85 years of age

Whereas only 1%-2% of individuals 70 years of age have Alzheimer's disease, in some studies around 40% of individuals 85 years of age have Alzheimer's disease. 

Nonetheless, at least half of people who live past the 95 years of age do not have Alzheimer's disease.
Common forms of certain genes increase the risk of developing Alzheimer's disease, but do not invariably cause Alzheimer's disease. 

The best-studied "risk" gene is the one that encodes apolipoprotein E (apoE)

The apoE gene has three different forms (alleles) --

  • apoE2, 
  • apoE3, and 
  • apoE4. 


The apoE4 form of the gene has been associated with increased risk of Alzheimer's disease in most (but not all) populations studied. 

The frequency of the apoE4 version of the gene in the general population varies, but is always less than 30% and frequently 8%-15%. 

Persons with one copy of the E4 gene usually have about a two to three fold increased risk of developing Alzheimer's disease. 

Persons with two copies of the E4 gene (usually around 1% of the population) have about a nine-fold increase in risk. 

Nonetheless, even persons with two copies of the E4 gene don't always get Alzheimer's disease. 

At least one copy of the E4 gene is found in 40% of patients with sporadic or late-onset Alzheimer's disease.
This means that in majority of patients with Alzheimer's disease, no genetic risk factor has yet been found. 

Most experts do not recommend that adult children of patients with Alzheimer's disease should have genetic testing for the apoE4 gene since there is no treatment for Alzheimer's disease. 

When medical treatments that prevent or decrease the risk of developing Alzheimer's disease become available, genetic testing may be recommended for adult children of patients with Alzheimer's disease so that they may be treated.
Many, but not all, studies have found that women have a higher risk for Alzheimer's disease than men. 

It is certainly true that women live longer than men, but age alone does not seem to explain the increased frequency in women. 

The apparent increased frequency of Alzheimer's disease in women has led to considerable research about the role of estrogen in Alzheimer's disease. 


Recent studies suggest that estrogen should not be prescribed to post-menopausal women for the purpose of decreasing the risk of Alzheimer's disease. Nonetheless, the role of estrogen in Alzheimer's disease remains an area of research focus.
Some studies have found that Alzheimer's disease occurs more often among people who suffered significant traumatic head injuries earlier in life, particularly among those with the apoE 4 gene.

In addition, many, but not all studies, have demonstrated that persons with limited formal education - usually less than eight years - are at increased risk for Alzheimer's disease. It is not known whether this reflects a decreased "cognitive reserve" or other factors associated with a lower educational level.

How is the diagnosis of Alzheimer's disease made?

As of June 2007, there is no specific "blood test" or imaging test that is used for the diagnosis of Alzheimer's disease. 

Alzheimer's disease is diagnosed when: 
1) a person has sufficient cognitive decline to meet criteria for dementia; 
2) the clinical course is consistent with that of Alzheimer's disease; 
3) no other brain diseases or other processes are better explanations for the dementia.

What other conditions should be screened for?

There are many conditions that can cause dementia, to include the following:
Neurological disorders: 
Parkinson's disease, cerebrovascular disease and strokes, brain tumors, blood clots, and multiple sclerosis can sometimes be associated with dementia although many patients with these conditions are cognitively normal.
Infectious diseases: 
Some brain infections such as chronic syphilis, chronic HIV, or chronic fungal meningitis can cause dementia.
Side effects of medications: 
Many medicines can cause cognitive impairment, especially in elderly patients. Perhaps the most frequent offenders are drugs used to control bladder urgency and incontinence. "Psychiatric medications" such as anti-depressants and anti-anxiety medications and "neurological medications" such as anti-seizure medications can also be associated with cognitive impairment.
If a physician evaluates a person with cognitive impairment who is on one of these medications, the medication is often gently tapered and/or discontinued to determine whether it might be the cause of the cognitive impairment. If it is clear that the cognitive impairment preceded the use of these medications, such tapering may not be necessary. On the other hand, "psychiatric," "neurological," and "incontinence" medications are often appropriately prescribed to patients with Alzheimer's disease. Such patients need to be followed carefully to determine whether these medications cause any worsening of cognition.
Psychiatric disorders: 
In older persons, some forms of depression can cause problems with memory and concentration that initially may be indistinguishable from the early symptoms of Alzheimer's disease. Sometimes, these conditions, referred to as pseudodementia, can be reversed. Studies have shown that persons with depression and coexistent cognitive (thinking, memory) impairment are highly likely to have an underlying dementia when followed for several years.
Substance Abuse: 
Abuse of legal and/or illegal drugs and alcohol abuse is often associated with cognitive impairment.
Metabolic Disorders: 
Thyroid dysfunction, some steroid disorders, and nutritional deficiencies such as vitamin B12 deficiency or thiamine deficiency are sometimes associated with cognitive impairment.
Trauma: 
Significant head injuries with brain contusions may cause dementia. Blood clots around the outside of the brain (subdural hematomas) may also be associated with dementia.
Toxic Factors:
Long term consequences of acute carbon monoxide poisoning can lead to an encephalopathy with dementia. In some rare cases, heavy metal poisoning can be associated with dementia.
Tumors: 
Many primary and metastatic brain tumors can cause dementia. However, many patients with brain tumors have no or little cognitive impairment associated with the tumor.

The Importance of Comprehensive Clinical Evaluation

Because many other disorders can be confused with Alzheimer's disease, a comprehensive clinical evaluation is essential in arriving at a correct diagnosis. 

Such an assessment should include at least three major components
1) a thorough general medical workup, 
2) a neurological examination including testing of memory and other functions of thinking , and 
3) a psychiatric evaluation to assess mood, anxiety, and clarity of thought.
Such an evaluation takes time - usually at least an hour. 
In the United States healthcare system, neurologists, psychiatrists, or geriatricians frequently become involved. Nonetheless, any physician may be able to perform a thorough evaluation.
The American Academy of Neurology has published guidelines that include imaging of the brain in the initial evaluation of patients with dementia. 

These studies are either a noncontrast CT scan or an MRI scan. 

Other imaging procedures that look at the function of the brain (functional neuroimaging), such as SPECT, PET, and fMRI, may be helpful in specific cases, but generally are not needed. 

However, in many healthcare systems outside of the United States, brain imaging as not a standard part of the assessment for possible Alzheimer's disease.
Despite many attempts, identification of a blood test to diagnose Alzheimer's disease has remained elusive. As of June 2007, such testing is neither widely available nor recommended.

What is the prognosis for a person with Alzheimer's disease?

Alzheimer's disease is invariably progressive

Different studies have stated that Alzheimer's disease progresses over two to 25 years with most patients in the eight to 15 year range. 

Nonetheless, defining when Alzheimer's disease starts, particularly in retrospect, can be very difficult. Patients usually don't die directly from Alzheimer's disease

They die because they have difficulty swallowing or walking and these changes make overwhelming infections, such as pneumonia, much more likely.
Most persons with Alzheimer's disease can remain at home as long as some assistance is provided by others as the disease progresses. 

Moreover, throughout much of the course of the illness, individuals maintain the capacity for giving and receiving love, sharing warm interpersonal relationships, and participating in a variety of meaningful activities with family and friends.
A person with Alzheimer's disease may no longer be able to do math but still may be able to read a magazine with pleasure. 

Playing the piano might become too stressful in the face of increasing mistakes, but singing along with others may still be satisfying. The chessboard may have to be put away, but playing tennis may still be enjoyable. 

Thus, despite the many exasperating moments in the lives of patients with Alzheimer's disease and their families, many opportunities remain for positive interactions. 

Challenge, frustration, closeness, anger, warmth, sadness, and satisfaction may all be experienced by those who work to help the person with Alzheimer's disease. For more, please read the Caregiving and Alzheimer's Disease: Caregiving Challenges articles.
The reaction of a patient with Alzheimer's disease to the illness and his or her capacity to cope with it also vary, and may depend on such factors as lifelong personality patterns and the nature and severity of stress in the immediate environment.

Depression, severe uneasiness, paranoia, or delusions may accompany or result from the disease, but these conditions can often be improved by appropriate treatments. Although there is no cure for Alzheimer's disease, treatments are available to alleviate many of the symptoms that cause suffering.

What treatment and management options are available for Alzheimer's disease?

The management of Alzheimer's disease consists of medication based and non-medication based treatments. 

Two different classes of pharmaceuticals are approved by the FDA for treating Alzheimer's disease: 

  • cholinesterase inhibitors and 
  • partial glutamate antagonists. 


Neither class of drugs has been proven to slow the rate of progression of Alzheimer's disease. 

Nonetheless, many clinical trials suggest that these medications are superior to placebos (sugar pills) in relieving some symptoms.

Cholinesterase inhibitors

In patients with Alzheimer's disease there is a relative lack of a brain chemical neurotransmitter called acetylcholine

(Neurotransmitters are chemical messengers produced by nerves that the nerves use to communicate with each other in order to carry out their functions.) 

Substantial research has demonstrated that acetylcholine is important in the ability to form new memories. 

The cholinesterase inhibitors (ChEIs) block the breakdown of acetylcholine. 

As a result, more acetylcholine is available in the brain, and it may become easier to form new memories.
Four ChEIs have been approved by the FDA, but only 

  • donepezil hydrochloride (Aricept), 
  • rivastigmine (Exelon), and 
  • galantamine (Razadyne - previously called Reminyl) are used by most physicians because 
  • the fourth drug, tacrine (Cognex) has more undesirable side effects than the other three. 
Most experts in Alzheimer's disease do not believe there is an important difference in the effectiveness of these three drugs. 

Several studies suggest that the progression of symptoms of patients on these drugs seems to plateau for six to 12 months, but inevitably progression then begins again.
Of the three widely used 

  • AchEs, rivastigmine and galantamine are only approved by the FDA for mild to moderate Alzheimer's diseasewhereas 
  • donepezil is approved for mild, moderate, and severe Alzheimer's disease. 


It is not known whether rivastigmine and galantamine are also effective in severe Alzheimer's disease, although there does not appear to be any good reason why they shouldn't.
The principal side effects of ChEIs involve the gastrointestinal system and include nausea, vomiting, cramping, and diarrhea

Usually these side effects can be controlled with change in size or timing of the dose or administering the medications with a small amount of food. Between 75% and 90% of patients will tolerate therapeutic doses of ChEIs.

Partial glutamate antagonists

Glutamate is the major excitatory neurotransmitter in the brain. 

One theory suggests that too much glutamate may be bad for the brain and cause deterioration of nerve cells. 

Memantine (Namenda) works by partially decreasing the effect of glutamate to activate nerve cells. 

It has not been proven that memantine slows down the rate of progression of Alzheimer's disease. 

Studies have demonstrated that some patients on memantine can care for themselves better than patients on sugar pills (placebos). 

Memantine is approved for treatment of moderate and severe dementia, and studies did not show it was helpful in mild dementia. 

It is also possible to treat patients with both AchEs and memantine without loss of effectiveness of either medication or an increase in side effects.

Non-medication based treatments

Non-medication based treatments include maximizing patients' opportunities for social interaction and participating in activities such as walking, singing, dancing that they can still enjoy. 

Cognitive rehabilitation, (whereby a patient practices on a computer program for training memory), may or may not be of benefit. Further studies of this method are needed.

Treatment of psychiatric symptoms

Symptoms of Alzheimer's disease include agitation, depression, hallucinations, anxiety, and sleep disorders

Standard psychiatric drugs are widely used to treat these symptoms although none of these drugs have been specifically approved by the FDA for treating these symptoms in patients with Alzheimer's disease. 

If these behaviors are infrequent or mild, they often do not require treatment with medication. 

Non-pharmacologic measures can be very useful.
Nevertheless, frequently these symptoms are so severe that it becomes impossible for caregivers to take care of the patient, and treatment with medication to control these symptoms becomes necessary. 

Agitation is common, particularly in middle and later stages of Alzheimer's disease. Many different classes of agents have been tried to treat agitation including:
·         antipsychotics,
·         mood-stabilizing anticonvulsants,
·         trazodone (Desyrel),
·         anxiolytics, and
·         beta-blockers.
Studies are conflicting about the usefulness of these different drug classes. 

It was thought that newer, atypical antipsychotic agents such as 

  • clozapine (Clozaril), 
  • risperidone (Risperdal), 
  • olanzapine (Zyprexa, Zydis), 
  • quetiapine (Seroquel), and 
  • ziprasidone (Geodon) 

might have advantages over the older antipsychotic agents because of their fewer and less severe side effects and the patients' ability to tolerate them. 

However, more recent studies have not demonstrated superiority of the newer antipsychotics. 

Some research shows that these newer antipsychotics may be associated with increased risk of stroke or sudden death than the older antipsychotics, but many physicians believe this question is still not resolved.
Apathy and difficulty concentrating occur in most Alzheimer's disease patients and should not be treated with antidepressant medications. 

However, many Alzheimer's disease patients have other symptoms of depression including sustained feelings of unhappiness and/or inability to enjoy their usual activities. 

Such patients may benefit from a trial of antidepressant medication. 

Most physicians will try selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft), citalopram (Celexa), or fluoxetine (Prozac), as first-line agents for treating depression in Alzheimer's disease.
Anxiety is another symptom in Alzheimer's disease that occasionally requires treatment. 

Benzodiazepines such as diazepam (Valium) or lorazepam (Ativan) may be associated with increased confusion and memory impairment. 

Non-benzodiazepine anxiolytics, such as buspirone (Buspar) or SSRIs, are probably preferable.
Difficulty sleeping (insomnia) occurs in many patients with Alzheimer's disease at some point in the course of their disease. 

Many Alzheimer's disease specialists prefer the use of sedating atypical antidepressants such as trazodone (Desyrel). 

However, other specialists may recommend other classes of medications. 

Sleep improvement measures, such as sunlight, adequate treatment of pain, and limiting nighttime fluids to prevent the need for urination, should also be implemented.

Potential and future therapies for Alzheimer's disease

A variety of clinical research trials are underway with agents that try either to decrease the amount of Aβ1-42 produced or increase the amount of Aβ1-42 removed. 

It is hoped that such therapies may slow down the rate of progression of Alzheimer's disease. As of June 2007, it is not known how well such therapies may work.

Caring for the caregiver and Alzheimer's disease resources

Caring for the caregiver is an essential element of managing the patient with Alzheimer's disease. Caregiving is a distressing experience. On the other hand, caregiver education delays nursing home placement of Alzheimer's disease patients. 

The 3Rs - Repeat, Reassure, and Redirect - can help caregivers reduce troublesome behaviors and limit the use of medications. 

The short-term educational programs are well liked by family caregivers and can lead to a modest increase in disease knowledge and greater confidence among caregivers. 

Educational training for staffs of long-term care facilities can decrease the use of antipsychotics in Alzheimer's disease patients.
Caregivers should be directed to support services, particularly the Alzheimer's Association (1-800-272-3900, www.alz.org/chapter/).

Alzheimer's Disease At A Glance

·         Alzheimer's disease is a brain disease of unknown cause that leads to dementia.
·         Most patients with Alzheimer's disease are over 65 years of age.
·         There are 10 classic warning signs of Alzheimer's disease: memory loss, difficulty performing familiar tasks, problems with language, disorientation to time and place, poor or decreased judgment, problems with abstract thinking, misplacing things, changes in mood or behavior, changes in personality, and loss of initiative.
·         Patients with symptoms of dementia should be thoroughly evaluated before they become inappropriately or negligently labeled Alzheimer's disease.
·         Although there is no cure for Alzheimer's disease, treatments are available to alleviate many of the symptoms that cause suffering.
·         The management of Alzheimer's disease consists of medication based and non-medication based treatments organized to care for the patient and family. Treatments aimed at changing the underlying course of the disease (delaying or reversing the progression) have so far been largely unsuccessful. Medicines that restore the defect, or malfunctioning, in the chemical messengers of the nerve cells have been shown to improve symptoms. Finally, medications are available that deal with the psychiatric manifestations of Alzheimer's disease.
·         


National Institute on Aging home safety 

for people with Alzheimer's disease

·         Introduction

·         Caring for a person with Alzheimer's disease is a challenge that calls upon the patience, creativity, knowledge, and skills of each caregiver. We hope that this booklet will help you cope with some of these challenges and develop creative solutions to increase the security and freedom of the person with Alzheimer's in your home, as well as your own peace of mind.

·         This booklet is for those who provide in-home care for people with Alzheimer's disease or related disorders. Our goal is to improve home safety by identifying potential problems in the home and offering possible solutions to help prevent accidents.
·         We begin with a checklist to help you make each room in your home a safer environment for the person with Alzheimer's. Next, we hope to increase awareness of the ways specific impairments associated with the disease can create particular safety hazards in the home. Specific home safety tips are listed to help you cope with some of the more hazardous behaviors that may occur as the disease advances. We also include tips for managing driving and planning for natural disaster safety. The information ends with a list of resources for family caregivers.

·         What is Alzheimer's Disease?

·         Alzheimer's disease is a progressive, irreversible brain disease that destroys memory and thinking skills. Estimates vary, but experts suggest that as many as 5.1 million Americans has the disease, which affects people of all racial, economic, and educational backgrounds. Although Alzheimer's primarily affects people age 60 or older, it also may affect people in their 50s and, rarely, even younger.
·         Alzheimer's disease is the most common cause of dementia in adults. Dementia is a loss of memory and intellect that interferes with daily life and activities. Dementia is not a disease; rather, it is a group of symptoms that may accompany certain diseases and conditions. Other symptoms include changes in personality, mood, or behavior.
·         Other causes of irreversible dementia include vascular dementia and alcohol abuse. The recommendations in this booklet deal primarily with common problems in Alzheimer's, but they also may be helpful for people with other types of dementia.

What are the Symptoms of Alzheimer's disease?

There is no "typical" person with Alzheimer's. There is tremendous variability among people with Alzheimer's in their behaviors and symptoms. At present, there is no way to predict how quickly the disease will progress in any one person or the exact changes that will occur. We do know, however, that many of these changes will present problems for caregivers. Therefore, knowledge and prevention are critical to safety.
People with Alzheimer's disease have memory problems and cognitive impairment (difficulties with thinking and reasoning), and eventually they will not be able to care for themselves. They often experience confusion, loss of judgment, and difficulty finding words, finishing thoughts, or following directions. They also may experience personality and behavior changes. For example, they may become agitated, irritable, or very passive. Some people with Alzheimer's may wander from home and become lost. Others may not be able to tell the difference between day and night—they may wake up, get dressed, and start to leave the house in the middle of the night thinking that the day has just started. People with Alzheimer's also can have losses that affect vision, smell, or taste.
These disabilities are very difficult, not only for the person with Alzheimer's, but for the caregiver, family, and other loved ones as well. Caregivers need resources and reassurance to know that while the challenges are great, specific actions can reduce some of the safety concerns that accompany Alzheimer's disease.

General Safety Concerns

People with Alzheimer's disease become increasingly unable to take care of themselves. However, the disease progresses differently in each person. As a caregiver, you face the ongoing challenge of adapting to each change in the person's behavior and functioning. The following general principles may be helpful.
1.     Think prevention. It is very difficult to predict what a person with Alzheimer's might do. Just because something has not yet occurred does not mean it should not be cause for concern. Even with the best-laid plans, accidents can happen. Therefore, checking the safety of your home will help you take control of some of the potential problems that may create hazardous situations.
2.     Adapt the environment. It is more effective to change the environment than to change most behaviors. While some Alzheimer's behaviors can be managed with special medications prescribed by a doctor, many cannot. You can make changes in an environment to decrease the hazards and stressors that accompany these behavioral and functional changes.
3.     Minimize danger. By minimizing danger, you can maximize independence. A safe environment can be a less restrictive environment where the person with Alzheimer's disease can experience increased security and more mobility.

Is it Safe to Leave the Person With Alzheimer's disease Alone?

This issue needs careful evaluation and is certainly a safety concern. The following points may help you decide.
Does the person with Alzheimer's:
·         become confused or unpredictable under stress?
·         recognize a dangerous situation, for example, fire?
·         know how to use the telephone in an emergency?
·         know how to get help?
·         stay content within the home?
·         wander and become disoriented?
·         show signs of agitation, depression, or withdrawal when left alone for any period of time?
·         attempt to pursue former interests or hobbies that might now warrant supervision, such as cooking, appliance repair, or woodworking?
You may want to seek input and advice from a health care professional to assist you in these considerations. As Alzheimer's disease progresses, these questions will need ongoing evaluation.

Home Safety Room-By-Room

Prevention begins with a safety check of every room in your home. Use the following room-by-room checklist to alert you to potential hazards and to record any changes you need to make. You can buy products or gadgets necessary for home safety at stores carrying hardware, electronics, medical supplies, and children's items.
Keep in mind that it may not be necessary to make all of the suggested changes. This booklet covers a wide range of safety concerns that may arise, and some modifications may never be needed. It is important, however, to re-evaluate home safety periodically as behavior and abilities change.
Your home is a personal and precious environment. As you go through this checklist, some of the changes you make may impact your surroundings positively, and some may affect you in ways that may be inconvenient or undesirable. It is possible, however, to strike a balance. Caregivers can make adaptations that modify and simplify without severely disrupting the home. You may want to consider setting aside a special area for yourself, a space off-limits to anyone else and arranged exactly as you like. Everyone needs private, quiet time, and as a caregiver, this becomes especially crucial.
A safe home can be a less stressful home for the person with Alzheimer's, the caregiver, and family members. You don't have to make these changes alone. You may want to enlist the help of a friend, professional, or community service such as the Alzheimer's Association.

Throughout the Home

·         Display emergency numbers and your home address near all telephones.
·         Use an answering machine when you cannot answer phone calls, and set it to turn on after the fewest number of rings possible. A person with Alzheimer's disease often may be unable to take messages or could become a victim of telephone exploitation. Turn ringers on low to avoid distraction and confusion. Put all portable and cell phones and equipment in a safe place so they will not be easily lost.
·         Install smoke alarms and carbon monoxide detectors in or near the kitchen and all sleeping areas. Check their functioning and batteries frequently.
·         Avoid the use of flammable and volatile compounds near gas appliances. Do not store these materials in an area where a gas pilot light is used.
·         Install secure locks on all outside doors and windows.
·         Hide a spare house key outside in case the person with Alzheimer's disease locks you out of the house.
·         Avoid the use of extension cords if possible by placing lamps and appliances close to electrical outlets. Tack extension cords to the baseboards of a room to avoid tripping.
·         Cover unused electrical outlets with childproof plugs.
·         Place red tape around floor vents, radiators, and other heating devices to deter the person with Alzheimer's from standing on or touching them when hot.
·         Check all rooms for adequate lighting.
·         Place light switches at the top and the bottom of stairs.
·         Stairways should have at least one handrail that extends beyond the first and last steps. If possible, stairways should be carpeted or have safety grip strips. Put a gate across the stairs if the person has balance problems.
·         Keep all medications (prescription and over-the-counter) locked. Each bottle of prescription medicine should be clearly labeled with the person's name, name of the drug, drug strength, dosage frequency, and expiration date. Child-resistant caps are available if needed.
·         Keep all alcohol in a locked cabinet or out of reach of the person with Alzheimer's. Drinking alcohol can increase confusion.
·         If smoking is permitted, monitor the person with Alzheimer's while he or she is smoking. Remove matches, lighters, ashtrays, cigarettes, and other means of smoking from view. This reduces fire hazards, and with these reminders out of sight, the person may forget the desire to smoke.
·         Avoid clutter, which can create confusion and danger. Throw out or recycle newspapers and magazines regularly. Keep all areas where people walk free of furniture.
·         Keep plastic bags out of reach. A person with Alzheimer's disease may choke or suffocate.
·         Remove all guns and other weapons from the home or lock them up. Installing safety locks on guns or remove ammunition and firing pins.
·         Lock all power tools and machinery in the garage, workroom, or basement.
·         Remove all poisonous plants from the home. Check with local nurseries or contact the poison control center (1-800-222-1222) for a list of poisonous plants.
·         Make sure all computer equipment and accessories, including electrical cords, are kept out of the way. If valuable documents or materials are stored on a home computer, protect the files with passwords and back up the files. Password protect access to the Internet, and restrict the amount of online time without supervision. Consider monitoring computer use by the person with Alzheimer's, and install software that screens for objectionable or offensive material on the Internet.
·         Keep fish tanks out of reach. The combination of glass, water, electrical pumps, and potentially poisonous aquatic life could be harmful to a curious person with Alzheimer's disease.

Outside Approaches to the House

·         Keep steps sturdy and textured to prevent falls in wet or icy weather.
·         Mark the edges of steps with bright or reflective tape.
·         Consider installing a ramp with handrails as an alternative to the steps.
·         Eliminate uneven surfaces or walkways, hoses, and other objects that may cause a person to trip.
·         Restrict access to a swimming pool by fencing it with a locked gate, covering it, and closely supervising it when in use.
·         In the patio area, remove the fuel source and fire starters from any grills when not in use, and supervise use when the person with Alzheimer's is present.
·         Place a small bench or table by the entry door to hold parcels while unlocking the door.
·         Make sure outside lighting is adequate. Light sensors that turn on lights automatically as you approach the house may be useful. They also may be used in other parts of the home.
·         Prune bushes and foliage well away from walkways and doorways.
·         Consider a NO SOLICITING sign for the front gate or door.

Entryway

·         Remove scatter rugs and throw rugs.
·         Use textured strips or nonskid wax on hardwood and tile floors to prevent slipping.

Kitchen

·         Install childproof door latches on storage cabinets and drawers designated for breakable or dangerous items. Lock away all household cleaning products, matches, knives, scissors, blades, small appliances, and anything valuable.
·         If prescription or nonprescription drugs are kept in the kitchen, store them in a locked cabinet.
·         Remove scatter rugs and foam pads from the floor.
·         Install safety knobs and an automatic shut-off switch on the stove.
·         Do not use or store flammable liquids in the kitchen. Lock them in the garage or in an outside storage unit.
·         Keep a night-light in the kitchen.
·         Remove or secure the family "junk drawer." A person with Alzheimer's may eat small items such as matches, hardware, erasers, plastics, etc.
·         Remove artificial fruits and vegetables or food-shaped kitchen magnets, which might appear to be edible.
·         Insert a drain trap in the kitchen sink to catch anything that may otherwise become lost or clog the plumbing.
·         Consider disconnecting the garbage disposal. People with Alzheimer's may place objects or their own hands in the disposal.

Bedroom

·         Anticipate the reasons a person with Alzheimer's disease might get out of bed, such as hunger, thirst, going to the bathroom, restlessness, and pain. Try to meet these needs by offering food and fluids and scheduling ample toileting.
·         Use a night-light.
·         Use a monitoring device (like those used for infants) to alert you to any sounds indicating a fall or other need for help. This also is an effective device for bathrooms.
·         Remove scatter rugs and throw rugs.
·         Remove portable space heaters. If you use portable fans, be sure that objects cannot be placed in the blades.
·         Be cautious when using electric mattress pads, electric blankets, electric sheets, and heating pads, all of which can cause burns and fires. Keep controls out of reach.
·         If the person with Alzheimer's disease is at risk of falling out of bed, place mats next to the bed, as long as they do not create a greater risk of accident.
·         Use transfer or mobility aids.
·         If you are considering using a hospital-type bed with rails and/or wheels, read the Food and Drug Administration's up-to-date safety information at FDA Medical Devices, Hospital Beds

Bathroom

·         Do not leave a severely impaired person with Alzheimer's alone in the bathroom.
·         Remove the lock from the bathroom door to prevent the person with Alzheimer's from getting locked inside.
·         Place nonskid adhesive strips, decals, or mats in the tub and shower. If the bathroom is uncarpeted, consider placing these strips next to the tub, toilet, and sink.
·         Use washable wall-to-wall bathroom carpeting to prevent slipping on wet tile floors.
·         Use a raised toilet seat with handrails, or install grab bars beside the toilet.
·         Install grab bars in the tub/shower. A grab bar in contrasting color to the wall is easier to see.
·         Use a foam rubber faucet cover (often used for small children) in the tub to prevent serious injury should the person with Alzheimer's fall.
·         Use a plastic shower stool and a hand-held shower head to make bathing easier.
·         In the shower, tub, and sink, use a single faucet that mixes hot and cold water to avoid burns.
·         Set the water heater at 120 degrees Fahrenheit to avoid scalding tap water.
·         Insert drain traps in sinks to catch small items that may be lost or flushed down the drain.
·         Store medications (prescription and nonprescription) in a locked cabinet. Check medication dates and throw away outdated medications.
·         Remove cleaning products from under the sink, or lock them away.
·         Use a night-light.
·         Remove small electrical appliances from the bathroom. Cover electrical outlets.
·         If a man with Alzheimer's disease uses an electric razor, have him use a mirror outside the bathroom to avoid water contact.

Living Room

·         Clear electrical cords from all areas where people walk.
·         Remove scatter rugs or throw rugs. Repair or replace torn carpet.
·         Place decals at eye level on sliding glass doors, picture windows, or furniture with large glass panels to identify the glass pane.
·         Do not leave the person with Alzheimer's disease alone with an open fire in the fireplace. Consider alternative heating sources.
·         Keep matches and cigarette lighters out of reach.
·         Keep the remote controls for the television, DVD player, and stereo system out of sight.

Laundry Room

·         Keep the door to the laundry room locked if possible.
·         Lock all laundry products in a cabinet.
·         Remove large knobs from the washer and dryer if the person with Alzheimer's tampers with machinery.
·         Close and latch the doors and lids to the washer and dryer to prevent objects from being placed in the machines.

Garage/Shed/Basement

·         Lock access to all garages, sheds, and basements if possible.
·         Inside a garage or shed, keep all potentially dangerous items, such as tools, tackle, machines, and sporting equipment either locked away in cabinets or in appropriate boxes/cases.
·         Secure and lock all motor vehicles and keep them out of sight if possible. Consider covering vehicles, including bicycles, that are not frequently used. This may reduce the possibility that the person with Alzheimer's will think about leaving.
·         Keep all toxic materials, such as paint, fertilizers, gasoline, or cleaning supplies, out of view. Either put them in a high, dry place, or lock them in a cabinet.
·         If the person with Alzheimer's is permitted in a garage, shed, or basement, preferably with supervision, make sure the area is well lit and that stairs have a handrail and are safe to walk up and down. Keep walkways clear of debris and clutter, and place overhanging items out of reach.

Home Safety Behavior-By-Behavior

Although a number of behavior and sensory problems may accompany Alzheimer's disease, not every person will experience the disease in exactly the same way. As the disease progresses, particular behavioral changes can create safety problems. The person with Alzheimer's may or may not have these symptoms. However, should these behaviors occur, the following safety recommendations may help reduce risks.

Wandering

·         Remove clutter and clear the pathways from room to room to prevent falls and allow the person with Alzheimer's to move about more freely.
·         Make sure floors provide good traction for walking or pacing. Use nonskid floor wax or leave floors unpolished. Secure all rug edges, eliminate throw rugs, or install nonskid strips. The person with Alzheimer's should wear nonskid shoes or sneakers.
·         Place locks high or low on exit doors so they are out of direct sight. Consider installing double locks that require a key. Keep a key for yourself, and hide one near the door for emergency exit purposes.
·         Use loosely fitting doorknob covers so that the cover turns instead of the actual knob. Due to the potential hazard they could cause if an emergency exit is needed, locked doors and doorknob covers should be used only when a caregiver is present.
·         Install safety devices found in hardware stores to limit how much windows can be opened.
·         If possible, secure the yard with fencing and a locked gate. Use door alarms such as loose bells above the door or devices that ring when the doorknob is touched or the door is opened.
·         Divert the attention of the person with Alzheimer's disease away from using the door by placing small scenic posters on the door; placing removable gates, curtains, or brightly colored streamers across the door; or wallpapering the door to match any adjoining walls.
·         Place STOP, DO NOT ENTER, or CLOSED signs on doors in strategic areas.
·         Keep shoes, keys, suitcases, coats, hats, and other signs of departure out of sight.
·         Obtain a medical identification bracelet for the person with Alzheimer's with the words "memory loss" inscribed along with an emergency telephone number. Place the bracelet on the person's dominant hand to limit the possibility of removal, or solder the bracelet closed. Check with the local Alzheimer's Association about the Safe Return program.
·         Place labels in garments to aid in identification.
·         Keep an article of the person's worn, unwashed clothing in a plastic bag to aid in finding someone with the use of dogs.
·         Notify neighbors of the person's potential to wander or become lost. Alert them to contact you or the police immediately if the individual is seen alone and on the move.
·         Give local police, neighbors, and relatives a recent photo of the person with Alzheimer's, along with the person's name and pertinent information, as a precaution should he or she become lost. Keep extra photos on hand.
·         Consider making an up-to-date home video of the person with Alzheimer's disease.
·         Do not leave a person with Alzheimer's who has a history of wandering unattended.

Rummaging/Hiding Things

·         Lock up all dangerous or toxic products, or place them out of the person's reach.
·         Remove all old or spoiled food from the refrigerator and cupboards. A person with Alzheimer's may rummage for snacks but may lack the judgment or taste to rule out spoiled foods.
·         Simplify the environment by removing clutter or valuable items that could be misplaced, lost, or hidden by the person with Alzheimer's disease. These include important papers, checkbooks, charge cards, and jewelry.
·         If your yard has a fence with a locked gate, place the mailbox outside the gate. People with Alzheimer's often hide, lose, or throw away mail. If this is a serious problem, consider obtaining a post office box.
·         Create a special place for the person with Alzheimer's to rummage freely or sort (for example, a chest of drawers, a bag of selected objects, or a basket of clothing to fold or unfold). Often, safety problems occur when the person with Alzheimer's becomes bored or does not know what to do.
·         Provide the person with Alzheimer's a safe box, treasure chest, or cupboard to store special objects.
·         Close access to unused rooms, thereby limiting the opportunity for rummaging and hiding things.
·         Search the house periodically to discover hiding places. Once found, these hiding places can be discreetly and frequently checked.
·         Keep all trash cans covered or out of sight. The person with Alzheimer's disease may not remember the purpose of the container or may rummage through it.
·         Check trash containers before emptying them in case something has been hidden there or accidentally thrown away.

Hallucinations, Illusions, and Delusions

Due to complex changes occurring in the brain, people with Alzheimer's may see or hear things that have no basis in reality. Hallucinations involve hearing, seeing, smelling, or feeling things that are not really there. For example, a person with Alzheimer's may see children playing in the living room when no children exist. Illusions differ from hallucinations because the person with Alzheimer's is misinterpreting something that actually does exist. Shadows on the wall may look like people, for example. Delusions are false beliefs that the person thinks are real. For example, stealing may be suspected but cannot be verified.
It is important to seek medical evaluation if a person with Alzheimer's has ongoing disturbing hallucinations, illusions, or delusions. Discuss with the doctor any illnesses the person has and medicines he or she is taking. An illness or medicine may cause hallucinations or delusions. Often, these symptoms can be treated with medication or behavior management techniques. With all of these symptoms, the following environmental adaptations also may be helpful.
·         Paint walls a light color to reflect more light. Use solid colors, which are less confusing to an impaired person than a patterned wall. Large, bold prints (for example, florals in wallpaper or drapes) may cause confusing illusions.
·         Make sure there is adequate lighting, and keep extra bulbs handy in a secured place. Dimly lit areas may produce confusing shadows or difficulty with interpreting everyday objects.
·         Reduce glare by using soft light or frosted bulbs, partially closing blinds or curtains, and maintaining adequate globes or shades on light fixtures.
·         Remove or cover mirrors if they cause the person with Alzheimer's disease to become confused or frightened.
·         Ask if the person can point to a specific area that is producing confusion. Perhaps one particular aspect of the environment is being misinterpreted.
·         Vary the home environment as little as possible to minimize the potential for visual confusion. Keep furniture in the same place.
·         Avoid violent or disturbing television programs. The person with Alzheimer's may believe a story is real.
·         Do not confront the person with Alzheimer's who becomes aggressive. Withdraw and make sure you have access to an exit as needed.

Special Occasions/Gatherings/Holidays

When celebrations, special events, or holidays include large numbers of people, remember that large groups may cause a person with Alzheimer's disease some confusion and anxiety. The person with Alzheimer's may find some situations easier and more pleasurable than others.
·         Large gatherings, weddings, family reunions, or picnics may cause anxiety. Consider having a more intimate gathering with only a few people in your home. Think about having friends and family visit in small groups rather than all at once. If you are hosting a large group, remember to prepare the person with Alzheimer's ahead of time. Try to have a space available where he or she can rest, be alone, or spend some time with a smaller number of people, if needed.
·         Consider simplifying your holidays around the home and remember that you already may have more responsibilities than in previous years. For example, rather than cooking an elaborate dinner at Thanksgiving or Christmas, invite family and friends for a potluck dinner. Instead of elaborate decorations, consider choosing a few select items to celebrate holidays. Make sure holiday decorations do not significantly alter the environment, which might confuse the person with Alzheimer's disease.
·         Holiday decorations, such as Christmas trees, lights, or menorahs, should be secured so that they do not fall or catch on fire. Anything flammable should be monitored at all times, and extra precautions should be taken so that lights or anything breakable are fixed firmly, correctly, and out of the way of those with Alzheimer's disease.
·         As suggested by most manufacturers, candles of any size should never be lit without supervision. When not in use, they should be put away.
·         Try to avoid clutter in general, especially in walkways, during the holidays.

Impairment of the Senses

Alzheimer's disease can cause changes in a person's ability to interpret what he or she can see, hear, taste, feel, or smell. The person with Alzheimer's should be evaluated periodically by a physician for any such changes that may be correctable with glasses, dentures, hearing aids, or other devices.

Vision

People with Alzheimer's may experience a number of changes in visual abilities. For example, they may lose their ability to comprehend visual images. Although there is nothing physically wrong with their eyes, people with Alzheimer's may no longer be able to interpret accurately what they see because of brain changes. Also, their sense of perception and depth may be altered. These changes can cause safety concerns.
·         Create color contrast between floors and walls to help the person see depth. Floor coverings are less visually confusing if they are a solid color.
·         Use dishes and placemats in contrasting colors for easier identification.
·         Mark the edges of steps with brightly colored strips of tape to outline changes in height.
·         Place brightly colored signs or simple pictures on important rooms (the bathroom, for example) for easier identification.
·         Be aware that a small pet that blends in with the floor or lies in walkways may be a hazard. The person with Alzheimer's disease may trip over the pet.

Smell

A loss of or decrease in smell often accompanies Alzheimer's disease.
·         Install smoke detectors and check them frequently. The person with Alzheimer's disease may not smell smoke or may not associate it with danger.
·         Keep refrigerators clear of spoiled foods.
·         Touch
·         People with Alzheimer's may experience loss of sensation or may no longer be able to interpret feelings of heat, cold, or discomfort.
·         Adjust water heaters to 120 degrees Fahrenheit to avoid scalding tap water. Most hot water heaters are set at 150 degrees, which can cause burns.
·         Color code separate water faucet handles, with red for hot and blue for cold.
·         Place a sign on the oven, coffee maker, toaster, crock-pot, iron, and other potentially hot appliances that says DO NOT TOUCH or STOP! VERY HOT. The person with Alzheimer's should not use appliances without supervision. Unplug appliances when not in use.
·         Use a thermometer to tell you if bath water is too hot or too cold.
·         Remove furniture or other objects with sharp corners or pad the corners to reduce potential for injury.

Taste

People with Alzheimer's may lose taste sensitivity. As their judgment declines, they also may place dangerous or inappropriate things in their mouths.
·         Keep all condiments such as salt, sugar, or spices hidden if you see the person with Alzheimer's using excess amounts. Too much salt, sugar, or spice can be irritating to the stomach or cause other health problems.
·         Remove or lock up medicine cabinet items such as toothpaste, perfume, lotions, shampoos, rubbing alcohol, and soap, which may look and smell like food to the person with Alzheimer's.
·         Consider a childproof latch on the refrigerator, if necessary.
·         Keep the toll-free poison control number (1-800-222-1222) by the telephone. Keep a bottle of ipecac (vomit-inducing agent) available, but use only with instructions from poison control or 911.
·         Keep pet litter boxes inaccessible to the person with Alzheimer's disease. Do not store pet food in the refrigerator.
·         Learn the Heimlich maneuver or other techniques to use in case of choking. Check with your local Red Cross chapter for more information and instruction.
·         If possible, keep a spare set of dentures. If the person keeps removing dentures, check for correct fit.

Hearing

People with Alzheimer's disease may have normal hearing, but they may lose their ability to interpret what they hear accurately. This loss may result in confusion or overstimulation.
·         Avoid excessive noise in the home such as having the stereo and the TV on at the same time.
·         Be sensitive to the amount of noise outside the home, and close windows or doors, if necessary.
·         Avoid large gatherings of people in the home if the person with Alzheimer's shows signs of agitation or distress in crowds.
·         If the person wears a hearing aid, check the batteries and functioning frequently.

Driving

Driving is a complex activity that demands quick reactions, alert senses, and split-second decision making. For a person with Alzheimer's disease, driving becomes increasingly difficult. Memory loss, impaired judgment, disorientation, impaired visual and spatial perception, slow reaction time, certain medications, diminished attention span, and inability to recognize cues such as stop signs and traffic lights can make driving particularly hazardous.
People with Alzheimer's who continue to drive can be a danger to themselves, their passengers, and the community at large. As the disease progresses, they lose driving skills and must stop driving. Unfortunately, people with Alzheimer's often cannot recognize when they should no longer drive. This is a tremendous safety concern. It is extremely important to have the impaired person's driving abilities carefully evaluated.

Warning Signs of Unsafe Driving

Often, the caregiver or a family member, neighbor, or friend is the first to become aware of the safety hazards of someone with Alzheimer's behind the wheel. If a person with Alzheimer's disease experiences one of more of the following problems, it may be time to limit or stop driving.
Does the person with Alzheimer's:
·         get lost while driving in a familiar location?
·         fail to observe traffic signals?
·         drive at an inappropriate speed?
·         become angry, frustrated, or confused while driving?
·         make slow or poor decisions?
Please do not wait for an accident to happen. Take action immediately!
Explaining to the person with Alzheimer's disease that he or she can no longer drive can be extremely difficult. Loss of driving privileges may represent a tremendous loss of independence, freedom, and identity. It is a significant concern for the person with Alzheimer's and the caregiver. The issue of not driving may produce anger, denial, and grief in the person with Alzheimer's, as well as guilt and anxiety in the caregiver. Family and concerned professionals need to be both sensitive and firm. Above all, they should be persistent and consistent.
The doctor of a person with Alzheimer's disease can assist the family with the task of restricting driving. Talk with the doctor about your concerns. Most people will listen to their doctor. Ask the doctor to advise the person with Alzheimer's to reduce his or her driving, go for a driving evaluation or test, or stop driving altogether. An increasing number of States have laws requiring physicians to report Alzheimer's and related disorders to the Department of Motor Vehicles. The Department of Motor Vehicles then is responsible for retesting the at-risk driver. Testing should occur regularly, at least yearly.
When dementia impairs driving and the person with Alzheimer's disease continues to insist on driving, a number of different approaches may be necessary.
·         Work as a team with family, friends, and professionals, and use a single, simple explanation for the loss of driving ability such as: "You have a memory problem, and it is no longer safe to drive," "You cannot drive because you are on medication," or "The doctor has prescribed that you no longer drive."
·         Ask the doctor to write on a prescription pad DO NOT DRIVE. Ask the doctor to write to the Department of Motor Vehicles or Department of Public Safety saying this person should no longer drive. Show the letter to the person with Alzheimer's disease as evidence.
·         Offer to drive or ask a friend or family member to drive.
·         Walk when possible, and make these outings special events.
·         Use public transportation or any special transportation provided by community organizations. Ask about senior discounts or transportation coupons. The person with Alzheimer's should not take public transportation unsupervised.
·         Park the car at a friend's home.
·         Hide the car keys.
·         Exchange car keys with a set of unusable keys. Some people with Alzheimer's are in the habit of carrying keys.
·         Place a large note under the car hood requesting that any mechanic call you before doing work requested by the person with Alzheimer's disease.
·         Have a mechanic install a "kill switch" or alarm system that disengages the fuel line to prevent the car from starting.
·         Consider selling the car and putting aside for taxi fares the money saved from insurance, repairs, and gasoline.
·         Do not leave a person with Alzheimer's alone in a parked car.

Natural Disaster Safety

Natural disasters come in many forms and degrees of severity. They seldom give warning, and they call upon good judgment and the ability to follow through with crisis plans. People with Alzheimer's disease are at a serious disadvantage. Their impairments in memory and reasoning severely limit their ability to act appropriately in crises.
It is always important to have a plan of action in case of fire, earthquake, flood, tornado, or other disasters. Specific home safety precautions may apply and environmental changes may be needed. The American Red Cross is an excellent resource for general safety information and preparedness guides for comprehensive planning. If there is a person with Alzheimer's in the home, the following precautions apply:
·         Get to know your neighbors, and identify specific individuals who would be willing to help in a crisis. Formulate a plan of action with them should the person with Alzheimer's be unattended during a crisis.
·         Give neighbors a list of emergency phone numbers of caregivers, family members, and primary medical resources.
·         Educate neighbors beforehand about the person's specific disabilities, including inability to follow complex instructions, memory loss, impaired judgment, and probable disorientation and confusion. Give examples of some of the simple one-step instructions that the person may be able to follow.
·         Have regular emergency drills so that each member of the household has a specific task. Realize that the person with Alzheimer's disease cannot be expected to hold any responsibility in the crisis plan and that someone will need to take primary responsibility for supervising the individual.
·         Always have at least an extra week's supply of any medical or personal hygiene items critical to the person's welfare, such as:


§  food and water
§  medications
§  incontinence undergarments
§  hearing aid batteries
        Keep an extra pair of the person's eyeglasses on hand.
        Be sure that the person with Alzheimer's wears an identification bracelet stating "memory loss" should he or she become lost or disoriented during the crisis. Contact your local Alzheimer's Association chapter and enroll the person in the Safe Return program.
        Under no circumstances should a person with Alzheimer's be left alone following a natural disaster. Do not count on the individual to stay in one place while you go to get help. Provide plenty of reassurance.

Who Would Take Care of the Person with Alzheimer's disease if Something Happened to You?

It is important to have a plan in case of your own illness, disability, or death.
·         Consult a lawyer about setting up a living trust, durable power of attorney for health care and finances, and other estate planning tools.
·         Consult with family and close friends to decide who will take responsibility for the person with Alzheimer's. You also may want to seek information about your local public guardian's office, mental health conservator's office, adult protective services, or other case management services. These organizations may have programs to assist the person with Alzheimer's in your absence.
·         Maintain a notebook for the responsible person who will assume caregiving. Such a notebook should contain the following information:


§  emergency phone numbers
§  current problem behaviors and possible solutions
§  ways to calm the person with Alzheimer's
§  assistance needed with toileting, feeding, or grooming
§  favorite activities or food
Preview board and care or long-term care facilities in your community and select a few as possibilities. Share this information with the responsible person. If the person with Alzheimer's disease is no longer able to live at home, the responsible person will be better able to carry out your wishes for long-term care.

Conclusion

Home safety takes many forms. This booklet focuses on the physical environment and specific safety concerns. But the home environment also involves the needs, feelings, and lifestyles of you the caregiver, your family, and the person with Alzheimer's disease. Disability affects all family members, and it is crucial to maintain your emotional and physical welfare in addition to ensuring a safe environment.
We encourage you to make sure you have quiet time, time out, and time to take part in something you enjoy. Protect your own emotional and physical health. Your local Alzheimer's Association chapter can help you with the support and information you may need as you address this very significant checkpoint in your home safety list. You are extremely valuable. As you take on a commitment to care for a person with Alzheimer's, please take on the equally important commitment to care for yourself. 


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