pacify or orientate? Alzheimers...

medpsychRN · Sep 9, 2006

Interesting post. I work nights on an inpatient psych unit. We are the overflow for the geropsych unit. Not all, but the majority of the dementia patients we treat have an advanced disease.

These patients come to us agitated. Reality orientation only increases their agitation. Medications are sometimes helpful. But medications don't make the patient any more agreeable to reality. It just makes them sleep...when they work. Ativan disinhibits patients. We use it rarely in cases of dementia. Atypical antipsychotics seem to work best. However, you have to be very careful when dosing elderly patients. They can experience side effects more quickly.

Restraints are useless and are only used when all else has failed and safety is an issue. If you thought they were agitated - restrain them...it gets worse!

We use lots of distraction techniques but what seems to work best is walking. I have walked many a mile at night.

I wish I could say that I know all there is to know about working with dementia patients. I don't. They teach me something new every time. I also wish (really wish!) I had the solution for calming someone. It is a horrible disease and these patients are suffering.

When it comes to "lying", either directly or by ommission, I have no problem. I'm going to use whatever works. I can spend the night trying to comfort someone or I can spend the night trying to convince them their mother is dead. I may win the war but I sure lost the battle. Am I lazy? PLEASE! Our dementia patients are 1:1. I work hard!

I am always open to suggestions. May I just say I know nothing about working in the NICU. If I'm getting advice from a NICU nurse, I'm going to believe (and respect) she know's what she's talking about.

There have been many great posts. Love the milking the cows thing! God over the intercom was brilliant. Can't wait to tell my coworkers about that!

sbic56, BSN, RN · Sep 9, 2006

What on earth is the benefit of orienting these patients?? Doing so is bringing "ethics" to an absurd level. They are not living in the here and now. There is no sense in orienting them to what they cannot deem as reality anymore in the first place. It would be considered cruel to do so, IMO. They aren't going to remember the interaction in a little while anyway, but they are going to become agitated when they are told they are wrong in the present. The brain is deteriorated to the point where their cognitive function is losing ground daily, so orienting to what is "real" hurts more than it helps. So, yes...go milk the cows and get god to come over the intercom, if it means a better day for the patient!!:wink2:

sprout · Sep 9, 2006

Alzheimers is a very challenging illness. My father had it and trying to orient did not help when he got to the end stage. I'm assuming that is where most of your patients are if they are in a lock down facility. It is frightening for these patients to be trapped in their bodies and the world around them is telling them a different story than what they are perceiving. Of course try to orient if possible, but that doesn't always work - nothing wrong with pacifying them or distracting them with another activity. They live in their reality and it's almost impossible to reorient them without agitating them if they are very adament. The nature of the illness. No sense in arguing - it's like arguing with a child - you'll end up more frustrated and they won't remember it even happening.

Warpster · Sep 10, 2006

Dalzac wrote, "My aunt was furious and raled at me for an hour. I didnt care My Granny and I had a great day at the beach."

When my mother developed some dementia due to sensory deprivation from blindness and deafness, I advised my dad to let her wander around in her past because, let's face it, it was a much better place than the present was. We could bring her into the present if we had to, involving her in her own health decisions for instance. Most of the time, we just let her live in the past when she was happiest, or at least when it was more interesting.

Her home health aides remarked that some of the stories she told would curl their hair.

I don't regret this choice one bit. Constant reorientation would have been cruel.

Acknowledgement of emotion (fear, anger) and redirection are generally better than reorientation with Alzheimer's patients. The perseveration will drive you around the bend sometimes, but remembering they don't want to be like that helps a lot.

lvs2nrs3535 · Sep 10, 2006

Tonight, in my LTC facility, I had an 89 year old patient who is on comfort care suddenly come back. (She has been failing, and we all expected her to pass). In the last two days she has eaten, her stage 3 wounds on her bottom have considerably improved, (with agressive nursing care also, but sometimes the most agressive interventions wont help a failing patient who is taking in no nutrition, right?), and she was coherent. I answered her call bell, this little skeleton of a sweet lady, whose daughters have been here every day to visit her. She said to me, "I'm so lonely, what am I doing here all alone? Where are my children?" I explained that they had been in earlier that day, but she didnt remember. Then she asked me, "Why am I so weak? Why can't I walk or get up?"

Now, I could tell she was 'with it'. Should I have said, "Sorry, but it is because you are dying?'

No. I am sorry. The truth is sometimes too cruel.

I said, Oh Sue, (not her real name), you are tired cuz you have been so sick, and you didnt eat the last 3 days. So, here, have some more juice, and let me clean your bottom and put on some more cream so it doesnt hurt so much. She accepted that answer, and fell asleep peacefully.

I stand by me 'lie', and there is no one that can tell me I did the wrong thing. If you havent been there, you just wont get it. As I have said before on this forum, I fell into LTC by accident. But I feel so strongly that there are so few people who can do this, and care, I think I may be stuck here.

Life. It throws you curve balls sometimes, huh?

:rolleyes:

It isnt easy. It is truly satisfying.

Alixandra · Sep 10, 2006

My grandma had Alzheimers and as the disease progressed there was no bringing her back to our reality.

She lived with us in the early stages and one day I brought my blanket into her room to watch TV with her. When I was done watching TV I went to leave with my blanket and she insisted that I was not going anywhere with HER blanket. Well I couldn't sleep without my blanket so I got my mom to help get my blanket back, keep in mind I was all of maybe 6 or 7 at the oldest, and I had been taught not to fight with adults. Since she was early on my mom told her that it was my blanket and remeber that hers was green and mine was red. Once my mom said it a couple of times she did remember that hers was green and that mine was red and I was allowed to get my blanket back and my mom told me to never take it into her room again to avoid the situation ever popping up again. I will say that her blanket and mine were identical except for the color(my dad got them while stationed overseas with the Air Force) so I can understand her confusion now, even though I didn't at the time. In this situation because she was in the early stages we could bring her back to our reality, but as she progressed you couldn't have brought her back to our reality with a sledgehammer.

My dad went to visit her in the nursing home after she finally couldn't be kept at home any longer. She had returned home after staying with us for awhile but started wandering and obviously that isn't safe. She was end stage at this point, she didn't have much verbal ability left. My dad introduced himself to her and she said hi to him. In the time it took for him to walk from the doorway to her bed she had already forgot who he was. He went to hold her hand and she grabbed his right hand and started staring at it. She then started rubbing his right index finger over and over and over again, looking at it and seeming really confused by it. She thought my dad was her husband(my dad's dad), who didn't have a right index finger. Her husband had been dead for over 14 years at that point. She never commented on the index finger, as I said her verbal ability wasn't much at that point, but he said you could really tell she was totally baffled by it's existance. I will say my dad and his dad looked like clones and in her reality her husband prolly hadn't gone gray yet. Are you telling me it would have been better to tell her that my dad was her son and her husband had been dead for 14 years. She had already gone through and 'got over' her husbands death when it happened and she didn't need to go through it again. trying to orient her would have only resulting in her getting violent and she would have had to be medicated. She was known at the home for being easily agitated and quickly violent when they would try to orient her to their reality instead of letting her be happy in her own reality. She went into the home in the mid to late 80's and the home was still trying to orient them to their reality instead of letting the residents live in their own reality. By the time she died in 1995 they had changed tactics and let the residents have their own realities and it helped greatly.

I know for my own grandma when they tried to orient her all it did was she would quickly get very agitated and violent and have to be medicated to get her back under control. I doubt she weighed over 100 lbs and was barely 5' tall but it would take 3 large male orderlies to restrain her so they could medicate her when she got agitated.

I will say I refused to visit her in the nursing home. I wanted to remember her for what she was, not what she had become. It was also pointless to visit as she didn't recognize anyone. My dad was the only one she ever even showed a glimmer of recognition and as I said she thought he was her husband, not her son. I just preferred to remember the grandma who got up with me everyday when she stayed with us and we'd turn on the TV and work out with Richard Simmons(it was the 80's when he had his TV workout show) or who played with me and who put her curlers in my hair to 'make me pretty' and who loved to let me play dress up with her clothes.

It is a horrible disease and most are scared to death of ever having it and Im sure it has to be scary as heck for the anyone who suffers from it. Im the beginning they know something is wrong but they don't know what and then it progresses from there. Trying to orient them is cruel and doesn't work. As I said my sweet little grandma(and she still was if allowed to live in her own reality) became like a wild animal when you tried to orient her, just ask the 3 men who had to try and restrain her, they usually got kicked, punched, bit, spit on, and more.

If I ever get this horrible disease I hope the people who take care of me let me live in my reality, not theirs.

Taryn

pyrolady · Sep 10, 2006

Ummmmmmmmm, Jesskanurse - your experience is a four year degree....let's see, NOT to be flaming anymore than what already is, but you are 23 years old according to your byline. That means you have approx. one year of experience. Please listen to those who have many years of experience - dementia is NOT a psychological condition (therefore, I would also wager your friend who have a Masters in Psych would know very little about actually caring for a dementia patient). It's nice that you had "great instructors" in school, we all have had one or two that stand out. However, I don't know about YOUR school, but dementia was taught in my geriatrics class NOT my psychology class. BTW, I too have a four year degree, as well as another bachelor's, and have been everything in a LTC from midnight charge (plenty of sundowner experience), to DON, to the Administrator. Please - work in geriatrics for awhile and then come back and revisit the subject. Thanks.

copperkiwi · Sep 10, 2006

I'm about to take my NCLEX-RN exam, if this situation comes up in the test what will be the right answer?Thanks.

hemoglobin · Sep 10, 2006

I love this thread. One, for the great information regarding dementia and two, for the wonderfully explicit example of bullheadedness. Brain anomalies are so fascinating to me! :wink2:

I came upon this thread while wandering on allnurses.com. I think this is really informational (like most of the threads on this www). I have heard about alzheimer disease but have never actually beind close to one. My grandmother at 90 y/o was as sharp as a cookie up till the moment she passed away. The only thing was she occasionally wandering out in the neighbor and forgot her way home, i don't know if that is alzheimer, or jsut forgetfullness.

IreneL · Sep 11, 2006

My DON mandated that we orient to reality 30 years when I was an aide. My favorite patient used to run an orphanage and was so happy " baking cookies" and " planting the garden" until she was "oriented" then she cried and cried because she was " in this horrible place" away from those she loved. I thought it was terribly cruel to insist on "care" that made her heart break over and over.

leslie :-D · Sep 11, 2006

My DON mandated that we orient to reality 30 years when I was an aide. My favorite patient used to run an orphanage and was so happy " baking cookies" and " planting the garden" until she was "oriented" then she cried and cried because she was " in this horrible place" away from those she loved. I thought it was terribly cruel to insist on "care" that made her heart break over and over.

same type experience except in nsg school.

my psyche instructor expected me to orient a young male pt w/end-stage AIDS dementia, who was frantic because "they" were trying to steal his baby and a poorly-controlled paranoid schizophrenic who actually let me sit next to him (the nurses were highly reluctant in letting a sn interact w/him) and even said that i was one of the good guys.

i was supposed to tell both of these pts what my name was, that i was a sn at _______ school, etc.

i refused.

i told the AIDS/dementia pt that i would protect his baby, as he gladly handed over the doll he had been clutching;

and i affirmed that yes, i was a good guy to the schizophrenic pt.

that was my last time on the locked unit.

my instructor accused me of enabling and i was transferred to detox.

still, i questioned reality orientation then and i reject it now-with these specific cases anyway.

leslie

Cora Zone · Sep 12, 2006

I had an experience in my first med surg clinical, as a student. The patient was convinced that she was going to take my two children (I think she thought that was what the IV pole was) out for hot dogs. As long as I did therapeutic lying, I was able to get her to eat her food, and allow me to help her with ADLs. A fellow student overheard this and decided I was doing harm. I allowed her to intervene because she had more experience and confidence than me. She was going to re-orient the patient and did she ever--in 15 minutes the patient was screaming, growling, cussing, and trying to bite me and everyone else. Then her primary put her in restraints, and her arms were a mess from yanking on them. And she hardly ate a thing all day. The day before, I'd actually had decent conversations with this patient and she ate all her meals. That was a lesson for me.