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How to deal with an aggressive dementia patient

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by Emily456 Emily456 (Member)

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Saiderap has 25 years experience and specializes in retired from healthcare.

526 Posts; 15,396 Profile Views

What really disturbs me is when I see or hear of patients like this who need to be in a locked unit or a psych ward where no visitors can enter or they need special equipment to protect their safety and no one seems to be concerned. I think it's time for a conference about this patient and time to find a locked unit for them.

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canned_bread has 11 years experience and specializes in Cath lab, acute, community.

351 Posts; 7,066 Profile Views

It sounds like classic sundowning (google search it).

I would ask the doctor for a sedative or anti-psychotic to be given at lunch. Even tabulate your experiences for the doctor. Make sure you chart them so they can see.

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icuRNmaggie has 24 years experience as a BSN, RN and specializes in MICU, SICU, CICU.

1,970 Posts; 25,328 Profile Views

When dealing with an aggressive and confused person I will act first and apologize later. By that I mean that I will be calling for all of the help that I can get. In this situation if less restrictive measures were not effective and the pt was at risk of harm, I would simply call 911.

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vintagemother specializes in Med-Surg, Psych, Geri, LTC,.

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I want to add the following. I've worked at 2 different "non medical" settings, assisted living and psych.

In the alf, we were supposedly required to leave the facility in event of emergency. At the psych setting, leaving your unit was considered pt Abandonment.

I have no idea what board of nursing rules state. I just know that if you leave to assist a problem, you could be charged with pt abandonment, which is Not Cool!

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hppygr8ful has 15 years experience and specializes in Psych, Addictions, Elder Care, L&D.

6 Followers; 3 Articles; 2,953 Posts; 33,485 Profile Views

A resident like the one described here needs ro be on a locked memory care unit. They do not need a psych consult as behaviors associated with Alzheimer's and other dementias do not meet the criteria for psychiatric illness. Most LTC SNF facilities are not prepared nor or their staff trained to deal with this kind of resident. Psych meds can be used but are not the end all be all as side effects tend to be more profound and risk of serious falls increases with their use and they are considered a chemical restraint. Medicare doesn't always cover memory care so families have to pony up the bucks to pay for that care. Often it is not the physician's fault but rather the family's inability or unwillingness to pay for a higher level of care.

Hppy

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Mama Jules has 26 years experience.

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I agree with the other posters that it may be time to discuss this resident being admitted to a lockdown facility. The problem is, at least in my state, the few places that have them stay full. I also agree with the poster who stated long term care facilities are not equipped to handle all geri-psych residents, yet here in our state, that's exactly where they are ending up.

Your resident is a classic example of someone who appears to be moving from a lower stage of dementia to a higher one. They have just enough cognition to know what they used to do, who they used to be, but not enough to be able to care for themselves independently. In many cases, they think they can but actually cannot.

The advice you got about redirection (allowing them to follow you, engaging them in conversations concerning their comments, etc) is very good advice. I have to question, however, if you having to perform tube feedings (which in SC, precludes someone from being allowed to stay in ALF unless they can care for it completely themselves start to finish; nor can they have a decubitus ulcer or surgical dressing) and other skilled nursing duties is really safe for a 1:40 nurse/patient ratio. You need help, sister. And fast.

Also, have you considered asking your doctor about adding Depakote to this patient's regimen? I find its mood alerting properties often work better at combating behavior problems in dementia residents than antipsych med does. Just have to monitor LFTs ever so often.

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hppygr8ful has 15 years experience and specializes in Psych, Addictions, Elder Care, L&D.

6 Followers; 3 Articles; 2,953 Posts; 33,485 Profile Views

Depakote and other anticonvulsants are considered psychiatric meds if they are being used for mood stability. So still considered a chemical restraint and need special psychotropic consent.

Hppy

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LessValuableNinja has 8 years experience and specializes in Cardiac (adult), CC, Peds, MH/Substance.

754 Posts; 5,585 Profile Views

Provide the patient with the opportunity for Haldol, Morphine. Check in after 3 hours. When patient is sleeping, gently slap them to get them to half-wake up so they can swallow the additional narcotics and ativan liquid. Check in once more at the end of your shift to ensure they are not dead, but not bothering you.

That was obviously a joke.

In all seriousness though I've found the best way that works for me is to direct them towards things that make sense to them at the time. For example, if a patient is constantly anxious, confused, disoriented, and states, "I just don't know what to do. What am I waiting for in this chair? Is it time to go to the party?" "No, Mrs Anderson. It's not time for the party. That's tomorrow. It's puzzle time. I brought you your puzzle. You have to finish the puzzle before it's time for the party to be talked about. After the puzzle, we should talk about what you're going to wear to the party." By the time they're done with the puzzle (a SIMPLE puzzle in most cases, the sorts toddlers use), they've generally forgotten about the party they're obsessing about from 40 years ago. And in my experience, they enjoy the puzzle and distraction. In your case, with the eagle, maybe it's appropriate to say something like, "Well, James, to get to the giant eagle, you first have to draw the eagle and show it to Mary (the nurse that sits next to you at the desk), so that she can put in the request." Or whatever seems like it would make sense to the patient. Understand that a lot of these patients are just really confused, but they're still people. The frustration and combativeness begins when they don't know what to do next. Because when they were "normal," maybe they always knew what to do, but now they don't. 99% of these situations, I find that a simple redirection works amazingly well. Give them something to do. Make what you give them to do connect to whatever they're obsessing about. They have an obsession-in-the-moment, and just need somewhere to direct the energy. Out of the thousands of times I've done that, I've had only a few incidents where the problem continued. Just realize that their reality is different than yours, and that their brain isn't quite firing right any more. For most people in this situation, their stress level will decrease, as will agitation, if you just give them somewhere to direct their energy in a way that applies to what they're obsessing about, but is safe (hello run-on sentence).

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LessValuableNinja has 8 years experience and specializes in Cardiac (adult), CC, Peds, MH/Substance.

754 Posts; 5,585 Profile Views

Just a note. I won't speak for my personal opinion, but if your response to this post was, "Heavily medicate the patient," (though you said it in a nice way), "Throw them in lockdown," or "Your workplace sucks. How can you have a confused person who gets agitated when they're confused and don't know what to do? Get a new job," you should probably have a self-reflective moment about why you got into nursing in the first place. Introduce the now-you to the you who wanted to be a nurse. Those responses physically pained me to read. Of course, I'm still in the honeymoon phase with nursing, after a career in the military and as an IT/project/operations manager, who really just wanted to "help people smile." What made you go into nursing? Consider that before you give those sorts of responses to a situation that probably requires no medication, lockdown, or quitting jobs, and involves a human being that just wants to understand their environment better and know what they're supposed to do.

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17 Posts; 886 Profile Views

I agree with you Saiderap and here.i.stand, it's not safe for her. I've expressed concerns. But I think it's time to go to the next person up. Because something needs to be done, and nobody seems to be taking the nurses opinions seriously. All that's ever said when I bring up this problem is "well census is low". It's sad when money is the main concern. They'll tell us it's not big deal, and that we can handle it, until something bad happens. Then they'll throw us under the bus.

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1 Follower; 51 Articles; 4,800 Posts; 93,801 Profile Views

This patient is not fit for assisted living due to her sundowning. It is time to think about alternate levels of care. And a geri psych consult for a medication regime that is better for this patient.

Sometimes Ativan has a paradoxical effect. That could also be happening here.

Also seemingly when the census is low, they keep just about everyone in assisted living who are not appropriate...

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1 Article; 630 Posts; 15,191 Profile Views

The patient begins with asking the same question multiple times. Like "how would I go about getting to giant eagle".

 

FYI- Giant Eagle is grocery store. The patient may have shopped at one her entire life like so many in this region.

Giant Eagle® Quick Facts

Founded in 1931, Giant Eagle is one of the 40 largest privately-held and family-operated companies in the USA.

Giant Eagle serves more than five million customers annually through nearly 400 retail locations in Pennsylvania, Ohio, West Virginia and Maryland. Giant Eagle is based in Pittsburgh, PA.

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