Encore Communities® & the Best Friends™ Approach

On February 22, 2022, David Troxel, MPH, led a webinar on trends in Alzheimer’s disease research and care and shared information on the Best Friends Approach, Troxel’s own unique method researched and developed with co-author Virginia Bell. The following post contains a summation of the topics discussed in this session.

In 1906, German physician and neuropathologist Alois Alzheimer noticed an unusual affliction with a female patient. This disease, Dr. Alzheimer noticed, produced symptoms such as disorientation, memory loss, and hallucinations, culminating in the patient’s death at age 50, which––even for the time––was a particularly young age to die.

In the subsequent autopsy, Dr. Alzheimer noted various abnormalities in the patient’s brain: an abnormally thin cerebral cortex, the presence of senile plaque (normally found in the elderly), and neurofibrillary tangles. Today, these features are still considered some of the primary indicators of what we now call Alzheimer’s disease.

Overview of Alzheimer’s Disease

While Alzheimer’s and dementia are often used interchangeably, dementia refers to a set of symptoms related to memory decline and impaired reasoning. Alzheimer’s, however, is a degenerative brain disease that leads to dementia symptoms.

The leading cause of dementia, Alzheimer’s symptoms tend to appear after the age of 60, and following this diagnosis, people tend to live for about eight years. In addition to disruptive memory loss, common early Alzheimer’s symptoms include:

  • Challenges in planning or solving problems
  • Difficulty completing familiar tasks
  • Confusion with time and place
  • Issues with visual images and spatial relationships
  • New problems with words in speech or writing
  • Misplacing things and losing the ability to retrace steps
  • Decreased or poor judgment
  • Withdrawal from work and social activities
  • Changes in mood and personality

It’s important to remember that, while symptoms will progress, Alzheimer’s affects everyone differently. Some people with Alzheimer’s act pleasantly confused by their surroundings, while others will grow agitated and combative.

Types of Dementias

While Alzheimer’s is the most common cause of dementia, there are additional types of dementia that lead to similar symptoms. These include:

Vascular Dementia

Caused by damage in the blood vessels that supply blood to one’s brain, vascular dementia symptoms include slowed thinking, problem-solving difficulties, and loss of focus. Compared to Alzheimer’s, these symptoms may be more pronounced than memory loss.

Lewy Body Dementia

Caused by abnormal clumps of protein in one’s brain, Lewy Body dementia symptoms include acting out one’s dreams in sleep, visual hallucinations, and decreased focus. In some cases, Lewy body dementia can cause tremors and rigidity.

Frontotemporal Dementia

This term refers to a group of conditions––including Pick’s Disease––that primarily impact behavior, emotions, and language capacity.

Mixed dementia

Different dementias are not necessarily mutually exclusive. Multiple studies indicate that people with dementia can have Alzheimer’s, vascular dementia, and Lewy body dementia.

Treatment of Dementia and Alzheimer’s

In recent decades, there have been several medications used to treat various types of dementia. Donepezil, for example, has been shown to improve cognitive abilities in some patients. Similarly, Memantine can improve one’s memory or slow its loss in some cases. Most recently, Aduhelm has been used to reduce some of the plaques that lead to Alzheimer’s.

Still, it’s important to remember that we have yet to find a cure for dementia or Alzheimer’s, and most of the medications aim to reduce the onset of symptoms rather than addressing the root causes of these conditions. Because of this, much of the work of dementia care falls on the ways in which we provide support and assistance.

Caring for a Loved One with Dementia

When a loved one begins to show signs of dementia, your first step should be to do your research. Consider the early signs of dementia in addition to their severity. Additionally, you’ll want to obtain an official diagnosis from a physician. Not only can a formal diagnosis inform you of the specific type of dementia you’re dealing with, but it can also make you eligible for Medicare and Medicaid assistance.

With a doctor, you’ll want to quickly consider dementia medications, as these are often more effective when implemented in the early stages. While all dementias are progressive conditions that will worsen with time, your goal should be to keep your loved one as healthy as possible by addressing the issues that are treatable.

By creating a therapeutic environment for your loved one––filled with music, art, exercise, and other activities––you can mitigate or delay many of the issues that come with dementia.

The Importance of Exercise

There is ample evidence demonstrating that exercise is good for the brain. As such, a routine physical activity regimen can be essential for prevention and the delayed onset of dementia symptoms. Exercise can also build morale, increase balance, and prevent falls.

The Power of Music

For many neurological patients, reading a book or watching a film becomes a difficult (if not impossible) task. Because of this, you should consider how you incorporate music into the life of your loved one. Not only can music generate movement, but it can also provide a necessary source of entertainment and connection to artistic beauty.

Additional Activities

While the link between dementia and depression is not fully understood in terms of causation, we do know that up to 40% of those with dementia also suffer from significant depression––a state which often leads many of those with dementia to withdraw from social encounters and cease to perform normal activities of life. Because of this, it’s important to spend time with your loved ones and provide the scaffolding with which they can engage in these tasks.

Some common helpful activities include:

  • Performing household chores
  • Watching and discussing videos on the internet
  • Playing word or board games
  • Cooking and eating meals together
  • Going for walks or hikes

The Best Friends Approach

Pioneered by David Troxel and Virginia Bell, the Best Friends Approach outlines a model of dementia care that strives to provide patients with a dignified life in an enriching environment.

By engaging your loved ones in purposeful and fun activities, you can help them feel safe, secure, and valued, ultimately reducing challenging behaviors of degenerative cognitive impairment.

The Best Friends Approach operates on six key principles:

  • Empathy and understanding of a person’s experience with dementia
  • Unconditional affection and warmth
  • Knowledge and use of a patient’s Life Story to make connections and build self-esteem
  • Practice with communication
  • Creative responses to behavior
  • Collaborative activities

Best Friends Dos and Don’ts

In alignment with Troxel and Bell’s practices, caregivers using the Best Friends approach must always demonstrate patience and compassion. From here, the authors provide a number of actionable tips.


  • Introduce yourself when interacting with a person. Especially if you’re working with a patient in a clinical setting, this can help a person better understand your role.
  • Keep talk simple with short explanations and sentences.
  • Patiently repeat important requests two or three times when necessary.
  • Fill in the blanks to facilitate conversation.
  • Apologize if things aren’t going well. You can always take a break and try again later.
  • Offer sincere compliments about past achievements or current successes.
    • Giving a compliment lifts the spirit and builds self-esteem.
  • Ask for advice and opinions on simple matters.
    • Ex: “Dad, do you think this color suits me?”
    • Asking an opinion shows you value a person’s thoughts.


  • Correct or argue.
    • In 2022, if a person notes that they approve of Eisenhower’s recent actions, you can simply reply that you agree.
    • Arguing and correcting doesn’t help, and it only serves to increase frustration.
  • Quiz or test a person’s memory.
    • Especially when caring for a family member, it’s tempting to quiz them about their life information in an attempt to gauge their memory; however, drawing attention to a memory deficiency only causes embarrassment and frustration.

Looking for Triggers

While dementia will look different in any person, most people will have some types of triggers that cause increased agitation or outbursts. To mitigate the occurrence of these behaviors, pay attention to:

  • Time of day: For some people, behaviors like wandering or aggression are more likely to occur at certain times. Pay attention to any patterns of this nature, as they can help you provide better care.
  • Overstimulation: Crowds, noises, and other overwhelming situations can result in agitation or confusion.
  • Environmental factors: Lights, new people, temperature, or even clutter in the room can cause additional agitation.
  • Medications: In some cases, certain medications may lead to additional agitation. Since a person may not be able to verbally communicate said agitation, it’s important to remain vigilant of behavioral cues that indicate a discomforting reaction.

Help Is Available

A key tenant of the Best Friends Approach is that persons with dementia have all the same feelings and needs as the rest of us. As such, treating them with dignity, respect, and compassion is the most effective way to provide care.

That said, providing this type of care can become complicated and exhausting. Particularly if you’re caring for a family member, the emotional toll of witnessing their cognitive impairment can be heartbreaking; however, it’s important to know that you’re not in this alone.

For additional support, you can look to:

  • Your friends at Encore Communities.
  • The Alzheimer’s Association’s 24-hour support hotline at (800) 272-3900
  • Local or virtual support groups for dementia caregivers

By proactively seeking the support of experts in the field and caregivers in similar positions, you can practice care for yourself that prevents you from burning out. Moreover, it allows you to be the best friend you can possibly be to your loved one.

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