help with dementia patient please!

leslie :-D · Jun 10, 2011

if he's that early in the disease process, i would suggest the doctor having a 1:1 with him.

he deserves to know what the heck is going on with himself.

granted, he may forget what was explained to him, but that remains to be seen.

i've fibbed a few times, just so i could be in their world for a bit.

but mostly, i treat them with sympathy, apologetic (i'm so sorry you're feeling this way.), and try to redirect them into talking about their past.

very few people forget their distant past...

and very few can resist talking about it either.

much luck to you and him.:)

leslie

loriangel14, RN · Jun 10, 2011

I work on a floor with a lot of such patients.We usually use the " it's too late to go anywhere to night and we have a bed you can sleep in for now" line. We also use medication and electronic wander bands to keep them safe. Asking them about their past helps and if they have funny ideas about where they are then we join them in their world. We have one man waiting for placement that believes he is on a cruise. He asks about what movie is being played today and when we are docking. If he wants to leave we tell we are at sea and he has to wait. It keeps him happy.

If your patient has family find out about his life. We had one man that was a farmer. He couldn't remember what he had for breakfast but he could tell us all about the animals they had and what it was like farming back then.

Ask your patient who Billy is or ask him about family. You can redirect by reminding him that it is almost meal time or asking if he is thirsty, hungry, needs to go to the toilet or is in pain. Sometimes confused people get agitated because they are uncomfortable but can't verbalize the problem. We are told with our wheelchair bound patients to monitor the 3 Ps, pain, positioning and potty.

allnurses Guide · Jun 10, 2011

i try to observe how the nurses talk to him but most of them seem to just tell him things like 'its late in the day, just wait till tomorrow' and get him to agree to wait till tomorrow. while this works for the moment i dont think this is the best way to respond to him

is he aware of how long it's been? does he forget that he was told to "wait for tomorrow" the day before?

if his memory is "only in the moment" then you would have to work with him from moment to moment. there will be nothing you can tell him that will stick. if these responses have worked for the moment and settled him down for the moment, then that is usually the best one can do.

i've seen a lot of people say to 'redirect' or 'reorient' dementia patients but can someone explain what exactly that means and how to do that in a case like this? thank you so much for any tips/advice!

be careful with this one.

i may try to reorient once, but if that proves to be highly upsetting to the patient, i know to leave it be. from that point on, i'm working with them within the context of their reality.

and this patient is forgetful. things aren't sticking. everything he will be told, even if he is told it everyday, will be like he's hearing for the first time (and in his reality, he is).

so then, how many times does this poor man need to go through the ordeal of "learning" he has dementia?

i truly believe that the hardest stage of dementia to work with, is those who have not, as i like to say, "gone over the top of the mountain of dementia". they retain enough lucidity to be indignant at the "preposterous" diagnosis of dementia, but too far gone to be safe.

very sad.

Nascar nurse, ASN, RN · Jun 10, 2011

Not sure I understand if he's "not that bad" why it has taken 2 months to find placement. Do you have assisted living homes in your community or dementia units? What makes him not able to still function reasonably well at home with some supervision?

I can tell you, after 25 years experience with dementia patients, reality orientation usually just ticks people off. It doesn't work and many times is just plain cruel. They no longer have the capabilities to process reality...they think they do though and that is the sad part of the disease. Because of their memory problems they are simply unable to remember how often they forget (heck that even confused me just to write it - haha). Just tell that poor man every day that he has dementia, he can't take care of himself, etc and every day he will respond with the same argument that he is just fine and is perfectly capable to taking care of himself. Eventually he gets the point that he doesn't like you (he can't quite remember why, but YOU are the one that is mean to him).

It is so much kinder to make them comfortable, promise to find some help tomorrow and promise him a good meal and comfy bed while we wait. Again, somewhere along they way, they remember that YOU are the one that tries to "help" them.

Tait, MSN, RN · Jun 10, 2011

This is a little off topic, but we were discharging a dementia patient home a few weeks ago when she stopped her nurse and asked if she had let the dog out. The RN said "of course". Her daughter then turned around and said "mom I had that dog put down three years ago". It was so sad to see her cry the rest of the way out.

Sometimes you just have to find what seems to settle them for the moment and run with it.

Tarabara · Jun 10, 2011

Not sure I understand if he's "not that bad" why it has taken 2 months to find placement. Do you have assisted living homes in your community or dementia units? What makes him not able to still function reasonably well at home with some supervision?

He seems to kind of go in and out of confused states. Sometimes he says the most random things, like when I asked him how we was doing he said, "i'm ok, but I cant fly today". Or he'll talk about things that obviously happened a long time ago and say they happened 5 min ago. But most of the time he does know he is in the hospital, he just doesnt know why he's here. That's where I have a problem, I cant reorient him because he does know he's in the hospital, I just dont know how to explain to him why he has to stay here right now. One day he said something to me like "i'm sick in the head" so I think he may realize he does have dementia sometimes, idk. I'm not sure exactly why its taken so long, I know the social worker isnt the most proactive person, and they've had issues reaching his daughter (she lives in another state) they're trying to work with her to find him a place because she's in charge of his finances.

Jenni811, RN · Jun 10, 2011

While i was in nursing school, i became certified as a dementia care specialist. I'm actually preparing my first education day EVER to nurses at our hospital. Yikes! so nervous!!!

So i will tell you this. That the stage he is in is probably the toughest stage. Because they are kind of aware that something isn't right about them. Not necessarily they have "dementia" but that something is different. This frustrates them, and and this stage they know when people are lying to them in certain situations. So in this stage it is NOT smart to say something like "You have dementia and we are looking for nursing home placements for you" Why? because he with it enough that he is going to think he can live on his own and doesn't need to go to a nursing home (although we know thats not the case).

So what is taught is what is called "validation therapy" you are not lying to the client, you are only getting into their world. Because their world is very very real to them. It is as real to them as this nursing board is to you. So if someone were to tell you that this nursing board is "all in your head" you would think they are crazy, right?? So therefore, you don't want to tell them that whatever they are thinking isnt real.

Validation therapy works best in a little more advanced stages than this, but i still think would be good for him.Take for example a patient i once had with more advanced stage dementia:

He was convinced he was on his brothers farm and it was time to milk the cows. Well, we know he isn't at his brothers farm, he is in the hospital. The nurse who had him originally told him "No, you are in the hospital. Look around you. this is a hospital room"...she meant well, but what she didnt realize is this patient REALLY TRULEY thought he was at his brothers farm. So when this nurse said that to him, he got extremely upset and was throwing things, and scratched his wife out of anger. I went in after he calmed down a little to try and get his meds in him (because his nurse was unsuccessful). Again- he tells me he is at his brothers farm and its time to milk the cows. So what do i do in this situation to use "validation therapy?" i told him " You're brother his handling the cows today and is giving you a break from milking the cows"....sounds GREAT to him, he gets a day off from milking the cows!!! I didn't lie to him, because his brother really is at home taking care of the cows (im assuming so anyway, it sounds very logical anyway).

He responded in a more relaxed tone "Oh. well that makes sense why he hasn't come to get me yet" Then i went on about his medications and how it was time to take them. Surprisingly, they still don't ask why they need these medications, like you think they would. But IF they did...just go over what the medications are...tell the truth. If you're giving a Namenda or Aricept i tell them its for "healthy brain function as you age" (explained in simply terms and not a lie!)

In this situation- try to come up with some creative for him that will relax him but not telling him a strait out lie or that he is getting sent to a nursing home. If he is so set on "Billy coming to get him" just tell him you are working on getting ahold of Billy or someone that can give him a ride because his car isn't here. Tell him that you can offer him something to do or eat while he waits. Our hospital...we have board games that volunteers come up and play with our patients. Volunteers are GREEAT!!! for this type of stuff. This man is probably board off his A$$. give him something to do...sit him up at the nurses station if you must. Put him in his own street clothes, give him a ride around the unit/floor in a wheel chair, take him for walks, take him outside!!! i love taking patients outside (Need a physician order though). Im assuming this would not be difficult to get for this patient. Of course i would suggest taking him in a wheel chair incase he does get smart and decide to leave. Make it sound super super positive "Hey 'Joe' i was going to step outside for a walk. Would you like to go with me?"

Sorry so long, but i really hope that helps you!!!

Jenni811, RN · Jun 10, 2011

He seems to kind of go in and out of confused states. Sometimes he says the most random things, like when I asked him how we was doing he said, "i'm ok, but I cant fly today". Or he'll talk about things that obviously happened a long time ago and say they happened 5 min ago. But most of the time he does know he is in the hospital, he just doesnt know why he's here. That's where I have a problem, I cant reorient him because he does know he's in the hospital, I just dont know how to explain to him why he has to stay here right now. One day he said something to me like "i'm sick in the head" so I think he may realize he does have dementia sometimes, idk. I'm not sure exactly why its taken so long, I know the social worker isnt the most proactive person, and they've had issues reaching his daughter (she lives in another state) they're trying to work with her to find him a place because she's in charge of his finances.

the term "I'm sick in the head" is very common. Alot of patients in this phase realize something is wrong, but they don't know. It sounds so awful to say "You have dementia" well, your right in saying that they have the right to know their disease. But chances are they won't understand that and what that means. Your better off saying something about "Well sometimes as we age our memory isn't as good as it should be and it gets difficult to remember things." it's more "simple" and they now know they have memory problems.

That is the TOUGHEST stage to be in i think. Because they know just enough that sometimes validation therapy doesn't always work, and they know there is something you are not telling them.

Jenni811, RN · Jun 10, 2011

This is a little off topic, but we were discharging a dementia patient home a few weeks ago when she stopped her nurse and asked if she had let the dog out. The RN said "of course". Her daughter then turned around and said "mom I had that dog put down three years ago". It was so sad to see her cry the rest of the way out.
Sometimes you just have to find what seems to settle them for the moment and run with it.

PERFECT example!!! it is all too common you hear people say this. you have to keep in mind that this patient thought her dog was live. So when her daughter told her that (although meaning well), it was like she heard this news for the first time! So i'm sure it was devistating.

We had a patient that would wrap her left-over food in a napkin to take home to her dog (who died when she was a young girl). Her dogs name was "Precious" so i would tell her "Im sure precious will appreciate the thought." Later after she was sleeping i would go in and retrieve the food she wrapped in a napkin. i don't want to upset her and tell her precious is dead. Let her have that happy moment, no harm in letting her keep the food so long as you retrieve it :)

cogath · Jun 10, 2011

Thank you Jenni811 I loved reading your post. I really enjoy working with dementia patients and have worked with them for two years. Do you have any information on becoming certified as a dementia care specialist?

I have nothing to add from my experience except to emphasize that re-orientation does not work. For example a lot of my patients ask where their mothers/fathers/siblings are. Many of their relatives are dead. Imagine hearing that your mother died each day, every day, as if it was the first time you were hearing about it ... that would be very upsetting!!

brielle776 · Jun 10, 2011

My very first patient ever in nursing school was a dementia patient. I remember the first day of clinical trying to feed him breakfast and he slapped apple juice all over my white uniform lol. At first I was really afraid of him, but after the third week in the nursing home I actually looked forward to taking care of him. I ended up meeting his wife who was such a sweetheart. Some days he would be angry and combative, and other days he would be depressed and really upset at times. He was never lucid though at least while I was around.

My fondest memory of him is one day while I was feeding him lunch he was talking to me about his wife, he talked about her a lot, and asked where she was or when she was coming to visit. He told me that people had been telling him that she often comes by to see him, so they can try to form a friendship again, and he began to cry. It made me so sad to see him upset, so I told him that his wife loves him very much and she comes by to see him all the time. I told him that when we were done eating lunch that we would go give her a call. I took him up to the nurses station and we called his wife and he talked to her for a few minutes and after the call he wasn't upset anymore. She thanked me for letting him call her, and for being so patient with him. It made me feel so good to know that I made my patient's day better even if it was only temporary. Even when I was assigned another patient I would always go back and check on him every day I was at clinical and ask him how he was doing. I know he doesn't remember me, but he would often thank me for helping him with eating and changing, ect. He was my favorite patient, and I will never forget him!