How to Tell if Someone With Alzheimer's Needs Assisted Living
It can be hard to decide when someone who has Alzheimer's should no longer live alone. With sufficient lifestyle supports and memory aids, some people with the disease live independently for years. The illness usually begins mildly, and it progresses at very different rates.

Eventually, though, you may have your doubts about how well things are going. Are you overreacting to ordinary problems? Or making excuses so you can postpone tough choices? It can be difficult to know. Confounding the issue is the fact that people with dementia are often able to conceal the severity of their problems, especially if you don't see them every day.

Here are some questions to help you decide whether the person needs more assistance. Each "yes" answer is a red flag that warrants a closer look.

Changes in communication

- Have letters and grandchildren's birthday cards slowed or stopped?
- Does she seldom initiate calls anymore (it's always you calling first)?
- Does she seem in a hurry to get off the phone, fail to ask you many questions, or seem unresponsive to your comments?
- Do you get nonemergency calls at unreasonable hours, or hear complaints from friends that they're receiving such calls?

As dementia progresses, she may find it difficult to follow the steps involved in writing, addressing, stamping, and mailing a letter. Phone conversations become difficult to follow. It can be worrisome when you can only get firsthand updates by visiting in person. And someone who can't write and mail letters may also have trouble completing the steps involved in cooking or driving. Odd communications in the evenings or at night can be characteristic of sundown syndrome, the worsening of confusion and other Alzheimer's symptoms that sometimes occurs late in the day.

Changes in self-care

- Is she losing weight inexplicably?
- Is she gaining weight inexplicably?
- Has her usual style (hair, makeup, clothing) become noticeably different?
- Does she dress appropriately for the occasion?
- Does she dress appropriately for the weather?
- Have you detected the smell of urine on her clothes?
- Does she stay up later and later, and then not wake until practically midday?

Unexplained weight loss may signal an illness, such as depression, or may reflect that she's losing the ability to go through the complex steps of shopping and cooking, or is even forgetting to eat. Conversely, she may forget she's just had a meal, and eat again and again. Obvious signs of a change in grooming standards, whether she's just more sloppy or more flamboyant or inappropriate, may indicate these tasks are becoming too much for her. Unpleasant body odors may mean she's neglecting to bathe or forgetting to toilet. Mixed-up hours (day and night) can be symptomatic of sundowning or depression, and tend to fuel unhealthy isolation.

Changes in social life

- When you pick her up for an appointment, is she routinely not ready yet?
- Does she forget you said you'd be visiting and seem surprised to see you?
- Does she berate you for being late when you're not?
- Does she no longer mention certain old friends, or when you mention them, is she dismissive?
- Has she quit longstanding social engagements (clubs, card parties, religious committees)?
- Has she noticeably lost interest in younger grandchildren (she's no longer asking about them, wanting to spend time with them, or sending them notes or gifts)?

A shrinking social life and increased isolation is not a natural function of aging. Unless she's so old that her longtime friends have all moved or died, it's more likely that she's withdrawing because of embarrassment about her dementia or inability to keep up -- or her friends are dropping her because of their own discomfort. Social appointments may also dwindle as her concept of time grows muddied. A person with Alzheimer's or other forms of dementia may forget meetings, anticipate them at the wrong time, and also lose track of recent acquaintances.

Changes in the household

- Have you ever come to visit and found the temperature of the house inappropriate (much too hot or too cold)?
- Are cupboards full of multiple units of the same item, more than she could reasonably consume?
- Is the refrigerator full of expired or spoiled food?
- Is the refrigerator nearly empty?
- Do you see any melted pots or pans with burned bottoms?
- Do you see signs of spills that haven't been mopped?
- Are there piles of unopened mail or obviously unread newspapers?
- Can you smell urine?

When you visit, keep alert for these signs that she's not keeping up with everyday home care. Simply buying the same foods over and over (a particular brand of cereal, 20 varieties of vinegar) is a memory problem that may seem harmless, if expensive. But forgetting to turn off burners, turn up thermostats, clean spills, or throw out old food represent safety hazards.

Other more obvious and more ominous warning signs that someone may no longer be able to live alone include:

- Having electricity or water shut off because bills have gone unpaid
- Letters thanking her for her contribution to a charitable organization that you're not aware she has a history of supporting
- Robbery (because she let someone in the house unsuspectingly or left a door unlocked)
- Wandering from home or getting lost

By Paula Spencer Scott, senior editor
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