How to deal with an aggressive dementia patient

CTnewgrad826 · May 4, 2015

Are they getting a goods night sleep? May be some recurring delirium. Regardless I would contact the doctor right away as clearly they need to be evaluated further and a med rec needs to be completed.

As for the patient leaving if they were to elope, what does the policy say to do? I work in a hospital but I would follow my patient and have someone call security in the mean time. You'd likely have to call the police however if this isn't outlined in the policy.

I'd try to keep the patient occupied during the day though. Stick to a routine, make sure they're sleeping at night, walking around and getting exercise during the day. Keep them oriented. Give them tasks to do. Make sure they're eating and what they're eating is good for them.

icuRNmaggie, BSN, RN · May 4, 2015

There should be a black mat or rug at the door.

Many dementia patients see that as a hole in the floor and will avoid the area. He may be over tired and you might try an hour long nap in the afternoon. He may be

manageable with an antipsychotic med. With the slow

geriatric metabolism it generally takes six hours

for oral medicatiions to be effective. It may help to give a dose of seroquel or remeron after lunch. Please inform your management, the family and the physician so that they can

address this. If the patient is violent call 911and request EMS. It sounds like he may need to be evaluated in a geri psych unit. Good luck to you.

MedChica · May 4, 2015

I don't see how you'd be doing this alone. You're not in that facility all by yourself.

When the facility alarms go off, everyone (CNA, Nurse, Housekeeping, Maintenance, etc...)should be making a beeline for the exits to recapture the pt.

Yes, running. You can't work psych in cute Koi clogs, I'm sorry.

Someone should already be on the phone with the A/DON. Yes, you must FOLLOW the pt and coerce them back. Call the daughter on your cell if that helps. If not, call the police and state the cause. Get a cop out there. You cannot lose your pt.

We've pulled residents off city buses. It can be done.

Is the neighborhood attentive? If you've got watchful homeowners nearby, they WILL alert you to a resident trying to escape.

Your pt doesn't seem all that aggressive. How exactly are you 'distracting' the pt? Why not give them something to do?

Reality orientation doesn't work when someone's mind is completely broken. It could actually create aggression.

Sometimes, you've gotta run with the delusions. I don't mind talking to residents for hours on end. Psych pts are funny. Characters. They're hilarious. I let them follow me around, too. It doesn't bother me. I'd rather them follow me around, a bug in my ear, than trying to break out. The discussion will be weird but fun.

"How do I get to giant eagle?"

I'd say something like, "I dunno. What's a giant eagle?"

Interesting dialogue will be had. If it's a destination (like, where they used to live before coming there. Home), lead the convo off on a tangent.

-- "How do I get out of here?"

Give them direction. Just don't provide the right ones. I just keep sending them to dead ends. They'll just walk to the other end, get distracted, come back around 30 minutes later and ask again. Good exercise.

Do they have friends in the facility? Sometimes, I put two talkative pts together and let them yack the other's ear off. If you eavesdrop, the discussion will be utter gibberish but they like it. Everyone needs to socialize.

-- "I'm trying to get home."

"Where do you live?" Then, redirect the discussion to something more interesting.

"Why?"

"It's dark outside/too much traffic, papa. Stay here with us until the traffic thins out/tonight and you can leave tomorrow."

I used to have a resident who wandered (sundown) and tried to elope every other day. He either had to pick up a car or go to work or was looking for an item for work or was waiting on a vehicle to pick him, etc...

-- "Papa, the car is in the shop. It won't be ready until tomorrow. Just wait here with us."

-- "Papa, you don't work today. It's --" ...nighttime/Saturday/Sunday/the weekend/the holiday, etc... " You're off. Why do you want to work on ____? You should be resting. I wish I was off. "

-- "Papa, it's night time. Why do you want to be running around at night - it's dangerous? Let's wait to leave until tomorrow when you can see? They'll pick you up tomorrow.

-- "Well, you should eat before you leave. You're gonna get hungry. C'mon - they're making --"

-- "...you can wait here for the night. We have a room for you with a tv in it and everything else. You don't have to pay for it or anything. Stay with us and leave tomorrow."

It's okay to phrase statements in an asking tone but you don't redirect a pt with questions. That gives them opportunity to shoot down whatever you're offering which shuts the dialogue down. "Is that something you'd like to do?" ; "Are you hungry?"

Ask questions when you're probing for info. You don't redirect a pt with a question.

You suggest. You make statements.

"Let's do --"

Food helps. I used to settle a pt with pudding every time he made a run for the exit. Talked him down; then, "I have some chocolate pudding...?"

EDIT:

I never worked ALF. I was just geripsych. So, pardon my confusion.

loriangel14, RN · May 4, 2015

It sounds like they need medication and a locked unit. It sounds like they are sundowning.

MrChicagoRN, RN · May 4, 2015

I was also wondering how OP was "distracting" them.

Also, I've worked on locked units with those type of doors. They can be set to alarm the moment the bar is pressed, giving the staff 30-45 seconds time to get to the door. Depending on your fire code, it may be possible to disable the release all together as long as all staff are always equipped with keys.

toomuchbaloney · May 5, 2015

I think there are a couple of issues here.

First, it is not clear that your facility is set up or staffed to safely accommodate patients with that level of confusion, agitation, and mobility.

Second, my experience with dementia patients suggests that something is "triggering" the behavior. Some have already questioned whether fatigue or similar might be contributing. I would also question discomfort, hunger, or the need to defecate or urinate. I often find that discomfort or an unmet need is often the root of repeated behavioral issues.

Too often dementia facilities don't extend enough activities for the more mobile and active patients. Many of these people worked hard all of their lives and raised families. They sometimes become agitated and restless when they don't see what it is that they should be doing when they recall that they should be doing something.

I agree that with your staffing you should recommend some visual barriers to elopement for your confused patients. You really don't want to have to leave the building to chase someone down.

Good luck.

Tenebrae, BSN, RN · May 5, 2015

We have this problem at the moment. We had a very demented patient sent to us (not a locked unit) who wants to go home 20 plus times a day.

- We have had to go back to the referer and say "this persons needs to be on a secure unit" The person has been reassessed and looking for a secure unit is underway. Often when this patient starts to wander it may take 2-3 health care assistants to intervene, which of course is then taking attention away from other patients who may need it

A couple of things that have helped in the interim.

- patient had a UTI, it took several tries before we got the sensitivities sorted and the infection treated.

- Regular medication, haldol TDS with extra for PRN

Patient still continues to be a handful. Have noticed since patient has been on the regular haldol the intensity is lessened

Emily456 · May 5, 2015

Yes, I do have 2 RCA's on staff. And if an elopement occurs everyone in the facility knows to come running. I am aware of the poor staffing. And I've made many complaints. Unfortunately I get the same answer every time. "Well census is low and we gotta take what we can get". This is an assisted living facility that seems to be turning into a nursing home or dementia unit. My patient does get seroquel and Ativan. One PRN seroquel and another scheduled for 4 pm. The Ativan is at 2 pm. I've documented all behaviors. And notified the doctor and family. The doctor has come in and I have him read the behaviors. It took 3 months of nagging from all of the nurses to get him to agree to even order the Seroquel. He's always very hesitant to order any type of antipsychotic medication or narcotic. The family is considering switching physicians, but haven't come to a conclusion. My patient does get aggressive. I have another very confused patient who carries a baby doll and my patient has tried to push, hit, and rip the baby doll out of her hands. My patient slams the door yells and insults us. I can handle that. I will read up on the protocol. I guess it just doesn't seem right to leave my other 40 patients behind with nobody, some of which are incredibly confused. Considering that she is a sun downer. So only me and 2 RCA's are on duty after 2 pm. By 6 all administrative positions are gone, which is when it really starts to escalate.

one thing that really helps to distract her is to talk about her grandson. "The baby with big blue eyes". Also to invite she and her friend to fold napkins. But when she really gets going, there's no stopping her. As for going along with her delusions, I do do that with her and it works. I guess my problem is when I'm in a med pass, she won't take her pills, I have to give insulin, flush peg tubes, do treatments yadayadayada... And then she's trying to escape im getting phone calls and orders, and my other patient is trying to pull the fire alarm. I hate to say it but sometimes I just can't find the time. Nurses keep telling me that I just need to accept that this is how it is in long term care. And I guess I do have to accept it. It just doesn't seem fair to me, or the patients, that I cannot devote as much time to them as they need me to. Because I'm working in a facility that has patients like a dementia unit/ nursing home that need extensive care, and we're still staffed like an assisted living facility

icuRNmaggie, BSN, RN · May 5, 2015

OP,

You will be held responsible if this patient elopes and walks into traffic and is injured or killed. It is unsafe for you to function as a psych nurse while being responsible for 40 assisted living clients. It is time to find other employment.

Emily456 · May 5, 2015

icuRNmaggie

i have been thinking about finding new employment.

Here.I.Stand, BSN, RN · May 6, 2015

That environment doesn't sound safe for this resident at all. My grandma did elope from her memory care facility--not a locked unit, and the Wanderguard system malfunctioned. She died of hypothermia before she was found. Has she been fully evaluated by her provider, by OT, by psych? You've gotten some good suggestions, and I know you're doing the best you can, but you're one person and can only do so much. You've been charged with an impossible task--to be security for this one resident, and to be the nurse for the whole building. This could end very badly if she's not in the appropriate type of care facility for her needs.