Combative dementia patient

[Just_Kidney, ADN, BSN, RN]

I'm a new grad working in a SNF. I have a resident on my hall with late stage Lewy body dementia who needs 1:1 care but due to understaffing, can't get it. I keep an eye on him as best I can but I also have 13 other patients. His biggest issue is constantly trying to walk without assistance and he's a fall risk. We don't do restraints of any kind at my facility including chair alarms. The second issue is he is 250 pounds of muscle. He's the strongest 80 year old I've ever met. I've worked with dementia patients for years as a CNA and my calm, patient attitude usually deescalates confused patients relatively well but this man is extremely combative even with me and is absolutely going to injure a staff member sooner or later. He throws punches right and left, will grab your hand and twist it sharply before you can react. We do the best we can but we have to help him with ADLs, he can't sit in a dirty brief all day no matter how violent he is. I bring him up to my DON daily but they can't find him placement anywhere else and I think they are genuinely trying. He needs to be in geropsych but those beds are hard to come by. I was just wondering if anyone has suggestions for me because I'm running out of ideas and I'm afraid he's going to hurt someone or we're going to hurt him trying to hold his wrists to keep him from hitting us I'm genuinely sympathetic to his situation but I'm running out of ideas. Thanks.

[litbitblack, ASN, RN]

Summarize his behaviors and redirection attempts to the MD. Make sure they are all documented including changing approach attempts and exactly what is going on at the time the behaviors are occurring. Have the MD review your summary and his medications. Not treating behaviors is just as bad as overmedicating. For behaviors that are occurring separate from ADL care I would get him busy with activities. Anything that can keep him occupied decreases behaviors. It sounds like he needs medication adjustments.

[CoffeeRTC, BSN, RN]

This can be very frustrating especially when you get more than one resident that needs the 1:1. Have you reached out to the family to find out what calms him? What worked/ didn't work in the past?

[garnetgirl29, BSN, RN]

I've dealt with difficult, combative residents and I always report aggressive behaviors to the MD so they can address the issues. We usually treat the behavior with a combination of medications (depakote, Ativan, Ativan/Bendaryl gel, Haldol) if other interventions fail and I have seen improvements with this. We cannot medicate (nor would I want to) to the point than the resident is lethargic, but just to make them more comfortable. If the resident is fighting and agitated, they are clearly not happy. Safety is always the primary concern. We also do not use restraints and my hall has 25 residents, the majority of which do have various degrees of dementia. I have 2 who are know to be aggressive & 5 major fall risks - 3 of which have falls on a regular basis. It is very frustrating. I hope you can find something that works for your patient!

[mtjoanna]

Document, document, document! Note every time he strikes out, especially at peers. Document your reporting his behavior to the supervisors and doctors. Chart the times these occur and the specific interventions you tried. Sometimes, having all that documentation can light a fire under complacent supervisors.

Also, ask about starting a program such as CPI, which teaches nonviolent self defense.