H. E. LOGUE, M.D.
H. E. LOGUE, M.D.
permission is granted for personal use
credit is given
To reproduce en masse or for profit contact H.E. Logue, M.D.
AND ESPECIALLY TO MY DAUGHTER
TAPLEY MARCELLE LOGUE-LOPEZ,
PEARLS FOR CAREGIVERS
This is a work in progress. It
is offered as it
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Invitation to Readers
to Reader or Facility
iv. Four A’s of
vi. a. Expectations of Early Dementia
of Moderate Dementia
of Advanced Dementia
2. Talk to me
4. I’m Cold
5. I am Hungry
7. Love me as I
8. The ADL
9. She stole my
11. Encourage me
12. I am a
13. Refrain from
16. This is not
17. Am I a
18. Sing to me
19. I want to go
20. The futility
Winner PCA (Patient Care Assistant)
About the Author
I extend my grateful appreciation
to Peggy Holly, my office administrator, who mercifully accepted this added
task of transcribing all the dictation for this project and acting as my human
dictionary as well. Thank you for accomplishing this task and for many in the
past where you have always been there for me.
You are the exceptional, most
loyal and enduring Administrative Care Assistant.
My thankful appreciation goes to
Dianne Moore, MHT (Mental Health Technician) who has been unsurpassed in aiding
me in my professional caregiving to thousands of patients.
To my colleagues and associates
who have given me the honor and privilege to be a fellow caregiver.
An important part of being a good
caregiver is to be a good teacher. When any of us have good and useful knowledge
and/or skills we must pass them on to students. All who will listen are
When we help someone in need it
is a blessing to that person and to ourselves as well. When in the act of helping that person in the
presence of a student or in relating the event to a student who learns, then we
are passing along our knowledge and skills on an ever expanding roster of
collection of pearls that I have found useful is to do my part in passing them
You are invited to join in and
participate. Send me your pearl(s) at
the web site above or the e-mail.
If your pearl is selected to be
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pearl it becomes part of this copyright You must indicate whether or not you
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Instruction to reader or facility:
If you are reading this on-line
simply enjoy. If you are reading this as
a part of a staff education then behind each Pearl you will find a sign-in
attestation page to acknowledge that you have read that Pearl and on what
date. This serves two purposes for your
supervisor. One is to know that you have
read it and the other is to hold you accountable that you know this about
The facility may alternately ask
you to sign one page that you have read them all.
Four A’s of Alzheimer
A good patient care assistant for
dementia will know the four A’s of Alzheimer disease, pretty much the same for
Amnesia – I have trouble with my memory. It starts subtly with “senior moments”.
It starts as a slow progressive loss, but the
farther we go into dementia the faster it gets.
The final stage is often frighteningly rapid.
Agnosia – I can’t remember the names of things and that
is embarrassing. For example, even my
children’s names. I have trouble naming
things such as a knife or fork, or a wallet or shoe or a car or watch. Help me with names please. Don’t
make me flounder and become
frustrated. Help me.
Aphasia – I have trouble expressing myself. Expressive aphasia. Sometimes I get really
agitated and it
irritates me when I can’t tell you what I want to say. Please tell me “it is
all right”. Comfort me. Work with me to help me get across my
message. I might be trying a crude pantomime.
In the beginning this can be mild language problems but can deteriorate
to gibberish, sometimes called “word salad”.
Sometimes I can’t process or comprehend what others say to me. Comprehension aphasia. This is maddingly
frustrating to both of us. Each of us
try and try, but the harder we try the more frustrated we both become.
Apraxia – I forget how to do things such as walk, brush
my teeth, feed myself or dress myself.
Please assist me. Sometimes when you do, it will trigger the memory for
me of how to do the activity. This also is
very frustrating for me. Please be
patient with me. Help me with the things
I can’t remember how to do.
To help remember these think of
amnesia being in the head, agnosia not remembering the name of the nose,
aphasia not being able to speak and apraxia not being able to use your hands. Hint
– head, nose, mouth and hands.
Our caregiver training begins
with children. Sometimes they are our
own and sometimes the children of others.
We nurture them and help them write on the memory of their brain their
progression through the first several chapters of their life and eventually
into mature independence.
The caregivers, perhaps nannies,
etc. who did this for a profession may years later be a caregiver to the parent
of those same children. At the behest of
those grown children the caregiver may be called upon to be a caregiver to
their parents as they write their final few chapters.
At first there are lapses and
mistakes. The affected person will try
to hide or cover or laugh away the mistake. We laugh with them, but the
mistakes progress until eventually it is tantamount to hitting the proverbial brick
wall of no return. The final chapter
begins after they have lost sound judgment, proper etiquette, social grace and
have lost a great deal of memory including who family members and friends are. We can see but they do not, the removing
bits and pieces of their life including people, life events, accomplishments,
aspirations, thrills and disappointments as they move backward deleting as
those go, finally reaching their infancy of wanting only food and comfort. Even significant segments of their life may
be cut out or dropped completely including such things as places lived, major
events, travels and other important functions. They want to be warm and to not
At this stage they need to feel
love, but they are unable to express it, any more than the unwanted, unloved
infant who develops marasmus (infant depression) and will die from it, if not
recognized and treated by a caregiver.
The end stage dementia person
needs the same understanding patient care assistant as the infant with
marasmus. When they feel unwanted,
unloved, insignificant and uncared for they become depressed and prefer the
comfort of death.
So be kind, comforting and loving
to them. It is our privilege and calling to be good caregivers, the raising up
of the next generation and on the easing down of the fading generation.
Remember to ease me down gently
and lovingly and say a prayer that when your time comes your caregiver will be
vi.a Expectations Early Dementia
As a loved
one, or a caregiver, there are things you should reasonably expect from someone
with dementia. Knowing this and expecting this will help prepare you to not be
so surprised or hurt.
If you live
with someone or have family members in the senior age group expect senior
moments. When you see senior moments acknowledge for yourself, ‘this could be
the beginning of dementia’. Possibly it
is not, but keep an expectant attitude.
early stages of dementia expect it to develop slowly, maybe even imperceptibly.
This is even more likely if the person is in a fixed routine. This stage might
last a year or two, or even three. When
they are in this stage and when you notice they are having difficulty with non
routine things such as balancing a checkbook, making plans or basically any
type of problem solving and also difficulty understanding or following
directions expect this to be some form of dementia. Be careful with this
because it is easy to give them a pass, such as, they were just not thinking or
everybody does that. Expect them to be hurt if you use the word dementia.
Suggest to them that you have noticed a couple of memory slips and you want
them to see their doctor and get some memory pills. Make sure your doctor is
sensitive to these issues in how he deals with early dementia patients. If he is not, then I suggest that you see a
geriatrician or a psychiatrist familiar with dementia treatment. Medications
started early, particularly some combinations of medicines can give early
dementia patients another couple of decent years. Furthermore, medicines are
getting better and better. Research is
This is the
stage, if not accomplished earlier, that you should get a DPOA, Durable Power
vi.b Expectations Moderate
When the person is routinely
forgetting appointments, forgetting that they have something in the microwave
or on the stove, or to take their medication, or to bathe, they have reached
the moderate stage of dementia. This stage will appear to be developing more
rapidly than the early stages. Look at
it this way, if someone loses a few points off l00 it may not be that obvious. But, if they lose a few points of 70
or 60 it
becomes quite noticeable. Expect them to be more defensive, demanding. They may
demand “I can do it myself” (much as a child might) and yet they frequently
require help with something. It is a
very awkward stage of dementia.
Try not to be confrontational or
argumentative but rather understanding, diplomatically helpful and
reassuring. Expect angry outbursts at
you and others, at least in the latter part of the moderate stage. Expect hurtful comments. Expect to be called
by a sibling’s name, or even a friend’s name. Expect to believe they are doing
this intentionally because at times they will unexpectedly sound brilliant. Expect
ethnic or racial slurs and to be accused of stealing from them. Expect to be
confused as to what to do. Do you let
them stay in their home, living independently?
How will you handle their mistakes when they are scammed or give
inordinate amounts of money to their newfound friends, or favorite
charity? When do you step in and get a
Durable Power of Attorney and put controls on their finances, or even get a
conservatorship. Expect to not know what
to do and to feel guilty about doing anything.
Expect to feel the need for help, seek help from your treating
physician, a psychiatrist, a social worker specializing in geriatric issues and
attorneys who specialize in elder law.
Expect to bite your tongue.
Expect to lose your cool and say things you wish you had not said. Expect to be
tired and frustrated. Expect to feel
unsupported by family and friends.
Most of all expect the need to
pat yourself on the back and survive this.
You must believe in yourself and that you will get through this. You may
need to be stronger and more firm than you are accustomed, but it must be done
for your sake and theirs. Trust me on this.
vi.c Expectations Advanced
Eventually dementia will rob the
person of all adult normalcy, social grace, judgment, how to eat, when to eat,
what to eat. They may not eat food and try to eat the napkin or styrofoam cup
or in some cases even excrement. Expect the need for professional help,
sitters, or nursing home, or even hospitalization.
Expect episodes of
psychosis/delirium which can be precipitated by any additional stress such as
an upper respiratory infection and especially a UTI (urinary tract infection).
Just these added stresses will be enough to “blow the fuse” and cause them to lose
what control they had and to become psychotic. When the stressor has been
removed they return to their premorbid state most of the time. Occasionally
they remain psychotic.
Often they will be combative when
you try to bathe them, or shave them, or dress them. They may not understand or
may not want to be bathed or dressed. Without warning they could do serious
damage by hitting you in the eye. Expect the unexpected, be cautious, and be
self-protective while being mindful of their needs as well.
Expect these final stages to go
rapidly. When they are not eating
properly or taking fluids properly, their organs begin to fail. Their kidneys
shut down. Their lungs get pneumonia. Instead of swallowing they may aspirate.
Expect their demise to be earlier
than you want and to feel that you have not done all you should have. Expect to
be asked about “code status”. As their
mind is ravaged it will deteriorate to the point that they become unaware of
themselves, their surroundings, their family and their life. They may not have
prepared a Living Will. They may no longer be capable of making informed
decisions for themselves. You must consider what you would want for yourself and
to make the decisions as to the best course for them. This can and does cause
family dissention. Be wise, discuss and plan ahead.
And, one final thing, expect them
to hear you even when they are unresponsive. Hearing was developed in the womb
and is the last sense to go. Be gentle and kind with the words you and the
others in the room use. Speak words of
love and appreciation for all the good that you had with the person. Thank them
for the good and joy they brought to you.
Express knowledge of the fatigue and struggle they are in and give them
permission to let go whenever they need to, that you are at peace with them and
you hope and believe that are at peace with you.
Touch me please; gently I hope.
From the moment
of conception we were touched and nurtured by our mother. For the majority of us, infancy provided
ongoing touching that showed love and caring.
It could be hugs, kisses, snuggling, diaper changes, bathing, assistance
with eating, walking or oral and body hygiene. It could even be discipline but
that is tricky and a separate subject.
similar these needs are to our demented patients, for that matter, even our
severely disabled patients.
Please know and
remember that when I am demented I am de-educated
by illness and my mental capacity is equal to my un-educated infant brain.
I still feel and
need someone as I did in my infant days; and some days so might you as well.
So touch me
gently please as if you care. I will
greatly appreciate your caring kindness.
I know my mom would smile and yours would be proud.
in my dementia I attempt inappropriate touching I hope you will understand my
impaired judgment and be diplomatic as you redirect me.
2) Talk to me. I hear you even if I do not
Soothing encouraging words are
most helpful. It is disheartening to
hear words in your conversation that pronounce or declare me “incurable” or “at
the end, why drag it out”. You really
don’t have any way of knowing. Be
honest. How many times have you been
On rounds recently an RN told me
at the bedside of a sick/sleeping patient; “oh he is a no code. The family can’t take care of him.
I think they just want hospice for him.”
Often patients in a coma or under
deep anesthesia not only hear conversation but record the comments word for
work in their subconscious.
A study was conducted on people
who had high regard for their surgeons but after successful surgery kept making
excuses to not return for followup visits.
However, they continue to say wonderful things about their surgeon.
Under hypnosis several of these patients
revealed being embarrassed by comments about them by the surgeon during
surgery. However, the patients had no conscious memory of the comments, but the
hurt had registered profoundly on the emotion. In each case the surgeon and the operating
room team confirmed the accuracy of the patient’s comments.
Your words have consequences so
do keep them therapeutic.
On an even more profound note,
consider this recorded incident at an air show. A plane crashed on the runway
in front of spectators. The pilot was
unconscious and was presumed by many to be dead. He “woke up”.
He then looked at the spectators and immediately walked directly to a
lady in the crowd and lectured her for saying he was a stupid pilot and should
not have put them in danger. She had in
fact said those things to the nearby spectators. She fainted.
The pilot claimed that he had had an out of body experience and that his
spirit was floating above the crowd and he was able to hear what people were saying.
We have many similar experiences where people during surgery have out of body
experiences where they describe things as if they were on the ceiling looking
down at the scene.
As caregivers, it behooves us to
be thoughtful and careful what we say.
Laughing is not just for
fun. It is for good health as well. Laughing releases endorphins, the body’s own
narcotic equivalent; it makes us feel good.
Endorphins boost our mood and reduce our pain and depression.
Years ago a study was conducted
to test the therapeutic effect of treating depression with laughter. I was told that it was done at UAB but I am
Treatment consisted of having
patients watch movies of comedy that would produce laughter, mostly slapstick
type comedy. I do not have the statistics or graphs to show you the
results. I only have related information
that those who were consistently aroused to laughter overcame their depression
as well as those treated with medical antidepressants.
You and I don’t walk around with
a movie in our pocket; however, our patients have a storehouse of laughable
moments in their life. Understanding that principle, we will have the
opportunities to reach out to their past, to their humorous moments. In fact
laughter that is personal to us is even more powerful than laughter coming from
a movie screen or TV. Demented patients particularly enjoy reminiscing about
the past times because those memories are still clearer than their more recent
experiences. Ask them about their youth, their teenage and young adult years;
what kind of things did they do? Did they grow up on a farm, or in the city?
From those answers you can retrieve some funny things and or stories from their
memories. Perhaps you should ask about
their first car, their school, and their classmates. Did they have a class clown? Were they the class clown?
You might start a drive to have
CD’s of comedy donated to the unit.
Laughter is infectious. It breeds more laughter within the person but
also from the people around them including ourselves and other patients.
Remember the old adage “Laugh and
the world laughs with you. Cry and you
PS: Don’t forget that the more we laugh the more
exercise our facial muscles get. That makes us feel and look younger to some
extent, but every little bit helps, right?
4) I’m cold.
I need a warm blanket. I wish I could tell you. I try but with my
word salad language you can’t
You are my caregiver, I depend on
you. I have to. I have no choice. Look at me. My skin is sort of blanched. I am not at all pink and rosy.
I am trying to curl up in a ball to conserve
heat. Don’t you see me fidgeting with my cover?
I just can’t figure out how to wrap myself up. I think I am shivering. My muscles will be tired but I will
I need a warm blanket. Look at me.
When you glance at me between text messages or chit chatting with
associates, I know and so do you a glance is a far cry from really looking at me. I am crying inside even
if I can’t verbalize it.
My metabolism (my internal
heater) is not as good as when in my youth like yours is now.
I need a warm blanket, please.
5) I am hungry.
My food tray is here but I can’t
feed myself. I see you go by and barely look
at me. Because dementia has robbed my speech I can’t tell you how that makes me
feel. I really wish I could because it’s
a terribly bad feeling. Like I am a
bother to you, a job task you might be able to ignore without it being noticed
by your supervisor. For the record, I am
noticing and by the way I am spoken of in the Bible as “one of the least of
these”. You might want to remember that
ultimately we are all watched twenty four seven.
Be patient with me and feed me
please. Your day will end not with
shame, but an earned sense of pride in a realistic lifted self-esteem.
Being a good soldier, worker or
caregiver doesn’t mean having the badges and the paycheck to show, it simply
means actually having earned them by your service.
You have both talent and
ability. Don’t let them wither away like
wasted muscles gone from disuse atrophy.
Your conscience also keeps a
record of your deeds, both positive and negative.
6) Motion – Living people are
people in motion.
People who are dead can’t and
don’t move. People that don’t move tend
to feel dead. Their room, or even their body, may feel like their prison. They
might even say, “I’m dead”. They may be
that much out of touch with life.
Help them! Move their limbs, turn their body, get them
up. If a wheelchair is necessary use it. Roll them around; engage them in any
and all activities possible. Introduce
them to others. If available and
feasible, use a rocking chair.
From conception to birth while in
the womb we are essentially constantly in motion and experiencing motion. Motion is natural to us. Motion should
be continued after birth. When infants and small children are not
continued in motion such as swinging, bouncing, riding in kiddy cars, and other
motion activities, then motion becomes less a part of them, less desirable and
can and does lead to motion sickness or even anxiety and insecurity because of
motion not being familiar to them.
Some people with dementia actually
revert to, or develop, anxiety about motion or even motion sickness. While we need to be aware of that we also
need to remember that for most people motion is essential to feel alive.
If I say “I’m dead” and I am not
very mobile please keep me moving. I am not dead yet. Help me feel alive.
7) Love me as I am.
You should love me or care for me
lovingly. Throughout life this is
especially true during infancy, preschool years and in dementia. During the in between years, I can be taught
and you can reason with me. During
infancy and dementia there is no intellectual basis for reason. While teaching
and learning is the key in infancy, dementia takes away that which was
previously learned and it becomes the caregiver who has to do the learning of
the needs of those who have dementia. As the dementia progresses the need
becomes more infantile, emotional and to the patient paramount.
Someone with dementia might for
example see you and for some reason think you “could be” or “might be” the
cause or reason of their unhappy state.
Just remember if you understand this and treat me lovingly you will have
a much better chance that I respond pleasantly or even happily.
8) The ADL tango.
As a seasoned patient caregiver
you either know about the ADL tango or you are about to find out if you try to
bathe me, brush my teeth, groom and dress me.
I did not like it as an infant when my resistance was limited to crying
and yelling. Now I don’t have to cry. I
can still yell but I can do more. Oh
yeah! We are definitely about to
tango. I have all kinds of moves. I will teach you some of them. I can hit, right or left, kick, sit, fall,
run, head butt or I might even spit at you.
You will need to be pretty good to out tango me.
The more you come at me in
uniform looking like Mr. or Ms. Authority with arm full of would-be weapons or
torture instruments, the quicker and more fierce our unhappy dance will
start. It can be even worse if I am gender
or race sensitive.
I suggest you try some pleasant
good morning uplifting conversation with me before announcing that you are here
to assist me to get ready for breakfast.
If I refuse maybe you could invite me for a stroll or to the TV room, of
course, it is a bribe to get me to finish my ADL’s.
Keep me in calm pleasant
conversation and we might just waltz through this dance.
9) She stole my watch.
Because I am forgetful and absent
minded I often forget where I put things. It is embarrassing to say I lost
something or I can’t remember where I put something. So, to save face, my subconscious mind,
teaming up with my unconscious mind will shift the blame to someone else. That is how she or he or whoever is the most
convenient will get the blame and the finger pointed at them as the thief.
You tried to persuade me that she
has been a loyal family helper for decades and there has never been anything
missing. Well, let me tell you, my watch is missing. You see my arm don’t you? There is always a first time
you know. I am really irritated that you don’t believe
A good caregiver knows to keep
looking and likely the object has been hidden from a would be robber but that
memory including where the object was hidden is one of my lost memories. Though I have many of those I don’t want
admit it. Let’s say you found the watch
in the vegetable bin of the refrigerator. The caregiver tells the adult child.
The result plays out similar to
this. Hey, pop, good news. Othello found your watch. It was in the
refrigerator. I answer; did you get it fingerprinted to see who put it
there? They knew I was about to catch
them so they brought it back. These type things happen in the late early stages
and in the middle stages, occasionally even in the latter stages. So, discuss with your psychiatrist. Sometimes
antipsychotics are used with good
efficacy, but poor at other times. These
medicines have risks of their own. The risk has to be measured against the
10) Caregivers beware.
Some of you forgot to care for
yourself. If you are employed, you
likely have days off. If you are a
caregiver for someone in your home it is unlikely that others are lining up to
offer you a day off, or rushing to give you relief. Sadly, it is not infrequent that as a
psychiatrist I see caregivers in families where there are 2 or more siblings,
sometimes even several, but one will get designated as the caregiver. Many reasons (read excuses) will be used,
such as, you don’t work. You are the
only one with the time. We all
work. I am sick myself. Mom/dad always listens to you better than
us. You were always his/her favorite.
You are the only one who can prevent her/him from having to go to the nursing
home; you know he/she doesn’t want that.
Believe me, the list is exhaustive.
How to protect yourself: don’t buy even one nickel’s worth
hogwash. Even if everything they say is
true it should not mean “therefore you have been sentenced to sacrifice yourself
to unilaterally discharge a caregiver obligation that collectively and equally
belong to each of them and you. No one
except a caregiver knows or understands the physical and mental challenges,
strain and effort required to make it through a 24 hour day so aptly called the
36-hour day in the excellent book by Nancy L. Mace, M.A. and Peter V. Rabins,
If they truly cared as much about
you or your health or your needs as they do about themselves, they would find a
way to help. So, it is up to you to care
as much about yourself as they do about themselves. You have to demand relief by getting quality
private recharging time. Perhaps they could take turns for a week or at least
take weekend turns to leave you that freedom.
Alternately, you could have them pitch in and help to have the patient
stay at a respite facility for several days.
And don’t even think of letting
them get away with not sharing the expenses.
That does mean all expenses.
Remember, if soft talk does not
work, speak up for yourself forcefully.
It is highly unlikely that anyone else will. If necessary get an eldercare attorney but
get help for yourself.
Don’t be a pushover. Don’t get
run over. Don’t take on unrealistic
Be rational and reasonable in how
much of yourself you can afford to spend to be a caregiver.
11) Encourage me
For what I can still do.
A person with advanced dementia
may have some special talent such as a solid musical background. They might
have been an accomplished piano player.
They are likely, even in dementia, to play tunes flawlessly from
memory. This is particularly true if
these tunes are from their youth and their prime. Encouraging them to play for
themselves as well as for those around them, usually gives them great pleasure
and satisfaction. Others may be gifted
artists. They might paint a chaotic
picture which might be analogous to the chaos of their mind. They also might paint great pictures from
yesteryear from earlier impressions or memories.
A mid octogenarian that I know
can’t balance the monthly checkbook and calls the bank 2 to 3 times per month
to argue with them that they keep getting her bank statement messed up.
However, she joined a bridge club and routinely wins. It is a carryover passion from her young
adult life. It was done so much and
practiced so much that even if some of the memory is damaged a great deal of it
is still there, just as with the piano player.
Even those with severe dementia
can respond to memories of the past such as picking cotton, or playing baseball
or basketball, etc. They might remember
hiking, fishing, or whatever they did, whether ministering or flying or
trucking or being a service person, or military person. Get them to talk about
what they did. Of course, don’t
frustrate those with aphasia who can’t really express themselves.
If I am the patient help me find
the still glowing embers in my struggling brain. You can build a brief fire in me that will
warm both our hearts.
12) I am a veteran
Please don’t startle me.
Did you know that when you rap on
my door it sounds to me like close range firearms? Then you open the door and come into my
room. It feels like I have been overrun
by the enemy. When you then begin to
touch me or pull at me it feels like I am being captured. I don’t know by whom or where you are taking
me. I don’t know my fate but I am pretty
sure it is not good. Remember I was
taught to resist so don’t be surprised if I fight.
Please pardon me but you see a large
part of my adult brain is not working so well these days. I frequently rely on
that part of my brain that is more intact which was when I was younger and in
The War. Remember too that what we learn
with intensity of training and especially with intense emotion is programmed to
stay in place longer and to stay at the forefront of my protective nature. Some of this is so emotional that it turns
out to be Posttraumatic Stress Disorder.
We are very apt to “go off” at you.
Some natural things will rattle me pretty bad. One thing that will make
me jump out of bed is a woodpecker pecking on a gutter drain. Please monitor the TV and don’t allow war
movies or other violent movies. Instead, try comedy or something heartwarming.
When you combine the knowledge of
the level of my dementia and my history it helps you to predict my
behavior. If I have regressed to young
adulthood and I had a violent difficult period during that time I am likely to
be in a pretty defensive mode. I could
very quickly become aggressive. If so, please gently talk me down. We don’t
need to fight. And oh, don’t forget to
thank me for my service to our country. It is important to me.
13) Refrain from destructo therapy.
This is a new craze that is
catching on in some places but it is wrong and dangerous. Don’t buy into
it. Don’t be misguided. People claim
that it is therapy; they are teaching people to get rid of their frustration by
violently getting it out of their system as they destroy things. Destructo therapy. It works like this.
A person is frustrated with
various things in their life, maybe their boss; maybe their spouse and they
feel constrained that they can’t get their feelings out. They pay to go into a
place and use hammers or other objects or their fist or their shoes to kick and
destroy such things as cell phones, TV’s, computers, and flower arrangements,
whatever. That is not therapy. It is
simply venting of anger. Emotion is
where the power is. The more powerful
the emotion, the more powerful the anger. Power/emotion fuels memory so when
one uses destructive activity such as this to focus their anger and violence as
a response to their emotion of hurt or rejection they become more empowered to
respond violently, perhaps even at a family member or friend from whom they perceive
pain or hurt. It is tantamount to
teaching people to be violent. In this
scenario destruction and violence becomes ones go to solution. This
definitely should not be taught. It is
incredible that people are paying to be taught to legitimize violence. I believe it is dangerous activity or worse
masquerading as therapy.
We need strong characterological
inhibitions and judgment in place to combat teachings such as these. It is bad
enough for anyone, but with a person who has dementia and is beginning to lose
their characterological inhibitions and controls, being exposed to seeing
something like this could be catastrophic.
It might prompt one to be violent toward their spouse.
You will be able to learn quite a
bit by observing me. This is
particularly true after I won’t be able to talk to you any more. Consider me
one poor excuse for pantomime.
If I am constantly in motion
getting out of the chair, walking, getting back in the chair, never satisfied
where I am, you might consider that I am restless. Why?
It could be because I have EPS (extrapyramidal symptoms), a side effect
of some of the medications I am being given that possibly could be changed or
balanced with other medicines. It could
be simply that I am very anxious or that I have an agitated depression. Do I look sad and dejected?
These observations can be very
helpful to the family or the doctor who might not notice these symptoms during
a rounding session.
Have you noticed me eating? Do I use my utensils properly? Can
I even use utensils? Do I need finger food instead? Can I swallow my food? Does it need to be mechanically
even pureed? What about my likes? If I am in your presence long and continue to
resist for example a routine breakfast, maybe I don’t like that. Maybe I would like a different type of
breakfast. You can help me a great deal
if you notice these things.
Is my gait steady? Has it changed any? Has my balance gotten worse?
The doctor needs to know. The family needs to
know. The staff needs to make sure the person is kept in close proximity and
Am I trying to tell you something? Perhaps if you can’t understand
else could. For example, male to male or
female to female. A particular dialect
might need to be matched as much as possible.
Body language is a form of
communication. Do I appear to be favoring a certain limb or area? Do I appear to be in pain? If you notice something
about a resident
please pass it along to the nurse or the doctor. Write it down.
I may be dehydrated if:
1) Am I not eating enough, or drinking
enough fluids? If my output is not
adequate or regular?
2) Do I appear to be hot or cold? If so I might have an
infection, flu, cold,
genitourinary, etc. My skin turgor is
sluggish, more like dough than rubber.
3) I have unexplained headaches especially
in the early morning.
15) Hallucinations and delusions.
My hallucinations and delusions
are more tricky and problematic for you than for me. Don’t tell me I don’t see
bugs, or children and especially my deceased parents, because I certainly
do. I may not be seeing them with my
eyes but I most clearly see them with my remote memory in a deeper part of my brain
and the image is as clear as with my eyes.
These memories are housed in the deepest more protected part of my
brain. They are very important to me now that I have lost much of my recent
intellectual knowledge and ability. That
remote part of my brain constructs these images for me and others like me. The brain fashions these images for us simply
from the signals received from the eye.
The brain also produces images just as clearly from thoughts during
dreams and so it draws images from the neurons of stored memory from the past.
Close your eyes. You can and do
visualize your surroundings and retained images or you may consciously create
images. Certainly dreams prove that. You see people and faces with changing
images, expressions and affect along with changing landscape. Notice also that it might include the
present, or the past, or even the future.
People even create and invent things during their dreams.
I thought if you knew all of this
it might help you to understand me when I am delirious or psychotic. Please don’t challenge me on what I see or
don’t see or hear, or don’t hear. Take
my word for it, or actions, as evidence.
I promise you they are reality to my brain at the time. Perhaps if you
can understand it you be able to help me deal with it. You don’t see my hallucinations or believe my
delusions so don’t go along with them or pretend that you do. That will only
encourage them. Spending time or giving emotion to bad things or wrong things is
tantamount to putting fertilizer on weeds.
Be kind to me; gently bring me
back to reality. Give me some
unchallenging comment such as ‘that’s okay’ or ‘that’s nice’ and then quickly
move to a different subject, you need to eat more of your breakfast. Here try this. Or, have a little more juice,
or why don’t we
take a walk or watch a TV program, or listen to music, or, etc. You get the idea.
The last thing a damaged brain
needs is to be overtaxed or over challenged.
Remember, you are here to help me, nor harshly grade me or embarrass me.
16) This is not my dad.
I have known my dad all my life,
of course, and I never heard him curse, or saw him hit anyone or be seductive,
impolite, rude, or unmanageable. Why is he doing this? Is he possessed?
I want my dad back. Can you fix him?
Your frustration is
understandable. Let’s explore the
logical answers to your questions. Your
dad has dementia. By definition his
brain function is impaired. Despite the
impairment and memory loss there remains a great deal of knowledge, memories,
unsatisfied urges, needs or wants now exposable Because inhibitions, laws,
morals, rules, social grace, etiquette, etc. are among the earliest things lost
with dementia. In his past he may have
witnessed such behavior or, read about them, or even preached against them.
These abhorrent acts can be activated or stimulated by something someone says
or does, or even seen on TV, or heard on radio.
It may even happen because the mind or brain is in the on position and
in a roaming mode rambling around through the neurons of recorded past and may
accidentally trigger these memories therefore consequent actions. It is
analogous to him roaming or rambling through the halls looking for something,
not knowing what, or just anything he happens to stumble upon.
No, I can’t fix him, but
redirecting him and using medication may be beneficial in controlling some of
the unwanted behavior. Helping to
educate you about his dementia may in fact help you more than him. For example,
it is wonderful to know that his brain had knowledge of this kind of behavior
that some have acted upon, but not him because of his great strong character
until the uncontrollable dementia destroyed some of his controls and
inhibitions and therefore part of the person and the dad that you have known.
Don’t be embarrassed by his
actions. Your dad’s damaged brain is using your dad’s body to mimic behaviors
known to him years ago but that have previously remained controlled and in the
past. He is non compos mentis. He cannot be held accountable for his
Lighten up, try every trick you
can think of to make him laugh and keep his mind focused on more civil or
17) Am I a different person?
You have never seen me be
anything but a gentleman/or lady. Lately, however, you have seen me act
differently. You saw me hit another
person who reached over and took a biscuit off my plate, or you saw me make a
sexually inappropriate comment or make a pass at a staff member or visitor or
even a family member. Perhaps you witnessed me make an ethnic slur. I might even invite someone to my room, or
bed, that I previously offended with a racial comment.
As a family member or caregiver
you have personally never witnessed or known of any such behavior on my
part. How can this be? You think; is he crazy, is he possessed, has
he changed, or worse has he always been this way and we just never knew? I know it must be confusing to you.
It is imperative that you
understand that all you have read above is a natural biophysical process. I plead with you to read this thoughtfully
and understand because it will help you have peace and calm while caring for
me. If you are really at peace with yourself
you can even appreciate humor with me.
All my life my brain has been a
sponge gathering gigabytes of information and knowledge about our society, our
interactions, our biases, belief systems, values, politics, etc. Many of these information bits were filed
away, never used or believed and maybe even abhorred. But, my brain is a just a
powerful sponge and storehouse. The
longer I keep this information the more crystallized it becomes and the more it
is layered over and protected.
As my brain deteriorates it
progressively does trigger bizarre actions.
It misfires like a badly damaged computer. You will see me try to eat
soup with a knife, or jelly with my fingers. That can be funny but at the same
time sad. It is from my basic memories
or attempts at feeding myself. My brain
is desperately trying to help me function.
It is simply the same process
while I am trying to communicate my brain is reaching into the deep past and
the well protected and previously banished phases now unprotected sneak out. I
am probably trying to say I appreciate you, or, I need your help, or, I need
your human closeness, touch and sound just as a baby would, or even that I
don’t like the way I am being treated. My failing brain misfires terribly at
times as I try to communicate with you.
Please understand me and laugh as you might when I try to eat soup with
18) Sing to Me
Don’t forget that my mind is
going back to the past. The thing most recognized and therefore enjoyed are the
good things from my adolescence and young adult life. Popular music of the era are favorites. When
you sing or even hum a few lines that were popular in my youth you will spark
dormant pleasure cells deep inside my brain.
I may even smile at you or say a few words or even try to sing with you.
Sing to me, sing with me; you
will have made my day. You will
experience gratification that is above and beyond your paycheck.
The most popular songs and tunes
will be from forty, fifty or sixty years ago and if you don’t know them, you
should ask or research some of the popular tunes of those eras. Become familiar with a few of these. Be proactive.
You should study it. It is part
of the tools of your trade.
19) I want to go home.
As my caregiver, you need to know
which home it is that I seek. I have
many as you will see. In early and middle dementia I may get confused in my own
home. Often just walking me to a
familiar room or bed will satisfy my need.
In middle and late dementia it can be very different. As our most recent layers of memory are
confused, damaged or destroyed please realize that the home in these memory
segments are damaged or have disappeared.
Therefore, look for homes closer to the more stable memory of
yesteryear, maybe decades ago. Often this memory will recede back to “the home
place”. We may also be asking or looking
for mama and sometimes daddy.
Reassurance and redirection are useful techniques in times like
this. Do not, repeat, do not fib and say
“mama will be back soon” or things of that nature. You could say something similar to “we are
going to stay here for a few days. It’s
a nice place and the people are really great or wonderful. I think we are going to like it.” When mama asks
“when is Daddy coming home?” I
have even said “I guess it will just have to be a surprise.”
Don’t forget that when a person
is truly miserable in pain or severely depressed a comment that they want to go
home may be code for “I want to go to Heaven”.
If that appears to be the case, you may try, “we have to wait until we
are called”. Then add some redirection
such as “since we won’t know the day or the hour we need to take care of
ourselves in the meantime”. Immediately then change the subject, ask them if
they want something to eat or drink or take a walk. In other words, change the
20) The futility of arguing.
So you want to argue with
me. You need to understand that it is
futile to argue with me. I suggest you don’t try. You will attempt to use
logic. I can’t use logic because that
part of my brain is damaged. I use emotion;
that is where my power is. It comes from
feelings. I still have those in
abundance, for example embarrassment, ridicule, neglect, disdain, contempt,
condescension and being deliberately ignored.
All of those things make me angry
or at the least will fuel any anger already present. The anger with emotion is
the power in my quasi logic. It makes me feel as if I am winning the
argument. It proves to me that I am
right and you are wrong. The more we argue, the more energized I will become in
my position. Since I can’t argue with you with logic I can only argue with
anger. If I can get you angry I can win
the argument. I have no other weapon and
I have no inhibition. It is no problem
for me to become loud and unmanageable.
I don’t foresee consequences. I
only want to win. I might get an
injection but if you engage in the argument you possibly will lose your
job. Think about it, that’s not
unfair. You see my brain is broken and
yours is not and besides that, you have professional training.
So let’s not both of us become
unhappy and angry. Instead, help me avoid arguments. Don’t challenge my erroneous beliefs. Try telling me
you will talk about it later,
or you will look into it. In the
meantime there is something we need to do now. Take me for a walk, offer me
some ice cream, and turn on my favorite TV program. Do anything to distract me from arguing.
I am calling on you for the art
of caregiving versus being my sitter, guard or warden.
This collection of Pearls was
initiated in January of 2013. As I do
the final proof in August I realize that I have just begun my 51st
year of practicing medicine. Forty-four of those years have been exclusive to
Two passions of mine are my
practice and to help inform the public of useful information about the various
mental illnesses and their effects on the person, family and society.
My goal in Pearls for Caregivers
is to give understanding and useful tips to those who become voluntarily, or
involuntarily, involved in caregiving.
Provided that goal is attained with the reader it will consequently
improve the life of the patient and the caregiver.
On my web site,
www.heloguemd.com, you will find a brief bio and a comprehensive curriculum
vita plus information on other topics.
H. E. Logue, M.D.
Legible Name of Associate
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