I have had a resident admitted to my unit that is causing anger and anxiety for my other residents. Many will not come to our dining room because of her behavior. This resident has the DX of Organic Brain Syndrome and Chronic Schizophrenia. She yells constantly with a voice comparable to a Drill Sarg. She is very loud, day and night, causing my other residents not to be able to sleep and they are staying in their rooms, rather than gathering to socialize with each other, because she is so noisy they cannot talk to each other. Many have made threats to hit her and of course, we take her from the area to protect her. We cannot take her to her room, because if this was done every time the behavior was displayed, she would never leave her room. Also, we cannot leave her alone for long because she ties to walk alone and has fallen 3 times in less than a week, in spite of the Nurse Alert alarm and the chair alarm. We have tried various tactics to distract her, such as TV, headphones with a varity of music selections, magazines, stuffed animals to hold, even put her with another resident who has similar behavior and they actually talked for a long while but then she started yelling once she became bored with the conversation and scared the other resident so we will not attempt that again. The other residents will not have anything to do with her because of her constant disruptions to their routine. The MD's are trying different meds but so far no results, we also have a Pysch. consult scheduled next week. The part that really puzzles me is that if you are with her, one on one, she is completely able to converse appropriately, and all of her details are correct. She seems to be totally oriented during one on one converstaions and can go into great detail about her life, both past and present. Nothing we have tried has held her attention for more than a few minutes. I think she will eventually be moved to our Alzheimer's Unit, simply because of her constant disruptive outbursts. I fully admit I am not a Pysch. Nurse, so I am calling upon any of you that can give me some insight and ideas to try as diversions or medications that you have seen used in the past to assist in contolling such behavior. I have never had a resident that I couldn't at least help a little bit and it makes me feel like I am missing something and that I am letting her down. Your input would be greatly appreciated.
Apr 13, '01
Duckie - sounds like a tough situation for all of you. I commend you for your dedication by trying so many different solutions.
Since you stated that she can converse coherently when 1:1 with staff, may I suggest Behavior Modification in conjunction with medication. At present, it appears she is given rewards and attention when she is disruptive which encourages misbehavior. Work out a plan with her to decrease inappropriate outbursts. Possibilities include 1:1 staff attention at set times during the day ONLY when she is able to control her behavior for the alloted time. This might be as little as 15 minutes to as much as 2 hours or more and gradually increasing as she is able to tolerate. Most important to success of this program is giving positive feedback BEFORE she escalates. Are there any activities she does enjoy? Like a short walk, tokens to make purchases in the gift shop, special foods? I realize this takes
time and effort for all involved but it might make a difference. Hope this helps.
Apr 13, '01
I would start a team (with overtime or added staff if necc) until you figure out what is coming out of an organic brain is hard enough but the schizophrenia is a glitch in any sure fire planning.
I would have hr on 1:1 24 hours with relief and a log kept documenting by time Q30 min. on behavior, any EPS, do this for two weeks then sit down and plan.
Apr 13, '01
Duckie this post was not ignored JFR... I am just not sure what to tell you. In a case like this, I figure it's better to shut up, than mislead.
Hope something works out for ya
Apr 13, '01
It's hard to comment because I am not familiar with your facility. It sounds as though the resident may not be suitable for your facility. Are you filling out incident forms when there is an outburst that greatly disrupts other residents? If nothing works and the resident needs to be moved, nothing is going to back up such a decision better than a stack of incident forms.
I do not think behaviour therapy is appropriate with this patient. There is a saying that you can't teach an old dog new tricks. Well that goes doubly for an old dog with organic brain syndrome.
What you describe appears to be anxiety-related. On a 1:1 basis she is able to cope enough to be calm and rational, but not so when surrounded with people. When you are next with her 1:1, find out if there are any issues she has with other residents. Is she aware of her condition and why she is there? Is there anything else which is causing her to become distressed? Do you ever bring up the topic of an outburst she had recently when you are 1:1 with her and can she provide insight into why she behaved that way? (she may be unable to reflect on these incidents, I don't know, as I am not aware of the extent of her brain damage). What she probably needs is an environment where she can behave in normal circumstances just as she does 1:1. You may be able to alter the environment or she may need to be transfered. Hope this helps. Well done for being so patient and caring towards this resident.
Apr 13, '01
I totally agree with Doc. She probably needs a transfer to the AD unit because she is not an appropriate candidate for the unit she is now on. She intimidates everyone around her, residents are threatening to hit her, she is a high risk for falls, she's keeping everyone awake at night. Sounds like she should have been moved before the holiday weekend. I've worked with many OBS, Schizophrenics. The only remedy that works is medication to control her outbursts. I can't say which meds because everyone is different. What meds have you tried already?
It's up to the psychiatrist to decide what is appropriate for her. Is she in a private or semi-private room? God help her roomate!
Maybe a stat psych consult if possible before she gets walloped by another resident.
PRN's? I've seen ativan work well, also haldol,but sometimes they become too lethargic. Music soothes the savage beast especially soft string music at night works sometimes. I really do not know whatelse to suggest to you, but if her situation becomes
too difficult, I'd try and get a stat consult. Let us know what the psychiatrist recomends for her. I'll be curious to know the outcome. Good luck and have a happy Easter!
Apr 13, '01
First of all the most important thing is safety. This patient is disrupting the whole unit. This patient is agitating and threatening to other patients, and other patients are stating they want to harm this disruptive patient. A 1:1 is necessary, especially when this patient is at risk for falling as well. The doctor also needs to change the medications to modify the disruptive behaviors you are seeing.....however, this won't cure the patient....only modify the behavior.....and maybe the medication will not work. You can try behavior therapy, but it may or may not work due to the organic brain disorder. If all of this does not work, then for the good of the environment (a.k.a unit or mileau) you probably need to transfer this patient to the other unit you had suggested. This other unit is probably a better fit for this patient and all the other patients as well.
Apr 13, '01
Has anyone tried administering a G.D.S. or a depression-in-dementia screening exam? [there are various versions, out there]. Many of the behaviors you describe sound like features of depression, which, remember, are atypical in this group. The tell-tale sign that makes me think of depression versus other psych. causes is the fact that she can converse with you one-on-one.
Hopefully, your consultant Psychiatrist will conduct these screenings, and begin with ONE psych. med at a time [many of them hit with multiple drugs/multiple classes thinking that one of them will do the trick].
Good luck, and let us know how it turns out.
Apr 13, '01
I feel for you. This is so totally frustrating. Even if you or another staff member make inroads because of chemistry or skills or kindness, often this is negated on your days off or over other shifts because of short staffing etc. I would suggest, however, that you see the site on Validation Therapy, www.vfvalidation.org,
scroll down to the bottom of the page and click on one or more. I have read some of her book and feel she really is on to something that may help. Maybe not right away or with this resident, but if more staff utilized some of her techniques, perhaps we could delay some maloriented behavior. Tell me what you think. It takes a while to sift through it . I tried the polarity technique without even thinking one day with a resident who was very anxious and fearful,of falling. I said "What is your worst fear and she said "I am afraid of who will take care of me when I can't take care of myself." Her fear was validated, and with more of these communication techniques, I saw improvement. I dunno, maybe it was the Prozac! But at least I didn't feel so powerless! If the link fails, go to a search engine and look for Validation Therapy, or the library The Validation Breakthrough by Naomi Feil. I would love to hear if anyone else is a fan.
Apr 13, '01
Unless some kind of medication doesn't help her, she definitely needs to be on an Alzheimer's unit. What was really sad where I worked last was ..the Alzheimer residents were on the same floor as the "coherent" residents. It was a zoo. Jack was always playing his harmonica with other residents yelling for him to stop. Edith would sing hymns all day and we were always asking her to sing softly. Fran would try to eat everyone else's food at her table. Doesn't matter what they were trying to do, I love em all. Taking care of the confused elderly is like taking care of a daycare. When I am 95 and wetting my diapers and trying to grab Joe's muffin, I hope someone kindly takes care of me.
Apr 13, '01
to greg in mass-You're absolutely right. Safety first because second is too late!!!
Apr 14, '01
First of all, I enjoy you input and read all of your inquiries....but to the dileema at hand, I would have to agree to get this pt to an Alzhiemers unit ASAP...combination drugs that I have seen docs use in the past work too...like a Haldol/Ativan dose. Do you have a gerontologist on board????
Apr 15, '01
First of all, I want to thank each one of you that responded. You are all great folks and I appreciate every idea that was given. I don't want to write a book but would like to make some further comments, regarding the posts. I really liked the idea of one on one, so I spoke to my DON and she flat out said no. I understand that it would take some rearranging of our staffing but if she could have someone 1:1 during waking hours, allowing time for naps and meals, I think it would be productive. I think the reason the idea was nixed was that to do this would be giving her special attention that others don't get so it's like rewarding her for the negative behavior. I understand the reason she said no, but I cannot say I like it. I think it could have had some promise. We tried her on Ativan QID and it did nothing for the behavior. The docs are trying Risperdol now but so far no changes are noticed. I have tried multiple times of sitting with her and just asking her questions, like one post suggested. At times she will deny yelling and at other times she will say she is sorry and within a few minutes, she's yelling again. I really feel she does comprehend to a certain extent. The other night, after several complaints about not being able to sllep from other residents, I went in and pretty much laid it on the line. I told her that the other residents were getting very upset with her and wanted her moved from the unit. I told her I didn't want this but what I wanted wouldn't matter if she kept upsetting everyone. She actually calmed down for over an hour but then started again. When I went in the next time I told her she needed to stop yelling because everyone was trying to sleep and for the remainder of my shift I listened to her yelling, " Make me be quiet, they're trying to sleep. I have to be quiet, they're trying to sleep." I have to tell you all, I'm getting very discouraged. I am coming home with horrible headaches, partly from her behavior and also the other residents reaction to her. I want to badly to make a difference but I know there are times that nothing you do will matter and I'm starting to think this is one of them. I have recommended that she be moved to the Alzheimer's Unit, not because I don't want her on my unit but like many of you said, it's the right thing to do, for all the residents. I have an incident report several pages long every shift on her behavior. I'm not sure when they will move her as the special unit is currently full. I fell like by moving her I am not making a difference, I'm just putting the problem on someone elses shoulder. I appreciate the website that was recommended by "cargal" and it may not help with this lady but could benefit someone else. This is one of the "down sides" to being a nurse, sometimes you wnat so badly to make a difference, but you just can't, no matter how hard you try. Thank you all again for your input and ideas, I really appreciate them all. By the way, HAPPY EASTER!!!!!!
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