For most of us, being able to drive is a sign of maturity and becoming an adult . Driving allows us a great degree of independence to “to come and go” as we choose; to handle the routine activities that allow us to function—going to the bank, doing grocery shopping, making a trip to the hardware store; to see friends, go to church, synagogue, or mosque whenever we want; to go to the barber or hairdresser; and, when necessary, to see the doctor. When it becomes clear that a loved one is no longer safe to drive, all of these “trips” fall on the shoulders of the caregiver(s). Many caregivers at this time may still be involved in the lives of young children, and/or the caregiver may be working outside of the home. Individuals with dementia in stage 4 on the functional assessment staging tool (FAST) scale, sometimes called the Great Foolers, may independently modify their driving by limiting nighttime outings and trips to unfamiliar locations. However, as the disease progresses, the person with dementia loses the ability to accurately evaluate her/his thinking and his/her response time increases—so that driving skill deteriorates without self-awareness. The challenge is to preserve the individual’s sense of independence as long as possible while at the same time protecting that person’s safety and the safety of others.

Caregivers sometimes allow driving to continue when it is clear that it is no longer safe. At one extreme, some caregivers may not want to “hurt the feelings” of the person and so allow driving to continue long past the time when it is no longer safe. At the other extreme, there are caregivers who want to “take away the keys” at the earliest sign of a memory deficit. Some caregivers may overreact when a loved one with dementia fails to come to a complete stop at a stop sign. Still other caregivers will need the support of family, friends, and professionals before making the decision to take away the keys to the car .

Once a person has been diagnosed with dementia, it is important for family and/or friends to be aware of changes in that person’s driving skills. The Hartford publishes a helpful resource guide entitled Warning Signs for Drivers with Dementia that provides family and friends with concrete behaviors that aide in making the decision to remove the keys (See appendix at the end of chapter). Many states offer driving evaluations through the Motor Vehicle Administration, and the physician can support the family by suggesting that the patient be tested to ensure driving safety and competence.

Regardless of whether the physician suggests a driving assessment or the family initiates the assessment, it is an extremely difficult issue to address. Not only is it important that the patient not drive if her/his driving is deemed unsafe but providing transportation is also a huge responsibility for the family. Checking out resources in a community such as “elder ride” services and public transportation may be helpful. The more alternatives there are to driving, the easier the adjustment will be. It is important for the person to continue to get out for essentials like doctor’s appointments, but also for social visits and enrichment. Feeling housebound can quickly lead to depression .

When driving becomes a safety issue, it is probably time to evaluate the living arrangements of the person with dementia. If the person lives in a remote area with few transportation options, it may be necessary to consider relocating to an area with more options, or to investigate senior living. Some of the transportation options include:

The term “sundowning” refers to a state of confusion that occurs at the end of the day and into the night. If the person has her/his days and nights confused and sleeps all day, sundowning might occur at midnight or in the early morning hours. The behaviors that accompany sundowning may include confusion, pacing, crying, anxiety, aggression, or ignoring directions—basically, an emotional “meltdown.” The exact cause of sundowning is unknown. Applying the theory of retrogenesis suggests a way to respond to sundowning behavior. When those with dementia experience sundowning, they are usually in stage 6 on the FAST scale or in the moderately severe stage of dementia. The person is functioning at a toddler level.

Consider the following scenario. A mother takes her three-year-old toddler to the pediatrician for a well-baby visit. The visit is scheduled at 2 p.m.—a time when the toddler is usually taking a nap. Following the appointment, the child is fussy, difficult to console, crying off and on again—and generally unpleasant the rest of the evening. The mother resolves that the next day she will be sure that the child will be back on schedule! How does this correlate to sundowning in the older person? Generally, those with Alzheimer’s are at their best early in the morning and deteriorate as the day progresses (unless they sleep all day and awaken late in the day—in this case, sundowning will probably occur around midnight). Sundowning generally occurs late in the day—perhaps when a caregiver is making dinner and/or tending to children returning from school . The first episode of sundowning often catches the caregiver off guard, and great efforts are made to comfort the loved one with dementia. When this pattern occurs, the following is often helpful. About an hour before the sundowning occurs, the caregiver should stop what he/she is doing, sit with the person with dementia, provide a snack—a drink and something to eat—and engage the person in a quiet but pleasant activity such as listening to music from that person’s era or perhaps look at picture albums together or watch an old black-and-white movie. By doing this, the caregiver is helping to restore the person with dementia so that he/she does not experience sundowning. If the person with dementia sleeps all day and awakens around 5–6 p.m., then the same strategies might be employed, but rather than intervening in the afternoon, the soothing interventions should occur around 11 p.m.

In addition to these strategies, there are videos that are made specifically to calm and engage the person with Alzheimer’s disease (AD; see www.​alzheimersvideo.​com/​). Another valuable website features 13 respite videos that provide caregivers with a way to improve his/her quality of life in this regard (see http://​www.​best-alzheimers-products.​com/​video-respite-for-alzheimers.​html). Using the respite videos provides a reprieve from the challenges of caregiving. All are designed to hold the attention of those with dementia through music, light movement, and reminiscence. The people on the videos become real friends to the person with dementia . As they have a conversation, or sing together, or remember times in the past with the people on the videos, the caregiver is able to experience a break from the caregiving role, time to prepare a meal, to write a letter, or to read a book. These videos have been successfully used in assisted living and skilled nursing facilities where the “change of shift times” with staff leaving a unit while others are coming into work can be quite chaotic. This is a time when anxiolytics and antipsychotic medications are often used to quiet residents who become disturbed with any change in routine. The videos can serve as an alternative to medication .

These tapes are wonderful additions to an overall care strategy. Each provides physical exercise in the form of light movement, socialization, reminiscence, and sensory and cognitive stimulation. All are ideal aids for caring for a person with dementia in the home, and they also work well in a group situation, in nursing homes, and Alzheimer’s day care facilities.

Caregivers of those with dementia when planning a vacation need to be aware that a vacation may not be the restful and relaxing get away that the caregiver had in mind (Carson 2012). Those with dementia do not always experience a vacation as a relaxing or fun time. In fact, traveling to unfamiliar locations might precipitate a catastrophic reaction in the person with Alzheimer’s or other dementia. A caregiver might be lulled into a false sense of security based on the person’s behavior at home and wrongfully conclude that the person with dementia will function just as well on a vacation. People with dementia do best with “sameness.” Responding to unfamiliar places, persons, situations, and a different schedule every day can be a recipe for a catastrophic reaction. A vacation disrupts all of that “sameness” and familiarity, and plunges the person into situations that are not only unfamiliar but also potentially frightening.

An individual’s reaction to a vacation is impacted by the degree of decline that has occurred due to dementia. A person in stage 4 (“the Great Fooler”) is probably able to handle with relative ease the changes that accompany a vacation. However, for someone functioning at the level of a toddler, i.e., 4 years old deteriorating to 2 years old, a vacation could be stressful for everyone involved. In fact, the answer for a caregiver who desires to take a vacation might be to consider placing the person with AD in respite care—which is available either through certain home health-care agencies, assisted living facilities, or by bringing into the home a familiar individual, a friend, or a family member, to provide care so that the person with AD remains at home following familiar routines. Such an arrangement allows for someone to stay in the home while the caregiver is away.

Sometimes, the primary caregiver decides that including the loved one with Alzheimer’s on a vacation is worth the effort. Planning and preparation, however, is vital in order to lessen the stress and make the vacation safer. It may help to take a short “test” trip to see how the person with dementia reacts to traveling. Planning the vacation destination for a location that is familiar to the person with AD and avoiding places that are overcrowded are also good strategies to consider. If the vacation includes visiting relatives and/or friends who are not aware of the changes that have occurred with dementia, it makes sense to forewarn those individuals about what to expect. For instance, informing them that “Sam still likes to use his hands to build things, but these days, he focuses on manipulating and building with Legos” gives them a heads-up regarding Sam’s condition. If the person with dementia is a wanderer, it is essential that he/she is enrolled in the Alzheimer’s Association’s Safe Return program and that he/she wears an identification bracelet before leaving on a vacation. If the vacation involves flying and/or staying in a hotel, it is also important for the caregiver to inform the airline and hotel staff that she/he is traveling with a memory-impaired individual.

The caregiver should also plan to address the special needs of the person with AD. For instance, what are the bathroom needs of the individual—is the person incontinent, and if so, how will this be handled on a trip? Packing ample incontinent products, wipes, and changes of clothing that are easily accessible when needed is an important consideration. Beverly Bigtree Murphy (http://​bigtreemurphy.​com. Accessed 11 July 2012) created a website that includes practical strategies for dealing with incontinence during automobile travel. If traveling by car, Bigtree Murphy suggests to the caregiver look for service stations along main highways. As mentioned in Chap. 6, these facilities usually have a single-occupancy bathroom that not only provide privacy but will also have a sink that allows for cleanup from a bowel movement. This allows greater privacy for both the caregiver and the recipient of care. Major rest stops are usually equipped with multi-stall units with a sink outside of where the toilets are located so that there is no privacy for cleaning an incontinent loved one.

Packing should focus on changes of clothing and bringing enough prescribed as well as “over-the-counter” medications to deal with the unexpected physical issues that might arise (i.e., diarrhea, constipation, headache, upset stomach, etc.). Additionally, the planning for a trip needs to take into account activities that the person with AD can participate in while traveling. These include, for instance, loading an iPod with the person’s favorite music, or bringing along a deck of cards to play with or, for some individuals, to just hold and manipulate (which may be soothing).

If possible there should be at least one additional person in the car who can focus on keeping the individual with AD calm, occupied, and safely secured with a seat belt. The itinerary for the trip needs to include regular rest stops. If the caregiver is traveling alone with the person and the individual with AD becomes agitated, it is important for the caregiver to stop the car and attend to the person’s needs. Driving while trying to calm an agitated individual is guaranteed to result in disaster.