Psychiatry - August 2008 - (Page 53)

[update on Alzheimer’s] they have lost, and caregivers can help them do this.24 For example, a patient with AD may not be able to remember the date, but he or she may remember where the calendar is in the kitchen. The spouse can help the patient compensate for not being able to remember the date by asking the patient where the calendar is instead. This can also prevent possible resentment by the patient for being repeatedly asked something he or she cannot remember (the date). Another way a caregiver or spouse of a patient with AD can help the patient use areas of functioning is through every day conversations. For example, I was treating a patient with AD who had been a soccer coach. I asked him about the secrets of his coaching success. He told me in much detail how he’d encouraged his players to practice dribbling throughout the house. He enjoyed talking about soccer and he remembered it well, which helped maintain his self esteem. Psychiatrists also should encourage patients with AD to continue taking on household responsibilities because this also helps patients maintain their self esteem. Caregivers, likewise, should encourage this, though the responsibilities these patients take on may become less demanding over time. A patient with AD may, for example, do the dishes each night after dinner, but then as time goes by, only dry the dishes. As another example of how these patients can gain self esteem by continuing to have responsibilities, a patient with early AD may find value in helping patients with latestage AD by reading to them.25 A caregiver or spouse may at times face uncertainty when deciding how much responsibility he or she should encourage the patient with AD to take on. On the humorous side, a patient with AD said he was no longer able to clean up his pet’s “mess.” The patient later acknowledged that this was a ruse. As the symptoms of AD worsen, the caregiver or spouse should continue to try finding ways to maximize the patient’s capacity to do things for himself or herself. For example, a patient with AD may lose the ability to fasten buttons or snaps or operate zippers on clothing. This patient, therefore, may benefit by converting to elastic waistband-only pants so that he or she can continue to put on and take off his or her own pants. The psychiatrist should also maximize gains from medication in patients with AD. A core example is the use of cholinesterase inhibitors. It may be that an AD patient cannot take either of two cholinesterase inhibitors because of side effects. What next? Should the psychiatrist consider a third cholinesterase inhibitor? What if the patient cannot tolerate any inhibitors? Perhaps the psychiatrist should then consider prescribing memantine, which has not been proven effective during the mild stage of AD.26 But the psychiatrist might reasonably consider this intervention if a patient is not able to tolerate cholinesterase inhibitors. Should the consideration of the psychiatrist go beyond this? One study showed that donepezil may be safe and effective at higher than usual dosages.27 This higher dosage could help some patients and thus increase their quality of life. Yet, this higher dosage may be more problematic, because it may be impossible to know whether this higher dosage is helping. The point is the psychiatrist should not decide prematurely that medications will not help a patient with AD when this may not be the case. TREATING PATIENTS WITH LATE-STAGE AD In the later stages of AD, it is increasingly important that a patient’s caregiver and/or spouse know that this patient’s quality of life is not determined solely or mostly by his or her cognitive status. Data suggest that many caregivers do not know this.3,4 If caregivers assume the opposite and give patients with AD less personalized care than they could, this erroneous assumption may do more harm to the patient than good. One concept that is particularly critical when caring for patients with late-stage AD is assisting these patients’ caregivers. One way a psychiatrist can help a caregiver immensely is by finding ways to help alleviate his or her most “catastrophic” fears, which I find usually are the following: 1) having an emergency situation he or she cannot handle and 2) “falling” apart or not being able to cope emotionally with the patient any longer. Accordingly, a psychiatrist can take measures to ensure that a caregiver has a phone number he or she can call for help 24 hours a day. The psychiatrist can also walk through different scenarios with the caregiver telling him or her exactly what to do step by step in the event an emergency situation occurs to help prevent the caregiver from feeling overwhelmed. The psychiatrist might also anticipate times in which a caregiver is likely to feel exceptionally stressed, such as when he or she has to take the patient to a medical appointment that in the past the patient has refused. In this example, the psychiatrist could take the initiative to call the caregiver and ask how things “went.” This may help to [AUGUST] Psychiatry 2008 53

Table of Contents Feed for the Digital Edition of Psychiatry - August 2008

Psychiatry - August 2008 Editor’s Message Editorial Advisory Board Contents Borderline Personality Disorder: Are Proliferative Symptoms Characteristic? Short-acting versus Long-acting Medications for the Treatment of ADHD Baby Stimuli and the Parent Brain: Functional Neuroimaging of the Neural Substrates of Parent-Infant Attachment These Boots Are Made for Stalking: Characteristics of Female Stalkers Managing Attention Deficit Hyperactivity Disorder in the Emergency Department Obstructive Sleep Apnea, Hypoxia, and Metabolic Syndrome in Psychiatric and Nonpsychiatric Settings Improving the Quality of Life in Patients with Alzheimer’s Disease The Process of Getting New Drugs to Market Journal Watch Classified Advertising Information for Authors

Psychiatry - August 2008

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