Before we provide appropriate activities and entertainment for our loved ones who have Alzheimer’s disease, we must provide a safe place in which to live. We need to know that dementia affects a person’s abilities in ways that can turn a normal living space into a potentially dangerous environment. Quality of life begins with safety. Whether your mother is living in her own home, your father is living with you in your home, or someone you love is living in a memory care community, Alzheimer’s safety is a primary issue.
There is tremendous variability among people with Alzheimer’s in their behaviors and symptoms. There is no “typical” person with Alzheimer’s disease. At present, there is no way to predict … the exact changes that will occur. We do know, however, that many of these changes will present problems for caregivers. Therefore, knowledge and prevention are critical to safety.
~ From Home Safety for People with Alzheimer’s Disease—National Institute on Aging, August 2010
How Alzheimer’s Disease Affects Safety
Environmental conditions that for most of us are normal and safe can become hazards due to the variety of physical changes and limitations that come with age. Dementia makes these environmental threats even worse, and the potential peril becomes a bigger concern as the disease progresses.
Memory is not the only thing affected by dementia. Because of failing physical abilities and diminished sense acuity, the person with a brain disorder like Alzheimer’s disease is more prone to injury from falling than is the normal aging adult. Sense of place and even sense of time can be affected by dementia; couple this condition with memory loss and the felt need to “be someplace else” that many people with Alzheimer’s describe, and wandering away and becoming lost become very real dangers.
Perceptual Changes and Alzheimer’s Safety
Changes in vision and perception are responsible for many of the accidents involving people with dementia. It is important to understand the difference between vision and visual perception. Vision, or sight, is the physical or physiological component of seeing; it depends on the health of the eye, the optic nerve and the part of the brain known as the visual cortex.
This is, of course, a very simplified explanation of how we see; vision per
se is a passive process; light enters the lens of the eye which forms an image that is sent to the brain. Perception, on the other hand, is the active part of the process. It is what we do with the image that “seeing” supplies to our brain, how we interpret the information. In simple terms, it is how we make sense of what our eyes see.
It is often the impairment to this active, perceptual part of the seeing process that causes problems. A dark pattern in a rug or carpet might be interpreted as as change in the level of the floor. It may be perceived as a step or even as a hole in the floor. Stepping up or down when there is no step or avoiding a hole that’s not really there can cause a fall.
Conversely, colors that are similar but in different planes or on different levels, or objects that are colored like their background can also lead to confusion and potentially dangerous situations. For example, if the floor covering is too similar in color to the paint on the adjacent wall, a person whose perceptual functioning is impaired may not “see” the intersection of the floor and wall, and walk right into the wall; humorous in slapstick comedy, but not here…
Dementia Affects Perception
Both parts of the perceptual process can be affected by dementia. Some of the purely physical problems, like near-sightedness or hearing loss can be corrected. If you suspect that your loved one is having trouble, especially seeing or hearing, have them tested. Any time a problem like this can be corrected it adds to quality of life.
Lighting also has an effect on visual perception. Improper or insufficient lighting can make seeing difficult and lead to any number of dangerous situations. This does not mean that more light is necessarily better. Too much light is a problem if it causes glare, and bright light can be difficult to “see through”, making us squint or causing discomfort to our eyes. Too much lighting can also wash out differences in level or orientation, making steps disappear and walls become extensions of floors. The picture at the right is an exaggeration of over-lighting, but dementia’s effect on perception can create just such exaggerations. Proper lighting is the key.
The Other senses
Vision is the sense that we depend on most, but it is not the only one that can be adversely effected by Alzheimer’s disease. All of the five senses (sight, hearing, taste, smell, and touch) become less acute as we age, and the changes in the brain brought on by dementia can exacerbate these changes. These changes do not affect safety as much as change in sight, but being aware of this eventuality can help you provide better care and contribute to the quality of life of your loved one. Read more about the senses and Alzheimer’s disease here.
There are two other, less well-known senses. Proprioception is closely related to touch. It is the sensory feedback that informs us where the parts of our body are and how they are moving. The vestibular sense is related to and dependent on the proprioceptive system. The vestibular system is what gives us balance, allows us to stand and move through space without falling over. It is dependent on feedback from the visual, auditory, and tactile systems. Obviously, personal safety is very dependent on these two senses, and both can be severely impacted by dementia.
Hallucination and Dementia
At one point Bernice was haunted by severe auditory hallucinations, which were disorienting as well as annoying. She spent a lot of time thinking about and looking for the party responsible for making so much noise, often in the middle of the night. Hallucinations are at or near the extreme affect that Alzheimer’s disease has on perception, and only about 25% of people with Alzheimer’s will ever experience them, but hallucination is quite common with Lewy body dementia and Parkinson’s disease.
Hallucinations can pose a real threat to safety, since the person hallucinating doesn’t know that what he or she is seeing is not real. Imagine seeing a large wild animal, or worse, some mythical creature sitting with you in the living room. A person whose physical abilities are severely compromised could be injured trying to escape such a predicament. Any false perception involving a hazard could present a potential danger.
Hallucinations aren’t necessarily bad
Not all hallucinations are distressing. Some people with dementia report seeing and even having conversations with children. They are often comforted by these encounters and enjoy the unexpected company. The children are not there, but to the person who sees them they are real. If there is no stress or anxiety resulting from an illusion, or if pleasure is actually derived from it, we think you shouldn’t be overly concerned. Holly’s grandmother once told Holly about a conversation she had one night with her husband who had been dead for several years. She didn’t have dementia, but she saw him and talked with him for sometime, until he told her it was time for him to go. This didn’t frighten her or concern her; rather, she was uplifted by the experience.
Visual hallucinations are most common but any of the senses can be affected. In fact, a single hallucination might effect vision and touch; someone might feel the fur of the dog they are petting; the dog that’s not really there. Or, as in our earlier example, hear the children that they see.
The sensory distortions caused by dementia are not necessarily hallucinations. The example of the black-and-white patterned floor pictured above is a case of visual distortion caused by neural damage resulting from dementia. The individual in that example is not seeing something that is not there; her brain is interpreting the visual input incorrectly. It may take some work to differentiate this type of illusion from hallucination. Sensory misinterpretation like this is not limited to vision.
The hazards created by hallucinations can be difficult to counter through environmental engineering. Some drugs may be helpful to counter this perceptual extreme. On the other hand, some medications prescribed for dementia can actually cause or exacerbate hallucination or cause other problems. If you suspect a loved one is experiencing hallucinations, consult your doctor.
Creating an Environment for Alzheimer’s Safety
Knowing how changes in the brain can compromise perception can help us create safer homes. We will look at some simple and inexpensive solutions to the potential hazards discussed above.
- Floor — All floor coverings should be sound. Frayed carpeting, loose tiles, and uneven transitions between floor types can be potential hazards for anyone, and these are usually easy fixes. Beyond that, the floor should be fairly boring, as flat as possible in every way. No unnecessary steps, rises or thresholds, very little pattern, and carpet should be short napped and provide a firm surface. Different floor surfaces, for example, from the carpet in the bedroom to the ceramic floor of the bathroom, can be chosen to differ in color and so provide a cue that the surface is about to change; this is especially important if there is a small height difference between the floors, as there often is. If there is a large height difference (more than ¼” to ⅜”), you might consider doing something to change that. Rugs are generally not a good idea, but they do warm up a room; if you have rugs, be aware of their potential danger. Finally, floors should not be too dark; depth perception is better with a light surface, and depth perception is important for walking and moving around in our environment.
- Walls — You can be a little more decoratively creative with the walls. In fact, color and pattern contrast is often a good thing. First, the wall should be easily differentiated from the floor. or it could be interpreted as being a continuation of the floor. Pictures and other decorations not only make a room more like home and provide sensory stimulation, but offer some visual cues about how far away that particular vertical surface is.
- Furniture — Furniture too should be easily discernible from the background to avoid accidents from walking into or tripping over
- Lighting — Lighting also has an effect on visual perception. Improper or insufficient lighting can make seeing difficult and lead to any number of dangerous situations. This does not mean that more light is necessarily better. Too much light is a problem if it causes glare, and bright light can be difficult to “see through” if it makes us squint or causes discomfort to our eyes. Bright light can also wash out details, can make a bump in the floor, a threshold, for example, disappear and become a hazard.
In general, natural light is better than artificial. Indirect is better than direct. Light that is too bright can make seeing difficult. Use curtains, blinds, etc. to mute direct sunlight; dimmers, shades, etc. to tame bright artificial lighting. Plan and position lighting to eliminate shadows, which can be misinterpreted.
Special Considerations for Kitchens and Bathrooms
- Like furniture, fixtures and appliances should contrast with their backgrounds. A white sink in a white vanity top, for example, can be hard to see. A white sink in a dark top makes using the sink much easier for a person with perception problems. If the toilet, wall and floor in the bathroom are similar colors, it might be difficult to find, and can lead to embarrassing as well as dangerous results.
- More Considerations for Kitchen and Bathroom — We often take for granted the cleaning supplies that we store in cabinets. Many of these are caustic or poisonous. Remember child-proofing the house? Many of the things you did to make the house safe for kids apply to creating an environment that is Alzheimer’s safe. Store cleaning supplies and any solvents, etc. that you are unsure of out of reach and in locked cabinets or closets.
- Garages, storage sheds, basements and closets, are often used for keeping materials that are potentially dangerous. Gasoline, paint, and fertilizer, as well as tools and machinery, can all pose serious safety threats. Make sure that these areas are inaccessible or free of dangerous items and substances.