Are you a “sock-shoe-sock-shoe” or a “sock-sock-shoe-shoe”?
We all have our own routines- our own patterns for completing tasks in our day. Dementia alters the ability to learn new routines or recover from a deviation in a routine. When early signs and symptoms of dementia emerge, there is usually a push from family members to implement change, and a push back from the demented person who is suddenly more rigid in his or her routine. The result is usually grid lock, peppered with resentment and misunderstanding. Who is right? Who should back down? The answer is maybe not who, but when.
Two factors are important to understand about the somewhat predictable behaviors in Alzheimer’s disease. The first is that structure and routine are absolutely imperative in maintaining function and independence. The second is that the ability to learn new routines is virtually impossible in the later stages. So the real dilemma becomes when is the best time to implement change, while the person has the ability to learn a new environment and a new routine, or once the ability to function has diminished to the point that the person that confusion makes change easier.
And the answer is… sooner is better. Personally and from my distant perspective, I would probably want to jump right in and implement new strategies and routines at the moment of diagnosis. More realistically though, I’d have to choose my battles. Starting with the hot-button safety items first (medications, burns/fires, finances), implementing small changes is the most realistic plan. For a variety of reasons, early stage folks reap great cognitive rewards by keeping a calendar or daily schedule of their lives. Orientation, memory, processing skills are just some of the cognitive skills enhanced through the act of taking an active part in scheduling. When these tasks are passively absorbed ( “Mom, don’t forget you have an appointment on Wednesday.”), active cognitive processes are not engaged. And anecdotally speaking, captains who perceive that they are steering their own ship are generally more cooperative and engaged.
In 2001, Nygard and Johansson used time aid interventions- clocks and calendars- to assist people with memory loss in managing daily routines and schedules. The results were weak but positive in supporting the idea that structure and routines compensate for memory loss in the early stages. Conversely, removing structure and routine in the late stages of Alzheimer’s has shown to be helpful in decreasing difficult behaviors.
I have learned to watch my clients before jumping in with suggestions and changes. Did you know that there is about 99 different ways to perform oral hygiene? Trust me when I say that everyone does it differently. It is important that I allow for personal patterns in accomplishing a task, including where items are located and in what sequence the steps are completed. Any recommendation I do have for someone with early stage Alzheimer’s is always offered as a way to improve upon the already fabulous techniques I have just witnessed- not as criticism or as a feedback meant to scrap the current routine. The best chance someone has of maintaining the ability to complete tasks like toothbrushing is to do it the same way over and over again, year after year.
If changes in routine or schedules are inevitable, and they usually are, engage the person actively in the process and be as consistent as possible in implementation. Allow at least three weeks to learn something new. Make room for personal preferences and curiosities, we all have them.