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Tips for Caregivers
We’ve covered the basics of what the medical community can do for your loved one, but there are lots of other ways of assisting someone with dementia. Obviously, each person affected with dementia is different, so not all of the following advice will apply to your situation. But, hopefully, you’ll find some tips in this chapter that will be helpful, especially combined with some added advice from me.
THE ROLE OF ENVIRONMENT
As a caregiver, you are in charge of your loved one’s environment, and, to some degree, this is the most important aspect of the care you provide. The best way to convince you of this is to talk about one place I visited, the Hebrew Home for the Aged in Riverdale, NY. They call their Alzheimer’s unit Memory Care Services, as they believe, and rightly so, that each of their patients still has some reserves of memory, and they look at their job as trying to keep their patients in the best frame of mind possible, rather than to just watch them slowly fade away. They try to maximize the faculties that their residents still possess by providing an assortment of different options and treatments, including yoga, aromatherapy, pet therapy, art therapy, massage, meditation, breathing exercises, and even laughter. The idea is to try to jiggle their residents’ circuit breakers in order to get whatever circuitry is still working in their brains to function.
Before you express your doubts as to whether all this can work, Brookdale Hospital funded a scientific study, complete with control groups, over a period of eighteen months, and the study found that patients with Alzheimer’s who received these various treatments became much improved in such areas as sleep patterns and behavior.
Understand, all this therapy is not going to halt the deterioration caused by Alzheimer’s. The patients studied were all in early to moderate stages of the disease, and eventually all would succumb to it. But as a caregiver, you know that what makes your day most difficult is when your loved one acts up, especially at night, which interferes with your own sleep. So, knowing that there are ways of controlling this type of behavior, without resorting to drugs, is important.
Part of the reason that those Alzheimer’s patients at the facility at Riverdale don’t act up has to do with the design. The area in which the Memory Care facilities are housed is fully carpeted, bathed in soft light, and all the doors are locked. This allows the residents to roam freely. The staff at the Hebrew Home believe that much of the agitation in Alzheimer’s patients is caused by frustration from being cooped up. But having the freedom to roam the halls and socialize with the other residents relieves their frustration and so keeps them from becoming agitated.
How can what goes on at the Hebrew Home help you? First of all, I believe it tells you that you must adopt a holistic approach. You have to examine your loved one’s surroundings and see what you can do to lessen the ways in which the environment might frustrate him or her. You also have to provide the means for your loved one to release the frustrations that are inherent in losing one’s mental faculties. You have to provide stimulation in ways that, after some experimentation, you notice offer solace to your care recipient.
Specifically, you might try burning a scented candle or incense to stimulate his or her sense of smell. You should try to find scents that are pleasing, but try to vary the scents so that they provide mental stimulation, rather than always using the same scent. If you don’t have a dog or cat, you might see if you could borrow one for a time to determine if your loved one gains some benefit from the company of a companion animal. If so, you might consider getting a pet of your own. (If you know any other families caring for someone with Alzheimer’s, perhaps you could all share a pet.)
Since your home won’t have the same amount of space as a facility, make sure that your loved one gets the chance to exercise, which for the most part will mean going for long walks. I’m sure that you’ll be able to tell by the reaction of your care recipient that going out for a walk is a time that he or she craves. If you don’t have the time or strength to accompany your loved one, hire a student to come after school and take your loved one for a daily stroll, even if it’s only around the block a few times. By the way, I was told of a facility that had a street scene painted on the walls so that when patients would walk around they would feel that they were outside. You might also try taking you loved one to a yoga class for seniors.
Art therapy can mean nothing more than sitting your loved one down in front of a coloring book or giving them some PlayDoh to form into simple shapes. It was actually the artist Matisse who discovered that people with dementia retain their ability to recognize shapes, so your care recipient may appreciate any form of “art” that you give them an opportunity to partake in.
The Hebrew Home actually adopts the Montessori method of childhood education, which takes into account each student’s level of ability when setting curriculum. While you shouldn’t infantilize your care recipient, you should keep track of how much he or she is capable of doing and offer tasks that will match their ability and even challenge them.
It seems that the more effort you put into finding ways of keeping your loved one active in a variety of different ways—smelling, hearing, touching, moving—the more you’ll be rewarded by a lessening of agitated behavior. Of course, as the disease progresses, your care recipient will lose certain abilities. So, while you want to offer challenges to keep your loved one’s mind occupied, you have to maintain a certain vigilance to make sure that an activity that once brought pleasure isn’t now causing frustration.
You should definitely take cues from your loved one’s past. If your grandfather enjoyed watching baseball games, take him out to watch the Little League games in your neighborhood. He’ll enjoy getting out and being in the fresh air as much as watching the game, but that’s the point. If he played the piano, he might still enjoy doing so, even if the tunes are simple ones. If you play, too, then maybe you could do duets. Hey, even playing “Chopsticks” might be fun.
If your grandmother would enjoy helping out by doing the dishes, let her, even if you have a dishwasher. It will occupy her and playing around with hot water stimulates the senses. If you’re worried about her breaking plates, or breaking a glass and cutting herself, buy some plasticware. However, don’t let her clean any sharp knives. If it turns out that after she’s done the dishes they still aren’t clean, stick them in the dishwasher. If she starts washing the dishes but gives up half way through, forget about it. The point is if your loved one will take pleasure in an activity, and can’t be hurt, then let her, much as children are allowed to play with pots and pans. The more flexible you are, the easier it will be on everybody.
Some activities may spring to the mind of your loved one on her own, such as heading to the sink to do the dishes after a meal. But others may need to be planned. Your father might actually enjoy a simple task like sweeping the kitchen, but would never think of it himself. So, see what happens if you hand him a broom and say, “Dad, care to sweep the floor?” If he goes for it, great. If not, try to substitute some other activity.
The experts will tell you to plan out your entire day. It’s true that following a routine may be comforting to your loved one, and it could also make things easier for you. But at the same time, if you do the exact same things every day at the same exact time, that might drive both of you crazy. You need to test the limits of your care recipient, because any challenges that he or she has to face will keep them from being too bored. How would you know if your mom would like to play solitaire unless you offer her the opportunity, even if she never played when her brain was healthy.
Another point the experts make is that an activity might be pleasurable for your loved one even if it doesn’t seem to be. Let’s say your father can no longer read—that doesn’t mean he might not enjoy looking at a newspaper. You might not be able to tell why he’s enjoying it, but you will be able to tell by the look on his face that it is a positive experience, and if that’s so, then make sure to give him the paper every day.
Scientists have been able to discover that people who are in a coma may, in fact, be more aware than it seems. Researchers have been able to communicate with some of them, even though the only thing they can do involves brain waves. While there’s no doubt that Alzheimer’s will have damaged many of the neural pathways in your loved one’s brain, there may still be some that are fully functioning, though your loved one may have no way of communicating that to you. So, learn to read body language, and if it seems like a certain activity brings pleasure or is calming to your loved one, even if you can’t understand why that might be, then just go along with it.
If your loved one had a career, keep that in mind when thinking of activities he or she might appreciate. Perhaps there might be some simple activities that would relate to what he or she used to do that would occupy their mind. A math teacher might take comfort in looking at a math textbook or playing with a calculator, if only because somehow it seems so familiar. A doctor or nurse might take pleasure listening to his or her own heart through a stethoscope. A chef might want to help prepare a simple meal. It won’t work for every possible job, but if you can think of a way to make it work, give it a try. The same would apply to hobbies—if your mom always loved to garden, let her have a hand in working in your flowerbeds.
TRY TO MAKE IT FUNCTIONAL
At the Hebrew Home, they have a “store.” The residents can earn points and then buy things for themselves when the store opens once or twice a week. Most of the residents are very aware of this store and they are eager to participate because they get a kick out of buying the little items that are available. This type of activity is not dissimilar to the times when children play store. So, when thinking of things to do, try to come up with activities that have a quotient of playfulness about them. You shouldn’t treat someone with Alzheimer’s like a baby, as you must help them to maintain their dignity as much as possible, but we all find games amusing, so try to make a “game” out of certain activities in order for your loved one to get more pleasure from it.
You don’t want to tire out an older person, but many people with Alzheimer’s still have a lot of energy, and if you don’t find ways for them to use up some of that energy, it’s only going to make them more restless. Since activities like playing a simple game are not mandatory, you needn’t worry if on some days the person you’re caring for doesn’t seem up to a lot of stimulation. On the other hand, if they never want to do anything at all, that’s usually not good, either. The reason may be that they just don’t know how to get started, in which case it’s your job to show them what to do. If you can never seem to motivate them, that would be something to report to the doctor.
LEARNING THE LANGUAGE OF ALZHEIMER’S
I gave a talk at the Hebrew Rehabilitation Center, which is associated with Harvard. I had dinner with some of the specialists there, and some were kind enough to write to me with their suggestions of material that should be included in this book. One of them, a “Dr. Ruth” herself, mentioned that an anthropologist whose wife was at their facility coined the phrase “Learning the Language of Alzheimer’s,” and she noted how apropos it is.
We are used to communicating with words, but those in the later stages of Alzheimer’s are almost like babies in that they may not understand what it is we are saying. They are more likely to pick up on our emotions, but only if these emotions are broadly expressed. Subtlety will be lost on them. If you want to express happiness, do it with a big smile, not a little grin. For example, if your father is looking for his mother, who died decades ago, don’t try to explain to him that she’s not around, but instead try to comfort him with a hug. No matter what you try, getting through is going to prove difficult to achieve. The following are some tips on how to best communicate with someone with Alzheimer’s:
| 1. | Pay careful attention to your body language. People with Alzheimer’s, especially in the latter stages, have problems understanding words. They may do better with sensing emotions, and one way they do that is by looking at the body language of the person talking to them. So, if you’ve got a smile on your face, that will set the tone for the “conversation,” while a frown may make your loved one start to fret, and that will probably prevent your meaning from getting across. Yes, you’ll be doing a lot of smiling, but even fake smiles have a way of lifting spirits a bit, so don’t resent them. |
| 2. | Make certain that you have your loved one’s attention. Look her in the eye. If she’s sitting down, get down to her level. Say who you are, as she may not know you right away and such cues can be helpful. Also, use touch to make sure that she is focused on you. |
| 3. | Obviously, you have to use simple phrases. If you don’t get a reaction, don’t raise your voice, as that may only frighten her. Instead, repeat what you want to say. And don’t use abbreviations or pronouns, as she may not be able to decipher them. Instead, use names and very specific terms. |
| 5. | You have to learn to listen with your eyes, for just as your body language will be important to getting your message across, the body language of your loved one will also provide you with many cues. |
| 6. | Be patient, because you may have to repeat what you say many times. If time isn’t of the essence and you’re not getting through, stop trying for the moment and try again later. |
| 7. | If the conversation is making your loved one upset, try doing something to distract her. If you can focus her attention on something else, like a snack or even just jangling your set of keys, then she’ll likely forget what was making her upset and settle down. |
| 8. | If your mother is on medication, pay attention to whether she is more communicative at certain times more than others. If you notice that the medication is helping or hurting at certain times of the day, avoid trying to communicate during those times. There may be other factors that make certain times of the day better, like after a nap, when her energy level is high. |
| 9. | Try to end every conversation on a positive note. It may be hard to tell whether your loved one actually got the message or not, as sometimes she may remember things that never actually happened. But if the overall feeling of an activity, like a conversation, was positive, that will have a more lasting effect. |
| 10. | When you’re talking to her, keep other distractions at a minimum. Definitely turn off the TV or radio; but you may need to pull down the blinds, as well. |
| 11. | Since your care recipient is likely to be of an age when hearing loss may have set in, look for signs that perhaps one reason he is not getting your message is simply that he is not hearing it. If he does have some hearing loss, that is also going to frustrate him, possibly triggering agitated behavior. If you suspect hearing loss, talk to your doctor about it. |
| 13. | If your words are not getting through, be aware that other parts of the brain may be working better than the sections that comprehend spoken language. You might not be able to get a specific message across by singing a familiar song to your loved one, but you might be able to calm them down by offering them something familiar if they’re lost in a very unfamiliar world. |
| 14. | The same is true with art. A person with Alzheimer’s may be able to draw, even primitively, and actually pass on messages, at least in terms of letting you know their mood. |
While you will slowly learn how best to communicate with your care recipient, keep in mind that others will not. Your father’s physical appearance will not be changing, so other family members who haven’t seen him in a while may not realize the changes that have taken place. At family gatherings, you’ll have to protect him a bit, and teach other family members how to best communicate.
SOCIALIZATION
One type of person who will know how to communicate with your care recipient will be someone else who has Alzheimer’s. At a nursing facility, the residents interact with each other all the time, and this helps to keep them from becoming frustrated. So if you know of any other families taking care of someone with Alzheimer’s (and you can certainly find them by joining a local support group), try getting your loved one together with one or two other people with Alzheimer’s. Hopefully, this type of socialization will be enjoyable and will have a calming affect. If that is what occurs in a facility, why shouldn’t it work for you?
BEHAVIORAL ISSUES
While it is possible to teach a child to follow rules, as the child’s mind is maturing and learning to make connections, the exact opposite is taking place in the mind of someone with Alzheimer’s. If the person in your care is acting up or not obeying you, enforcing discipline is going to be difficult and perhaps harder and more frustrating on you then anything else. Again, that word “flexible” comes into play. You have to keep your loved one safe, so at times you will have to be inflexible, but most of the time it is better to bend like the blade of grass than stand firm like the oak tree.
One example I’ve read about is that of someone with Alzheimer’s who insists on sleeping on the floor rather than in their bed. First of all, you probably can’t guess why they want to sleep on the floor, and they can’t tell you. If it appears to be linked to a fear of falling out of bed, you could potentially place a rail on the side of their bed, but you could go to the trouble of doing so only to discover that was not the cause, and then what will you have gained? The most pragmatic solution is to put their mattress on the floor, so that they’ll be comfortable, and let them sleep there. Tell yourself that at least you won’t have to worry about them falling out of bed.
The bottom line is that since it is easier for you to change your behavior than to change theirs, it is better to find ways of accommodating their wishes than having constant struggles. That’s not to say that you shouldn’t try to track down the cause of some change in behavior. There is a reason why your loved one is acting up, and perhaps if you find the cause, you can instigate a change. For example, it’s possible that the medication that your mother is taking is making her dizzy. A change in medication might help, which is why you should report such changes in behavior to your doctor. You should also discuss these issues with other family members and friends, because even if you can’t spot the cause doesn’t mean someone else won’t have a helpful suggestion.
By the way, you could try to see if other caregivers have run into a similar behavior pattern and see if a solution is available by checking online at various websites that have boards where members exchange information. Just because one trick worked for one person doesn’t mean that it will work for you, but there are plenty of ideas out there, many of which you probably wouldn’t come up with yourself. For example, one common tip offered to caregivers whose charge is prone to what’s called “wandering” (leaving the house and taking off on their own), is to place a black rug or mat in front of the door. Many people with Alzheimer’s will perceive that rug as a hole and so won’t approach the door. I don’t know who first discovered that trick, but it’s a very useful one and probably not one you would have thought of on your own. You can also disguise a door in other ways, such as attaching a poster to it so that it will appear to be an ordinary wall.
It seems losing depth perception is one common side affect of Alzheimer’s, so there may be many other ways in which this plays out that you might not realize. For example, if your care recipient refuses to get into the bath, it might be because he or she can’t tell how deep it is and is worried about it being too deep. Thus, whenever your loved one acts in a way that doesn’t seem to make sense, see if you can discover if there is a “good” reason for their actions, at least from their viewpoint.
Other ways to deal with wandering include repositioning your locks either higher or lower than normal. A person with dementia may not think to look there. You could also install a lock that requires a key to open it from the inside, but this option carries the risk of not being able to get out if there is a fire or other emergency. You would then have to keep a key near to the door, within everyone’s reach, including any children you might have in your home with you. There are also plastic covers that you can place over a door handle that are meant to keep children from being able to open the door (you have to squeeze the plastic cover in order to get a grip on the door knob), and this may work. Sometimes simply putting a sign on the door that says “Stop” will keep your loved one from leaving. And, if no solution seems to keep your loved one from leaving from time to time, putting an alarm on all your doors will at least alert you that the door has been opened and your loved one may be heading out. (If your care recipient doesn’t sleep well and so keeps you up, you might have a tendency to take a nap during the day. That might give your care recipient the opportunity to wander off, so that’s another good reason to have an alarm on the doors—you’ll wake up and know that something is amiss.)
It’s also possible to put a tracking device on your loved one, a GPS gizmo that will allow you or the police to find them if they got lost. To me, this would only be appropriate for someone who is in the early stages of Alzheimer’s, is able to go out on their own, but occasionally loses the ability to get back home. Otherwise, it would seem to me to be a better idea to do everything possible to keep them by your side. On the other hand, putting an ID bracelet on them, or sewing name tags in their clothes, or at the very least making sure there is a piece of paper in their pockets with their name, address, and phone number would be a good idea. You can also register your loved on with the Alzheimer’s Association Safe Return program, which will help the police locate them.
By the way, there are some caregivers who worry that if something should happen to them, for example, if they were in a serious car accident, their loved one might be at risk, so they wear bracelets that say they are a caregiver and their loved one is at such and such an address and who to contact in an emergency.
When searching for a wanderer, it’s been discovered that they follow certain patterns, such as following fences or power lines. You might also have to play detective, thinking backward in time, so that if they used to work downtown, see if their goal isn’t their old place of employment. It also seems that they are more likely to wander off in the direction that the door they used to get out faces, so use that as a clue.
AGITATION
One reason that your loved one might want to wander off is if they feel agitated, which is fairly common among those with Alzheimer’s, as they become frustrated with their condition and especially the way they interact with their surroundings. The best way to deal with agitation is to keep it from happening. Keeping to routines and making sure that everything your loved one uses, like glasses or the TV remote, is always in the same place may help. It will also help if you reduce clutter in the spaces he or she use most, so that a sense of normalcy prevails.
Some agitation is caused by delusions. Your care recipient may have problems distinguishing between what is going on in his head and reality. When this happens, don’t merely dismiss what he is seeing, but try to offer comfort, because to him it is real. On the other hand, be careful of what he may be watching on TV, because he might not be able to understand that what he is seeing is not real and that may cause him to be anxious.
In an Alzheimer’s patient’s weakened mind, delusions can be triggered by other physical problems, such as a urinary tract infection or a toothache. The patient may not be able to explain that this other problem exists, and so rather than complain about the discomfort, what is exhibited is delusional behavior. This means when your loved one seems to be suffering from delusions, you have to be very attentive to everything that he or she is doing. Even though your mother can’t tell you that she has a toothache, you might notice that she’s not eating certain foods, or that perhaps she’s staying away from the cup of tea she usually loves because the heat is setting off pain. Or maybe she’s holding her cheek. You might have to make an educated guess that she does have a toothache and take her to a dentist. I know, this is quite complicated, but if you can discover the root of a problem like this, the source of the delusions will go away, and both she and you will be better off.
SUNDOWNING
Another common syndrome is what has been labeled “sundowning,” which means that many people with Alzheimer’s seem to become more agitated at night. If your loved one is a sundowner, you might also notice more instances of Elder Rage after the sun has set.
The big problem with having the person in your care in an agitated state at night is that you can’t sleep. Sleeplessness can make your job much worse and is a serious issue. Here are two different approaches to this problem.
One is to find a place that offers care during the night instead of the day. The Hebrew Home at Riverdale initiated such a program. In order to help those taking care of patients with dementia who were suffering because of the lack of sleep, this facility started a program where they pick up seniors who are sundowners and take them to their facility for the night, making sure that there is plenty to do to keep them occupied, which will automatically be the case because there are other sundowners there. (If you want to read more about this program, you can find an article in the New York Times at www.nytimes.com/2009/06/14/nyregion/14cover.html.)
Not only does this program allow the caregiver to get a good night’s rest, but because their care recipient will have been up all night, he or she is likely to sleep during the day, giving the caregiver time to do other things. If you don’t live near a facility that offers something similar, see if other caregivers in your area are struggling with the same problem, and if there are enough of you so that you represent a significant demand, you might be able to convince a facility in your area to start a nighttime program.
The other approach is a combination of medicinal and behavioral therapy. Hopefully, you’ll never feel the need to ask your doctor to give your loved one so much strong medication that he or she becomes like a zombie. It also may not be obvious what the proper dose of medication is for the person in your care. Even doctors admit that figuring out what combination of medications will bring about the best results is an art and not a science. Thus, in order to find the right combination, your doctor may have to make a series of adjustments. Rather than get upset with your doctor for this, encourage your doctor to try various approaches. Try to work with your doctor by taking notes and telling your doctor exactly what changes in behavior, both good and bad, any latest combination of drugs has caused. By working together, hopefully you’ll find just the right combination that will keep your loved one from being overanxious while still maintaining their alertness.
Some caregivers don’t like the idea of medicating their parent or spouse, but you have to remember that this is also for you, so that you can get some rest. However, one serious downside to such medication is that it can leave the patient disoriented. If your mother is taking a sleep aid, either she might not wake up to go to the bathroom and will wet the bed, or else she might be dizzy when she does get up to go to the bathroom and thus fall and hurt herself. That’s not to say that you shouldn’t use such medication, but that you must be alert to such issues. Even if she normally doesn’t need diapers, you might want to use them. And you might want to place a baby monitor in her room so that when she gets up to go to the bathroom, you’ll know about it and can assist her.
Also, just as you can do with young children, if you keep a sundowner as active as possible during the day, the likelihood increases that he or she will be sufficiently tired at night to fall asleep. So, if sundowning is a problem with your loved one, keep them busy during the day.
You also need to see whether your loved one’s diet has any involvement in changes in sleep habits. Try to limit sugary sweets, especially late in the day, as these might be causing them to be more active at night. Also, don’t serve the big meal of the day right before bedtime, but rather offer smaller meals throughout the day.
If not addressed, sundowning can turn into a vicious cycle. Your loved one keeps you up at night so you’re both exhausted the next day, and so the day goes by quietly, with maybe both of you taking naps, and then that night the pattern repeats itself. That’s why you have to take action of some sort right away, or this pattern of being up at night and quiet during the day will become ingrained and much harder to change. Of course, I would suggest employing behavioral techniques first, like keeping your loved one active, but don’t hesitate to bring in your doctor to help with medication if behavioral techniques are not sufficient. Sleep deprivation is considered a form of torture, and it will definitely impact your health if it goes on for too long. On the opposite end of the spectrum are those who won’t allow a facility to use any behavioral modification medication on their loved one, fearing that it will be abused. While that danger exists, a reputable facility will only administer it for the right reasons. I know of at least one case where a family didn’t allow a facility to medicate their mother—she was often aggressive without the medication—and so for the safety of the staff and the other residents, this woman was asked to leave.
Of course, as your loved one goes through changes, the dosage of drugs may have to change, so this may be a never-ending process. Still, because drugs can be so helpful with behavioral issues, it’s worth the effort of working with your doctor to maintain the best possible dosage, as in the end you, the caregiver, will benefit.
Let me reiterate that it’s very important to report to your doctor any other medications and supplements that you give your care recipient. You may think giving aspirin or any over-the-counter medication has no bearing on your care recipient’s condition, and normally it wouldn’t. But every medication has an impact on other medications in a person’s system, and if the effect is, say, to multiply the effect of one drug, you could make a perfectly safe drug dangerous. So never administer medications, even over-the-counter ones, without checking with your doctor. And if your loved one has more than one doctor, be very diligent about letting each doctor know which medications the other has prescribed.
The important thing is to understand that other caregivers have managed to find a solution to this problem, so you too must do whatever it takes to find an answer that works for you. If you get the idea in your head that you’re stuck in this situation, you will be, and that would be terrible. The only solution at that point, for the sake of your health and sanity, would be to send your loved one off to a facility, and if that’s something you’d like to put off as long as possible, make sure to take care of this issue as soon as it arises.
ELDER RAGE
Sometimes, simple agitation grows in intensity, which has been dubbed Elder Rage. For the most part, Elder Rage is verbal—as in a person may scream or use profanity—but sometimes it can become physical, as well. If you’re caring for someone who is bigger than you are, this could be dangerous. The rage is an outgrowth of the agitation they may be feeling, but it is exhibited in a much stronger form. The person you’re caring for may get very upset with you or with something else, or maybe even seemingly at nothing at all, as delusions can also trigger Elder Rage. Or the cause might be so slight that the reaction far outweighs the source of irritation.
In part, someone who exhibits Elder Rage does so because of a loss of inhibition. When you become upset, you try to control your emotions, especially in certain surroundings. But someone with dementia doesn’t have those brakes. A person with Alzheimer’s will express all their emotions without any filters. Since we’re not used to that behavior, at least in adults—certainly babies and toddlers don’t hold back—it appears to us to be an extreme type of behavior. But if you look at the situation in its proper perspective, that of delusional thinking, it will be easier for you to accept these emotional outbursts.
I read a story about a caregiver who kept trying to convince her father’s doctor that he was exhibiting Elder Rage, but every time he was examined by the doctor, he was as sweet as he could be, so she wasn’t able to convince the doctor that he needed to be placed on medication. She had to look around until she could find a psychiatrist who would put her father someplace where he would be under observation for a long enough period of time that her father exhibited the rage she’d been complaining about. After the proper dose of medication was determined, she also used tough love to keep him in line, not giving him dessert, which he loved, when he acted up, and rewarding him with an extra dessert when he showed good behavior.
I give you this story to show you that it might not be that easy to get the help you need, which is why you have to be persistent. Again, I said the help you need. You’re kind enough to be shouldering this responsibility, but that doesn’t mean you need to be tortured on top of everything else.
There are two other factors about your care recipient’s behavior to keep in mind. First, if you have any outside help that comes into your home to assist with caring for your loved one, you might lose a good person if your loved one regularly becomes uncontrollable. You might have no choice but to put up with such behavior, but that’s not true of someone you hire. And, if the time comes that you can’t handle your loved one anymore, be aware that not every facility will accept someone who exhibits Elder Rage, which might mean the facility you would really like to use will have to be crossed off the list. Doing your best to get this Elder Rage under control could be important if the moment arrives that you need to put your loved one in someone else’s care, and you want that to be at the best possible facility.
However, if your loved one is continually showing signs of Elder Rage and you can’t seem to control it, at the very least you have to make sure that there is nothing within reach that could be used to harm anyone. You may not have to get a metal detector for your house, but you will have to be vigilant about keeping any sharp instruments out of reach.
If your care recipient does become violent from time to time, and if you are not strong enough to handle the situation, you need to find someone you can call in an emergency to help you. You can call the police, but that might lead to your care recipient being arrested, which is only going to further complicate your life. So, see if you can develop a plan to keep yourself safe when you’re faced by Elder Rage that won’t involve the police. On the other hand, if you’re in a situation where you’re in danger and there’s no one else to come to your aid, by all means do call the police. Eventually, you may be able to sort the problem out and at least you’ll be safe in the interim.
DON’T BE OVERPROTECTIVE
Some cases of Elder Rage are perhaps justified, at least to some extent. If you, as a caregiver, are overprotective, treating the person you’re caring for like a baby, and that person retains some capabilities, you’re setting yourself up for a negative reaction. Certainly, there are activities that must be curtailed. It seems many caregivers have to struggle to take away car keys, for example. Even the slightest chance that your loved one might cause a car accident is reason enough to enforce a no-driving rule, and, yes, that will cause frustration and anger for a time. But if the two of you have lots of little fights over matters of control, then maybe you’re the one who is going to have to compromise. Your loved one is an adult, after all, not a child, and so has many years of being independent. Of course, that’s likely no longer fully possible, but you can understand that this situation is frustrating.
If your mother wants to dress herself, don’t worry if she tends to put on older or less fashionable outfits. If she likes a certain yellow blouse and it’s becoming frayed, see if you can’t find one that is almost like it and buy it for her, rather than fight with her over what she’s wearing. Yes, she’s not being entirely rational, but just because you’re technically right doesn’t mean that the two of you need to argue over what she wears every day. In the long run, these minor battles will eat away at your resources, and you need to manage them carefully.
At some point, you might begin to feel that you’re always giving in, and out of frustration you dig your heels in and try to assert as much authority as possible. The problem is that you’re not dealing with someone who is fully rational. And, if your loved one is bored, fighting may be a way of relieving that boredom, so it’s just not a struggle that you can win.
Every book and website aimed at caregivers tells you that, rather than struggle with your care recipient, you have to keep a smile on your face, because the person you’re caring for will pick up on your feelings. If you won’t argue with them, they’ll soon stop trying to start an argument. That’s certainly good advice, but at times it’s going to be hard to follow. It won’t necessarily even be the fault of the person you’re caring for. You could be exhibiting sadness for some other reason than being a caregiver, or perhaps the loneliness of your situation could have you in the dumps.
What do I do when I’m feeling a bit sad? I’ve got a drawer where I keep old letters and other communications that bring a smile to my face when I reread them. If I’m feeling down, I open up that drawer and spend a few minutes reading the missives I’ve put aside for just that purpose. I suppose if I was more of a techie, I’d save e-mails in a folder in my Outlook that would accomplish the same thing.
You could also tear out articles you read that bring a smile to your face. Or make a copy of a favorite passage from a book and keep it with you. Uplifting music can also help. Make a CD or playlist on your iPod of music that lifts your spirits. Maybe you have some cute footage of your grandchildren that brings a smile to your face. If putting together one DVD of the best of these is beyond your ability, or beyond the capability of your equipment, ask your son or daughter to do it. It’s really not all that complicated if you know how. You could even ask your grandchildren to make silly recordings for you.
You’ll know best what type of material can lift your spirits, but this is a job you must do before you’re feeling low. You want to be prepared to face those bad days with something that will make you feel better as quickly as possible. Once you get started, it will be easier to add to your collection, but you have to make that initial first step.
You should also make a list of friends or relatives who know how to lift your spirits and keep that list handy so that you can make a quick phone call. Sometimes, a five-minute call will really make a difference and allow you to get through the rest of the day. (On the other hand, if there’s someone who brings you down and their number comes up on caller ID, let the call go to your answering machine.)
By the way, you might think of changing the message on your machine to add that sometimes you won’t pick up because you’re too busy taking care of your loved one. That way, if you don’t pick up when a caller expects you to be home, that person will be less likely to worry and you’ll feel less guilty about letting your machine pick up your calls.
You also need to pay attention to your environment. If you’re lacking light, then either move outside, or open all the blinds, or turn on a bunch of lamps. Lamps are available that specifically mimic daylight, so sitting under one of them might be helpful, especially in winter when it’s harder to get outside. The air inside your house can also bring you down, so open the windows and let in some fresh air. If the air is too dry in winter because of the heating system, use a vaporizer. Both you and your care recipient will benefit.
It might also be helpful to look at your loved one differently, especially if he or she is the source of you being in the doldrums. Maybe just going over and giving them a hug would help lift both your spirits. Or, if there is something that you know gives them joy, do that activity together. Maybe just make silly faces at them, which will take out some of your aggression without actually fighting with your distressed loved one.
ELDER-PROOFING YOUR HOUSE
I’ve mentioned some tips with regard to maintaining a house environment for someone with Alzheimer’s, but you should really look at every aspect of your home to make sure that there is nothing dangerous in it and that it is as easy as possible for your care recipient to manage. For example, your mother might forget where things are, but she still might be able to read, so if you put labels on things, this could be helpful to her. I’m not just talking about drawers, as in “Socks,” but even items that are quite visible, like the toilet. She might not recognize the toilet for what it is, but if she is able to read a sign that says “Toilet,” a light will go on in her brain and she’ll use it.
If you keep the temperature in your hot water high, lower it so that your care recipient won’t accidentally be scalded. Take a careful look around your kitchen and make sure that nothing dangerous is in reach. This can be more difficult than with small children because, while they’re not tall enough to reach many things, your care recipient is. You might want to add an automatic shut-off switch to your stove, which may be annoying to you at times, but could prevent a serious accident.
Lighting is also important, both inside and outside of your house. Older people are always prone to falls, but that’s especially true of those with Alzheimer’s, so the better lit your surroundings are, the less likely an accidental fall. That is also true of any type of clutter. If you have any children around the house, make sure they understand how important it is not to leave their belongings lying around. Any inherently unstable furnishings, like scatter rugs, should also be removed.
REPETETIVE BEHAVIOR
One common aspect of dementia is that your loved one may repeat certain questions or actions over and over. To some extent, this is to be expected with short-term memory loss. You may have answered this particular question one minute ago, but as far as you loved one is concerned, she never got the answer and so she asks it again.
There are two main ways of handling this type of situation. One is to write the answer down, like what time dinner will be served, and leave it someplace apparent. You might even place a chalkboard in a prominent place where you can write down this type of information. If that doesn’t work, you’ll have to try to distract your loved one’s attention to another subject. If the question is about mealtime, a little snack might work, as she won’t feel as hungry. Or, introduce an activity that will be distracting.
The one thing you shouldn’t do is tell your dad that he just asked that question. He won’t remember, and it will only make him more anxious. If you don’t have time to do something distracting, it’s probably simpler just to answer the question again and again over the period of time that question remains in play.
If, instead of asking a question, your loved one is doing something else over and over—picking at a shirt and obviously demonstrating anxiety—try to see if you can discover the source. If, for instance, your dad needs to go to the bathroom, helping him do so might end that repetitive behavior.
EXERCISE
Another type of repetitive behavior is pacing. On the one hand, exercise is a way of reducing stress, but too much can cause physical problems on joints, not to mention on your nerves. Taking your loved one out for a walk, even one of over an hour, might reduce the pacing, and it would be good for your health, too. Keep in mind that constant pacing can be an intermediary step to wandering, so make sure that you take the necessary precautions that I’ve already mentioned if it appears that pacing might indicate an urge to wander.
It’s been shown that walking can actually slow down the advance of Alzheimer’s, so by taking your loved one for a walk every day, you might actually be helping to keep both of you healthier.
While an electric treadmill might be too dangerous for your loved one, some are available that are strictly mechanical, meaning it’s the person’s feet that move the tread, not a motor, and so if the person stops walking or falls, there are no moving parts to injure anyone. Placed in front of a TV, this might be a way for your loved one to “pace” without actually moving through your house.
If, however, your loved one seems unwilling to move about—and not getting enough exercise can certainly have an adverse affect on his or her health—see if you can discover the cause of the inactivity. There are a few reasons that might not be readily apparent—a loss of balance, poor vision, pain in one leg—that might be cured by the use of a cane. You might try offering a cane and seeing if that helps to get your loved one to move around more.
You may think of exercise as being important for your care recipient, but there may be a side benefit for you—better sleep. Though you don’t want to tire her out completely, if you make sure that she gets enough physical exercise every day, it will likely help her to sleep better. If the weather doesn’t permit going outdoors, some malls have early morning group walks, or else you can look for a day-care facility for seniors where she will have a chance to move around.
EATING
Depending at what stage of Alzheimer’s your loved one is in, you may run into different sets of problems regarding eating habits. Some people with dementia regularly forget to eat, and they may lose too much weight, while others will forget they just ate and so eat again and be liable to an unhealthy weight gain. Even with a loved one in the early stages of Alzheimer’s, you have to keep careful watch.
If your loved one is capable of feeding himself or herself, allow them to do so, even if the process is a bit messy. If it helps, cut food into small pieces and allow them to eat with their fingers. For drinking, use straws or a child’s sippy cup. Older people, even those who do not have Alzheimer’s, often don’t drink enough and risk becoming dehydrated, which may cause constipation and other health problems, so be certain that your care recipient is getting enough liquids during the course of the day. If the weather is warm, or if your home is dry in winter because of the heat, it’s important to increase their liquid intake.
As the disease progresses, you may find that you’re going to have to encourage them to perform such necessary tasks as chewing (by helping them to move their mouths up and down) and swallowing (by gently caressing their throat), so while you may not love the messiness of one stage, you need to appreciate it for what it still allows your loved one to do on their own.
It’s likely you’re going to have to prepare special meals for your loved one; for example, if chewing is difficult because of dentures, he or she will need softer foods. But just because your mom is getting a separate meal doesn’t mean that she should eat alone. Eating a meal is usually something we do together, so if she can’t sit down at the dinner table with the rest of your family, try to have at least one person sit with her while she’s eating.
People with Alzheimer’s regress in so many ways, and one way, worth seriously watching, is in their eating habits. They seem to prefer salty foods, like chips or nuts, and sugary foods, like ice cream. If they have health problems like high blood pressure, for which salt intake must be regulated, or diabetes, which means their sugar intake must be strictly limited, this can be a problem, especially as they may make quite an effort to get at such forbidden foods. If that’s the case, you won’t be able to keep these foods in the house. On the other hand, if your husband never liked leftovers, that problem will disappear as he won’t remember what he’s eaten recently, and you can probably make dishes that you enjoyed and he never did, as he won’t remember that he doesn’t like that particular dish.
If your loved one always asks for the same favorite dish, as long as it supplies the proper nutrition and is not too difficult for you to prepare, don’t worry about the sameness. If having the same dish encourages your loved one to eat, and if he or she doesn’t remember that this dish was served the last six nights in a row, by all means, go ahead and humor them. On certain matters, you have to put yourself in your loved one’s shoes and not worry about what makes sense to you.
HOLIDAYS
Food and holidays go together, but holidays can be problematic to someone with Alzheimer’s for several different reasons. The first has to do with holidays triggering memories of the past, which can be painful, given their current circumstances. Holidays also can mean crowds, which can be disorienting. Try to limit your loved one’s time in crowded situations, and if she has to be present, make sure there is someplace you could take her to give her a breather, like a spare bedroom.
While holidays are supposed to be happy times, for some people they can cause the opposite effect—I’m not talking about your loved one, but you. You may feel the burden of being a caregiver more strongly during the holidays because they cause you to remember how your loved one was before this terrible disease struck.
It’s important for you to be aware of this potential effect. I’ve already suggested some ways to help combat the blues, but they can only be effective if you’re aware that you are feeling down. So, when the holidays come around, monitor your mood. If you do seem to be more down than usual, then put in the extra effort to actively raise your spirits. If the depression lasts beyond the holiday period, you might want to consult your doctor about it. You can suffer from depression just as much as your care recipient, so don’t ignore it.
PERSONAL HYGIENE
Personal hygiene often presents problems between the patient and caregiver because of issues of modesty. Your loved one may try to avoid a bath or shower, not because they like being dirty but because they feel very uncomfortable having you involved in keeping them clean. You may not feel any better about it, and your body language may end up being part of the problem. If you’re both embarrassed and both react negatively, bath time could turn into a battleground.
If your loved one is worried about falling in the bath, one simple way of alleviating that fear is a pair of bath shoes with non-skid soles. Or, if that’s not an option, you can purchase a chair constructed for using in a bath or shower (made of aluminum and plastic with holes in the seat so that the water drains.) Adding a handheld showerhead for your loved one to use while sitting on a chair will make it easier on both of you. You should definitely add bathtub bars for holding on, and it’s also possible to convert your bathtub to one that has a door on the side, so there is no danger climbing in and out of the tub. I’ve already mentioned that many people with Alzheimer’s have problems with depth perception, so stepping into a tub can seem quite scary to them.
Some middle ground must be found between cleanliness and safety, as you should never leave someone with dementia alone in a bath or shower. Do everything you can to preserve their sense of modesty, even allowing them to wear a bathing suit if that removes much of their anxiety, but always make sure that you have everything you need in the bathroom, so that you never have to leave your care recipient alone to go get a robe or answer the phone.
Depending on how difficult these experiences are, you may have to allow for longer periods of time in between major washings. Twice a week is probably acceptable for someone who doesn’t move around that much and so never works up a sweat. However, if their ability to go to the toilet is limited and they must wear diapers, you will have to clean down there regularly to keep skin irritations from developing.
One method of keeping patients clean in hospitals and other health facilities is the towel bath. The patient is on a large bath towel, and other towels are used to cover the parts of the patient not being cleaned, while a damp cloth and no-rinse soap are used for the actual cleaning. (For more on this subject, read the book Bathing Without a Battle.)
One reason that you need to clean someone with Alzheimer’s regularly is the issue of incontinence. Incontinence in people with Alzheimer’s is often just a matter of forgetting to go, so gentle reminders throughout the day can be helpful. But you won’t be there to remind your loved one at night, and the easiest solution is to just start using adult diapers as soon as the problem arises. The odds are that your care recipient won’t think twice about it, even though you may hesitate, so rather than delay using them, start right away. You may want to double up on them at night and also place a washable pad on top of the sheets.
For men, make sure that the penis is pointing downward because that’s where the absorbent material is located. If it’s pointed up, there’s a greater chance for leakage.
Tip: When traveling, even just around town, keep a spare set of clothes in the car, just in case there’s an accident.
DRESSING
Make getting dressed part of your care recipient’s daily routine. Even if you don’t plan on going out, don’t let him lounge around in his pajamas all day. If possible, try to make getting dressed something that takes place at the same time every day so that he expects it and won’t fight you. If he wants to select his own outfit, try to keep the options that are visible to a minimum. If he selects the same outfit every day, just buy a few that are identical so you can wash his clothes without causing a fuss. Using clothes that don’t require complicated maneuvers, like buttoning, is usually best. Pants with an elasticized waist, like sweatpants, for example, need only to be pulled up. If he can dress himself, put out the clothes in their proper order, undergarments first. If you’re supervising, hand them to him one at a time.
Even if having him dress himself takes longer, let him do it. Try not to show frustration if he’s having a particularly hard time with a garment. It’s important that he feel some measure of independence, and so if he can dress himself, let him.
SEXUALLY INAPPROPRIATE BEHAVIOR
If you read about two people with Alzheimer’s in a facility who don’t have any memories of their spouses and who form a romantic relationship, you might think, “Isn’t that cute.” But when you’re taking care of someone in your home and they act in a manner that is inappropriate, especially if there are children around, then “cute” is the last word that will pop into your brain.
When your care recipient takes off clothes in front of others, or masturbates, or makes remarks about wanting to perform some sexual act, perhaps even in an aggressive manner, that is going to be embarrassing, to say the least. Of course, it’s the disease that is at work here, but that doesn’t make it any less disconcerting.
One aspect that you have to consider is that those with severe dementia who can’t verbalize what they are feeling will exhibit those feelings by acting out. So, if your mother can’t tell you that she’s hot, she may show you by disrobing. Since she may also have lost her sense of cultural norms, it won’t occur to her that being naked in front of other people is not part of our social fabric. The same may apply to a male who exposes himself and masturbates. He no longer has the ability to understand that this is behavior that is not acceptable in public.
Your first line of attack is to let your loved one know, in gentle terms, that this behavior is not proper. Even if this is embarrassing to you, use direct language, because someone with Alzheimer’s is much less likely to understand euphemisms. So don’t say “Stop touching yourself down there,” but instead say “Stop masturbating” or “Leave your penis alone.” If one way of saying it doesn’t work, try another. But keep in mind that if one phrase works one time, that doesn’t mean it will work the next, so always be prepared to give these suggestions using a variety of different wordings.
As with any behavior that you want your loved one to stop, redirecting their attention is certainly the next approach to use. If you can divert your loved one’s attention toward something else, there’s a good chance that he or she will forget the stimulus that initially caused them to become aroused. If it happens often enough in public, outside of your home, you may want to carry around a loose robe that you can quickly use to conceal him or her. It may also be helpful to dress your loved one in trousers without a fly, like sweat pants, which will make it more difficult to expose genitalia, particularly in the case of men.
You might also consider keeping a diary of this behavior. Take note of triggers. Maybe seeing a certain person triggers inappropriate sexual behavior, in which case avoiding that person, at least in public, may be helpful. The stimulus could even be an actor or actress who appears on a certain TV show. People without dementia can develop crushes on celebrities, so why not someone with dementia? If that’s the case, you want to make sure to avoid that program. Also, if you notice that this behavior takes place after a particular medication takes effect, note that too. (Certain antidepressants can, as a side effect, cause a heightened desire for sex.) If your loved one drinks alcohol, which loosens everyone’s inhibitions to some extent, determine whether that might be a trigger. In any case, if you take careful notes, you can then inform your doctor and obtain advice about the problem.
If this type of behavior is accompanied by violent behavior, then that changes everything. This is more likely to occur if such behavior has been exhibited at times prior to dementia setting in. Maybe this violent behavior was tempered before dementia, or only brought on by alcohol use, which can be halted, but now it becomes more pronounced because the patient with dementia has lost the control over their temper that they once could maintain. In such cases, you will have to let your doctor know. It may be caused by medications, in which case an adjustment may help; it could also be tempered by medication, which your doctor can prescribe. If the violence puts you at risk, immediately call another relative or the police. If the person you’re caring for is prone to violent behavior, always make sure that nothing lethal is within their reach, and make sure that you don’t allow your care recipient to get between you and a door to escape, especially if you are female and your loved one is bigger and can overpower you.
Of course, as we all should know, age does not remove sexual desire or the need for sexual release. If your loved one feels the need to masturbate, he or she should be given the privacy in which to do so. It is not uncommon in facilities that two people with dementia will develop a sexual relationship. It is difficult for caregivers in these facilities to be able to judge whether any sexual activity is consensual on both sides, so not every facility will offer those in its care the privacy to engage in sexual activity with another patient. (The potential reaction of the families undoubtedly also plays a role.)
Some male patients exhibit sexual aggression toward any female with whom they come into contact, which means that you cannot have a female come in to give you assistance. There are definitely men who work as home attendants, but to be honest, this is usually a job performed by women, so you may have to do some research to find a male, and the cost may end up being higher as well.
Whatever you do, don’t try to hide this behavior from family and friends. First of all, “hiding” may entail cutting yourself off from them, and if you’re having to deal with such difficulties, you need more help—physical as well as moral support—not less. So be open about it, explain what has been happening, prepare visitors so that they won’t be surprised, and then make the best of it. I’m not saying that this will be easy, but the “easy” way out, cutting you and your loved one off from contact with other people will, in the long run, be much more difficult on you.
VIOLENT BEHAVIOR
While sexual behavior can be very aggressive in nature, there is a tendency toward violence among those with dementia that may have a variety of triggers, not just sexual tension. Research has shown that different types of dementia seem to lead to different types of violent behavior. Those patients who have more damage to the frontal cortex, such as people with Huntington’s disease, lose their sense of inhibition, and so when faced with something tempting, like someone of the opposite sex, they may act impulsively, and in ways which are not acceptable. Those with Alzheimer’s tend to misinterpret the meaning of what is going on around them, and so they feel paranoid, as well as frustrated by their inability to communicate, and they may react with violence toward actions they interpret as presenting some danger, though that’s not actually the case. Those with Alzheimer’s who act aggressively are said to be nonimpulsive—they are reacting to something going on around them, which they misinterpret or else overreact to because of their feelings of frustration. This is different from the impulsive acts of those with other types of dementia, who are more likely to be kleptomaniacs, for example, taking whatever they see and want. Those with Alzheimer’s tend to be more violent, acting out, as opposed to merely stealing, and the more paranoia they feel, the more they tend to act aggressively.
Your doctor can prescribe the proper medication to help your loved one control his or her aggression, which is why you have to report this behavior to your doctor so that you can get this help. Of course, if your loved one is residing in a facility, you have to be concerned that he or she may be the victim of aggression as well as commit acts of aggression. Studies have shown that violence is occurring with greater frequency in many facilities because the tendency toward violence increases in Alzheimer’s patients as they progress toward the latter stages of the disease, and most facilities have a much greater proportion of people in advanced stages rather than early stages.
If your loved one is in a facility, you have a duty to examine them for any signs that show they’d been attacked, like bruises. Some residents in care facilities have been seriously hurt. If you notice any signs of abuse, don’t hesitate to immediately bring them to the attention of the staff.
AS TIME GOES BY
As time passes, despite any drugs that your loved one may be on, he or she is going to slip into the next stage of Alzheimer’s. The changes you notice may be subtle, but after a while they’ll be sufficiently noticeable and there won’t be any mistaking what has taken place. This might make you sad, and that’s understandable, but you can’t dwell on this deterioration. If you let yourself sink into the doldrums each time a new stage or partial stage is reached, you will soon be unable to pull yourself out of the blues. Instead, you have to accept what has happened and move on, learning to adapt to the new conditions of your life together and appreciating the capabilities that your loved one has left. As one person said, you have to learn to live with the new normal, as this is part of the process and will happen again and again.
Easier said than done, you say, and that’s understandable. But you can do it. Instead of letting your emotions take over, you have to think like a general or a CEO and map out the new strategies you will need to cope with these changes. The more you look at it from a practical point of view, the more you see these new challenges as hurdles to conquer and the less sad they will make you feel.
However, I want to return to something I said in Chapter 2 concerning feelings. If you try to bury some feelings, you may end up burying all your feelings. If this happens, you may not feel as sad as you might otherwise, but that means you also won’t feel as happy. You’ll slowly deaden all your feelings, and that is not good. So, while you need to channel your feelings of sadness so they don’t become overwhelming, you also need to give in to them from time to time. It’s okay to go into a corner and cry for ten minutes. It’s actually more than okay, it’s good for you to let the sadness out. But there’s a difference between relieving yourself of some of the weight of your feelings in a physical form, such as crying, and letting them overwhelm you psychologically. You have to learn to manage your feelings so that you let off some of the pressure from time to time, and then channel your emotions into something more active. It’s a balancing act, and it may take you some time to learn how to do it, and occasionally the adjustments will be harder to take than at other times. If the burden becomes too difficult, if you feel as if you’re going to break apart, that’s when you’ll have to start thinking about putting your loved one into a facility. But adjusting to the wall that will slowly be encircling your loved one is not easy for anyone, so don’t feel badly or guilty if these rough patches get to you, because they get to everyone in your situation.