Alzheimer’s disease unfolds over the course of decades. In the early stages (as discussed in part one), the afflicted person displays increasing loss of short-term memory and becomes increasingly disengaged from activities. Higher level, complex skills such as doing a checkbook and using a computer become more of a challenge. Older, overlearned skills work well whereas learning new skills or habits become increasingly difficult. Rehabilitation is self-generated if started early.

If memory loss becomes severe enough to meet the criteria for dementia, rehabilitation must be accomplished by others (e.g., family, home care, or facilities) as independence is lost. The goal of treatment and rehabilitation is not to restore memory but rather to increasingly mold the environment to take advantage of learned habits and skills and keep the person with memory loss engaged and active. Competence no longer matters. What matters is productivity. Short-term memory fails to the point where the forgetful person increasingly lives in the moment.

Early Dementia. Most persons in the early dementia phase live at home with spouses or close to family who look in often. There needs to be a caregiver who compensates for severe forgetfulness. Complex tasks like preparing meals, shopping, problem-solving, and driving are usually unsafe. Structured day programs or unique personalized care such as provided by CompanionPlus is very helpful for both the person in this stage as well as their caregiver. Initiation is limited to the point where the caregiver must nudge or prompt or arrange for activities to occur. For example, the person can still golf (if that skill was learned before), but someone else must organize and monitor the outings. Regularity and routine are essential to safety and well being. Personal care remains fairly good and communication works albeit with lots of repetition and forgetfulness. The goal of rehabilitation is to keep the person engaged in what they still do well and in simple activities that do not involve short-term memory.

Middle Dementia. Most persons in the middle dementia phase can no longer attend to personal care. They usually need cues and prompting to change clothes, to toilet, to engage in things they like but forget to do. Communication is difficult because of even more severe forgetfulness and expressive language deficits (there are many what-do-you-call-its and empty speech). Care at home is a challenge for any one person as 24 hour supervision is necessary.

Rehabilitation consists of structuring the environment rather than trying to make the person fit into the environment. A memory care facility with well structure programs and experienced staff can make a remarkable difference in quality of life. Participation in structured activities, one-on-one or in small groups works best. Music, reminiscing, old TV shows, old movies, recordings of great sporting or historical events provide stimulation and engagement.

Late Dementia. Fortunately most of the hundreds of clients I have worked with do not live into this stage of very severe dementia where total care is needed for basic functions like eating. Communication and mobility are lost. The object here is to make the person as comfortable as possible. In this stage of care hospice services are often very helpful even if the person resides in a facility.