Providing Vision Care for The Alzheimer s Patient Author: Linda Ward

Transcription

1 Providing Vision Care for The Alzheimer s Patient Author: Linda Ward Alzheimer s disease is a progressive brain disorder. It gradually destroys memory, reason, proper judgment, communication skills and the ability to carry out daily activities. Individuals with Alzheimer s disease may show changes in their behavior and personality, exhibiting such behaviors as agitation, anxiety, hallucinations or delusions. There are currently more than 5 million people throughout the United States with this disease. At this time there is no cure for Alzheimer s disease, however research for new treatments and cure is being done. This research has been an avenue of care and support for individuals with the disease and their caregivers from the onset of the disease until the end of life. 1 There are seven stages of Alzheimer s disease. Below is a list with a brief description of each stage. Stage 1: No impairment Individuals have no memory problems evident in a medical review or to a Health Care Provider during a medical evaluation. Stage 2: Very mild cognitive decline Individuals may be experiencing normal age-related changes or this decline in cognitive skills may be the earliest onset of Alzheimer s disease. Names, words, location of eyeglasses, keys or other objects they use everyday may be forgotten. These problems are not evident in a medical evaluation or to family, co-workers or friends. Stage 3: Mild cognitive decline While this early stage of Alzheimer s disease may not always be diagnosed, family, friends and co-workers may begin to notice a cognitive decline. A medical evaluation might show measurable problems with concentration and memory. The individual may have problems reading and retaining information, along with decreased ability to remember names when being introduced to new people. They may also have performance issues in social and work settings along with difficulties organizing and planning.

2 Stage 4: Moderate cognitive decline A medical evaluation at this stage will clearly detect a cognitive decline. Remembering personal history or recent events and occasions becomes more difficult. The person may seem withdrawn, especially in social situations. Tasks as simple as planning dinner might be frustrating for the individual. Stage 5: Moderately severe cognitive decline This is considered mid-stage Alzheimer s disease. There is major memory and cognitive gaps during this stage. The individual may need some assistance with daily activities. They will not be able to recall their address and telephone number or remember which college they graduated from. Confusion about where they are, the date and day of the week is common in this stage, but they usually do not require help with normal activities such as eating and using the toilet. Stage 6: Severe cognitive decline In stage 6, the individual s memory loss continues to get worse. They may forget the name of their spouse or caregiver, but will know them from the familiar face. Recent experiences may be forgotten and there may be confusion with surroundings. Normal daily activities, such as getting dressed and toileting require assistance. They have increased urinary or fecal incontinence. Behavioral problems such as delusions, suspiciousness, compulsiveness and receptiveness may be exhibited. These individuals tend to wander off and get lost. Stage 7: Very severe cognitive decline Individuals in this stage lose their ability to control movement, speak and respond to their environment. They do not have recognized speech, however may utter out words or phrases at times. They need help eating, toileting, walking and sitting without support. They loose the ability to smile and hold their head up. Their muscles grow rigid and lose flexibility. 2 There are several challenges presented when providing vision care to patients with Alzheimer s Disease. The following text lists these challenges and gives suggestions on appropriate actions to take with each challenge. Orientation Stage 5 or higher Alzheimer s patient have problems with orientation and can have a tendency to wander. I have had to retrieve patients who have wandered off from the exam room or waiting room many times. When dealing with this situation, it is best to politely approach the person and distract them. This could mean sitting with them in the waiting room for a short time until the doctor is able to see them, or offering a drink of water. The main point is that you do not ignore them, as they may wonder right out the door. In the case of this happening, let someone in the office know that the patient has left the office and

3 follow them. You should walk with them and talk to them kindly, trying to divert them to walking back to the clinic. Asking them if they would like to have a drink or snack is usually a good attention diversion. They are more likely to come back with you if they do not feel threatened. Special Needs In some cases the patient is dropped off to your office, and the office staff is expected to deal with any special needs that they have. I recall this happening in our office. We had an elderly, confused patient in the waiting room. The patient suddenly had to use the restroom. In the midst of her confusion she came through the waiting room door and down the hall to our office manager s office looking for the restroom. Unfortunately, she did not make it to the restroom - she had an accident right there. The staff politely escorted her to the restroom and asked how to call her driver to pick her up. The staff did not want her to feel embarrassed, so someone stayed outside the restroom with her until her caretaker arrived. We called her caretaker later to reschedule her appointment. Completing Paperwork Pre-testing In the large majority of cases a relative or caregiver is present to assist the patient in completing the paperwork; however, there are times when the patient is delivered to the office and left on their own. The receptionist should be able to determine that the patient is confused and offer to assist in completing the paperwork. The receptionist will need to determine who can sign off on the authorization for treatment. If a patient is clearly incompetent to sign authorizations for treatment or other legal documents, then they should not be obtaining the patient s authorization, but should be getting the guardian s consent. Also, keep in mind that discussing the patient s medical information in public is disrespecting the privacy of the patient and is a violation of HIPAA regulations. The patient should be taken to a quiet room when helping them fill out their information. The technician should then be notified about the situation, so they will know that the patient has some special needs. It would be a good idea for the patient to stay in that room until the technician is ready to come get them for the work-up. This will cause less confusion for the patient. The least amount of environmental changes, the better. When addressing the patient, it is best to refer to them as Mr. or Mrs. unless they request that you call them by their first name. The patient might want to shake your hand. In the case of someone who has middle stage Alzheimer s disease or is severely mentally confused, be careful about shaking their hand. You are better off to reach higher and shake their wrist instead. I learned this the hard way when I nearly had my fingers broke by a patient who innocently reached out to shake

4 my hand. She put me right on the floor with her grip. She did not know when to let go. The patient should be guided to sit on the chair, providing extra assistance if the chair has wheels. If possible you should ask another assistant to help you as you perform the autorefraction or other tests that require the use of equipment. The other assistant can help hold the patient s head steady, and reassure the patient so you can get an accurate reading. Visual acuity testing can be a challenge with some patients, especially if they do not like to sit in one place for long. By sitting on a stool next to them they will not feel like you are towering over top of them. Setting eye level allows the patient to feel more relaxed. You may have to get up from the stool to point at one letter at a time if the patient does not understand what to do. If that does not work, you can try using a picture chart. The patient may be able to recognize the pictures easier than letters and numbers. The Examination During the doctor s exam it is important to keep the patient as calm and comfortable as possible. You may need to sit or stand next to the patient during the exam and help hold the patient s head steady for the doctor. Sometimes gently talking to the patient and reassuring them works well. Some patients like to have their hand patted gently. This helps relieve them of the stress. The assistant and the doctor will have to try several things to make the patient as comfortable as possible. Sometimes nothing works and the patient just needs to be scheduled for another time when they are less agitated. Alzheimer s patients typically do better in the early morning, rather than late in the afternoon - a symptom known as Sundowners. Choosing the Eyewear If the patient requires a change in eyewear, be sure to let the Optician know that you have a person with special needs so they can plan accordingly. The stress of the exam can make some patients very tired and agitated, therefore best judgment should be used as to whether the patient should be rescheduled for a different day to choose the eyewear. The optician can help the patient by choosing sturdy frames that would work well with the patient s prescription. No more than two or three frames at a time should be shown to the patient. Too many frames at one time could be overwhelming and cause more confusion and agitation. The staff needs to be respectful and take time with the patient. The more the patient is hurried the more confused they may become. If the caregiver recognizes the ability of the staff to work well with the Alzheimer s patient, they will become a loyal source of referrals. Understanding Caregivers

5 There are many types of caregivers ranging from family members to private nurses to nursing home assistants. Usually the caregiver is quite considerate when it comes to the needs of the patient, however they may not always be pleasant to deal with. There are many emotions associated with caregivers. We may look at the patient as the sweetest lady we have ever met, but their daughter or son may differ in that opinion. We all come from different backgrounds. It could be that the sweet lady we are seeing is not the sweet lady their loved ones grew up with. They may still have bad feelings about them, and now have the responsibility of taking care of them. This can cause a lot of tension and stress for the caregiver. Sometimes the family members are devastated that this is happening to their loved ones and the emotions are just too much for them to deal with, so they act out by being rude and grouchy. The staff needs to show empathy to the caregiver, being as helpful as possible. They may need to vent their frustrations. Sometimes they just need a good ear to listen. The office can assist the caregiver by providing resource pamphlets from the local Alzheimer s Association. Information about respite and adult day care facilities may be helpful. The Alzheimer s Association can provide information about the Safe at Home program and support groups in the area. Being knowledgeable and providing helpful resources demonstrates your optometric office s desire to care for the patient and caregiver beyond vision care alone. 1 Copyright Alzheimer s Association, Chicago, Illinois. Reproduced with permission 2. Copyright C 1983 by Barry Reisberg, M.D. Reproduced with permission.

6 Providing Vision Care for the Alzheimer s Patient To receive one hour of continuing education credit, you must be an AOA Associate member and answer seven of the ten questions successfully. This exam consists of multiple-choice questions designed to measure your level of understanding of the material covered in the continuing education article. To receive continuing education credit, complete the information below and mail with your $10 processing fee, ($10 per hour of CE) before December 31 st of this year to the: AOA Paraoptometric Resource Center, 243 N. Lindbergh Blvd, St. Louis, MO Name Member ID number Address City State ZIP Code Phone Address Card Type Exp. Date Card Holder Name Credit Card Number 3 Digit Security Code Authorized Signature Select the option that best answers the question. 1. When the patient requires a change in prescription the Optician should a. Take time with the patient b. Use judgment as to whether to reschedule the patient for another day c. Show them sturdy frames d. All of the above 2. What stage of Alzheimer s disease is best described by that the patient may forget their spouse s name, may be confused with their surroundings, may exhibit suspiciousness, may need help getting dressed and may wander off. a. Stage 6 b. Stage 7 c. Stage 4 d. Stage 5 3. If an Alzheimer s patient arrives at the office without a caregiver, as the first step you should a. Call the caregiver to reschedule a time when the caregiver can be present. b. Let the patient do the paperwork by themselves c. Take the patient to a quiet room and offer to assist with the paperwork d. Ask someone in the waiting area if they know this person.

7 4. When dealing with caregivers you should a. Show empathy and be as helpful as possible b. Provide a good ear to listen c. Offer helpful resources to caregiver d. All of the above 5. When completing paperwork, if the patient is clearly incompetent the receptionist would be in violation of HIPAA regulations to be obtaining the patient s authorization and consent from the guardians. a. True b. False 6. Which of these is not a challenge when dealing with a person with Alzheimer s? a. Emotional issues of their caregivers b. Slurred speech c. Tendency to talk excessively d. Fatigue and agitation they may experience from the examination 7. Alzheimer s patients typically do better in the late afternoon for their examinations a symptom known as Sundowners. a. True b. False 8. It is better to move the Alzheimer s patient around from one location to the next to keep their attention and focus a. True b. False 9. At what stage would a medical examination clearly detect a cognitive decline? a. Stage 1 b. Stage 2 c. Stage 4 d. Stage What should you NOT do if the patient becomes agitated and confused? a. Speed up the examination process so they can leave as soon as possible. b. Pat their hand to comfort them. c. Schedule an appointment for another time. d. Offer a drink of water or snack