Advice on dealing with dementia patient

Nurses General Nursing

Published

I started a job as a HMA, and the patient I have has dementia. When I first got the assignment, her condition was not that bad. She would only repeatedly ask me "what time it was?" and a few other things. She even understood that I was there to help and look after her.

Shortly, her dementia had gotten worse. On several ocassions she has tried to kick me out of her house, charged after me with her cane and threaten to hit me with it, and even punched me. At one point she had cornered me in the house, while hurling her cane trying to strike me with it. It had gotten so bad that I had to call her son so he could calm her down. I notified the nurse and let her know about her change of behavior. She said that she'll have a doctor prescribe her sedatives so she will sleep through the night.

I don't think the sedatives are working well enough, because she still gets up a few times in the middle of the night, turning the lights on and off, walking in and out of the room confused before she eventually goes back to lay down. I usually have to remain VERY silent so she doesn't hear or see me. If she hears or sees me, she will become very irate and will spend the entire duration of my shift threatening to kick me out, and asking "who sent me" and "why I am here" nonstop. You cannot make a sound with her, even the slightest. she hears everything if I change position on the couch or open a stick of gum, she hears it, and she wakes up asking "what's that sound? where is that coming from? why are you here? get out of my house now.." And she will not go to sleep.

The other midnight aide who visits, reported that she pulled a knife on her and came charging at her with it, telling her to leave or she'll call the police. She had to hide all of the kitchen knives

The only time patient is not easily agitated is in the morning when my shift is almost over, which is why the aides on the morning shift don't have any problems with her.

Specializes in LTC, Hospice, corrections, +.

I sympathize with your situation, but am not sure if I have any good ideas. Is the son a resource that is close by? How aware is he of the escalation of behaviors? You need to be documenting and reporting the behaviors (as you indicated you have done) each time and your agency needs to respond to your safety concerns. My first thought tho is that as long as the son still calms her I would make him very aware of the behaviors and call him when neccessary. Good luck, this is a tough situation.

I sympathize with your situation, but am not sure if I have any good ideas. Is the son a resource that is close by? How aware is he of the escalation of behaviors? You need to be documenting and reporting the behaviors (as you indicated you have done) each time and your agency needs to respond to your safety concerns. My first thought tho is that as long as the son still calms her I would make him very aware of the behaviors and call him when neccessary. Good luck, this is a tough situation.

Yes, the son is close by. The night I called him, he said that if she doesn't calm down after talking with her, he will come and get his mother himself. He was very nice.

But the next time I came to work, there was a letter saying that we were not allowed to call the son under any circumstances. So I cannot call him if she acts out again. And the nurse does not always pick up her phone when you call her. It's a very distressing situation to be in. Everytime I go to work, I pray that she is sleep...because if she sees an arriving aide during the midnight shift she becomes confused and says that "I don't need anyone here this early. I never had anyone stay with me at this time. Leave my house" and this can go on for quite some time.

Specializes in Developmentally Disabled, LTC, Clinic, Hospital.

Has she been checked for an underlying infection? A simple UTI can escalate dementia symptoms rapidly. Often the elderly can have something as serious as pneumonia and never present with an outward sign, other than behaviorial changes. Perhaps you could try mentioning a UA.

Vicki

She sounds exhausting to care for. Come to think of it, she sounds exhausted as well. IMO, she needs to be re-evaluted by a physician (and yes, an infection may be involved) and placed in a facility better equipped to keep her safe and supervised. Is she alone in the house besides hired caregivers?

If you can't call the son, the nurse can and should to update him on her decline.

She sounds exhausting to care for. Come to think of it, she sounds exhausted as well. IMO, she needs to be re-evaluted by a physician (and yes, an infection may be involved) and placed in a facility better equipped to keep her safe and supervised. Is she alone in the house besides hired caregivers?

If you can't call the son, the nurse can and should to update him on her decline.

She is very exhausting to care for. I am scared to move when I am in that house lol The nurse told us to be very very quiet, which I am but there is only so quiet I can be. Once I went to the bathroom, and she heard the door shut and came running to the door asking "what is that sound, who is there?" Sounds really disturb her. If you go upstairs to get her medication, she will immediately grab her cane and come running behind you, asking why are you in her kitchen/dining room.

Yeah, I'll ask the nurse if possibly she has an infection. And the family is aware that her dementia has gotten worse. One of her sons visited from out of town a few weeks ago and was disappointed to see the condition his mother was in.

The patient is never alone, she has 24 hour care. I suspect it hasn't always been that way because she has been complaining that she doesn't like all these 'strangers' coming in and out of her house at odd hours. That really is what's bothering her. When she acts out like that, she is upset that we are there at midnight (she thinks it's morning tho). It really confuses her.

Has she been checked for an underlying infection? A simple UTI can escalate dementia symptoms rapidly. Often the elderly can have something as serious as pneumonia and never present with an outward sign, other than behaviorial changes. Perhaps you could try mentioning a UA.

Vicki

She does leave to go to doctor appointments, but I am not aware if she is being checked for an infection. I'll mention it to the nurse when I go to the office.

I can understand your situation because I took care of an elderly man who has Alzheimers. How well does she know you or does she at all? I would be very fearful of a stranger in my house late at night too if I didn't know them and I can't even imagine if I had dementia too! I would find out who the day nurse or aid is and ask them how their relationship is with her. If there's a nice friendship developed and she (the elderly) feels trust in this other person ask if you can visit with both of them during the day on your own time just for a bit a few times so she can get to know you better during daylight hours sitting on the porch having a pleasant conversation with the other nurse or aid. Hopefully, for the elderly's sake, you're the one and only one that tends to her during the night and it's not different people every other night, etc. That would be aweful for this woman. Tell her about yourself, your family, kids, etc. Ask her during your visit if she remembers your name, if not, tell her again. Ask several times throughout each visit. Maybe she can relate your name to someone in her family and that way when you are there at night and she becomes startled you can remind who you are and how it relates to someone in her family so hopefully she will feel safe again. I would calmly walk her to the couch and reassure her that you are there to protect her and give her comfort when she needs it and your not there to cause harm in anyway. Building trust is the most important thing to an elderly. I know this is easier said than done and it takes time. I don't know what approaches you've made to help comfort her or help her get to know you better, but this is the way I would handle it. Just trying to help so your nights will hopefully be a little more peaceful. Take care!:redpinkhe

i definitely agree with ruling out any infectious process, as well as getting her to feel safe w/you...

building a friendship.

i'll tell you what else worked with me.

we had this very confused pt, who was assaultive and violent.

one minute she'd be hugging me, the next, whacking me w/her purse or whatever she could grab.

when she would verbally attack me, one day i 'snapped' back and said, "don't blame me, your son did this".

the assaults shifted from me to him.:chuckle

and while she ranted and raved about her son, i would agree with her:

"YOU'RE RIGHT ETHEL. GOSH DARN JUNIOR AND THE LIKES OF HIM", with waving fists.

ethel would pause with eyes widening then narrowing, followed by "you b*tch. how dare you say that about junior".

i would feign surprise and respond, "what? junior is wonderful".

then the whole thing would be over...

best of friends again.

my point being, is if you start agreeing with everything they're saying, chances are it will throw them off and at least redirect them.

i shared my story w/other staff members and they started doing it too...

with the "you're right ethel! i agree with you!" with the by-golly fervor.

it seems to work and we know how to redirect her.

and we choose to work w/her this way, rather than sedate/snow her, which is what she doesn't want at all.

plus, these folks are more apt to fall if ambulatory and sedated.

but remove the knives and other dangerous weapons, will you please?

and, i don't agree with the advice about tip-toeing around her house.

it only creates more suspiciousness on her part.

wishing you all the very best.

leslie

I can understand your situation because I took care of an elderly man who has Alzheimers. How well does she know you or does she at all? I would be very fearful of a stranger in my house late at night too if I didn't know them and I can't even imagine if I had dementia too! I would find out who the day nurse or aid is and ask them how their relationship is with her. If there's a nice friendship developed and she (the elderly) feels trust in this other person ask if you can visit with both of them during the day on your own time just for a bit a few times so she can get to know you better during daylight hours sitting on the porch having a pleasant conversation with the other nurse or aid. Hopefully, for the elderly's sake, you're the one and only one that tends to her during the night and it's not different people every other night, etc. That would be aweful for this woman. Tell her about yourself, your family, kids, etc. Ask her during your visit if she remembers your name, if not, tell her again. Ask several times throughout each visit. Maybe she can relate your name to someone in her family and that way when you are there at night and she becomes startled you can remind who you are and how it relates to someone in her family so hopefully she will feel safe again. I would calmly walk her to the couch and reassure her that you are there to protect her and give her comfort when she needs it and your not there to cause harm in anyway. Building trust is the most important thing to an elderly. I know this is easier said than done and it takes time. I don't know what approaches you've made to help comfort her or help her get to know you better, but this is the way I would handle it. Just trying to help so your nights will hopefully be a little more peaceful. Take care!:redpinkhe

Okay that is a good idea. She hasn't gotten to know me very well. When I was doing the afternoon shift briefly I told her what I was going to school for. And when I switched to midnights I kinda became a stranger all over again.

Yes, there are different aides coming in at midnight. All together there is 3-4 of us, and this is just causing confusion. I don't blame her for feeling this way, it is a major adjustment to get used to a different person sitting on your couch while you sleep at night

You might try having her son or someone she trusts write her a note explaining about the 24 hour care with his signature and hers on it too. If she is much less confused during the day have him or someone else she trusts explain about the caregivers when she is lucid and oriented-- put it in writing and see if she will initial or sign her name to the note. Then when she is confused, you can have her read it and that may help calm her down.

Something like:

Mom, you have caregivers in your home to help you and to keep you safe. There will be someone there 24 hours per day to be with you. The caregivers are Nancy, Susie, Joan and Karen. You know them all and they can be trusted.

Love, Jimmy

If she can read it when she is confused, you can refer her to it explaining: "Mrs. Jones, You already know about us and it has been approved by you and Jimmy. Here is the letter"

This has worked for me in the past, depends on the patient!

earle58 has some great ideas there for distraction. It DOES throw them off when all of a sudden they were ready for a confrontation that doesn't happen. Their minds can jump so quick and their thought processes are so screwed up that it can be difficult (and challenging and amusing at times!) to keep up with them.

Something else I've had success with in the past to distract them is to get them to talk about their past. They don't remember anything short term but ask them who sat behind them in 3rd grade or what kind of dog they had when they were little or what color was their first bicycle and they merrily start down memory road instead of whacking you with a cane. Doesn't always work, may not work for long but it's worth a try!

Does she sleep during the day? Sleep deprivation can be a major contributor to confusion. I think sometimes we forget that although the elderly may doze a lot, there's a difference between a doze and deeper, quality sleep.

+ Add a Comment