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DISORIENTATION IN ALZHEIMER’S DISEASE
Disorientation (not knowing where one is and not knowing the correct time/date/month etc.) is now being described as a very early feature of the condition. Being so closely linked with memory this is not so surprising. Usually it is the more distant things that go first, like the current year or year of one’s birth. For most people it is the bit of the date of one’s birthday that is used the least. Gradually the person will become muddled as to the correct month and then day of the week, etc. Getting lost outside the home does happen, but in the early stages the person can often remember their address and be got home from their expedition. Later getting lost may prove to be a recurring dilemma, especially for carers who always fear the worst in terms of accidents or illness.
Disorientation in time may take place inside the home but a person’s problems with finding their way around their home rarely occurs until much later. It is well recognized amongst carers and professionals that moving someone from their usual environment can have important consequences. Sameness and continuity are very important for the confused person. They will be continent, eat, go to bed or put on the television because they are in familiar surroundings and patterns of behaviour develop. Many mentally frail people when assessed in hospital do disastrously when asked to make tea or perform other tasks. Take them home for the test and many pass with flying colours. They slot back into their routine. This is why home visits are so important before deciding on the fate of someone who is elderly and chronically confused. A sudden change of environment can not only precipitate an acute (or acute on chronic) confusional episode, it can also deprive the person of their last tentative and precarious hold on independence.
One of my patients has a moderate degree of Alzheimer’s disease with poor memory and a tendency to wander. She actually managed at home with comparatively little in the way of services, having meals on wheels and an excellent home help as well as a caring family. Her family, however, found her wandering a strain as they lived an hour’s drive away and would get calls from perplexed shop owners or from the police. Against advice they arranged for her to be moved to a new flat nearer them so that they could supervise her more. Unfortunately she never accepted the new place as ‘home’. Every time they called she would get up with them to leave this ‘funny place’. She wandered even more, and on one occasion managed to get back to her original address and persuade the local police and firemen that she had been locked out. It wasn’t until they broke down the door and entered a derelict flat that they realized their mistake! Sadly she never settled and indeed was made far more dependent because she could no longer function in her new environment. The kitchen was strange and she could not remember the new way to the toilet and became incontinent. From the best motives came a personal disaster and the eventual outcome was institutional care in a long-stay unit for the elderly mentally infirm.
Keeping routines simple and regular can maintain a confused person in familiar surroundings. Reality orientation techniques are often used in institutional settings but there is no reason why the same basic format cannot be used at home. This involves the use of calendars, clocks and newspapers as well as repeating the day and month (and often clearly labeling the toilet). Visitors should be introduced by name and with an explanation of who they are.
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