How do you manage hospitalized dementia patients at night?

[beeble]

For example, someone fairly severely confused, not combative, but who attempts to get up OOB multiple times t/o the night/ is a fall risk, ect..

On our unit, we have a bed alarm, but it gets exhausting responding to that and redirecting t/o night when you are assigned 5 other patients, are in another room, ect.

A 1:1 was not an option as it would have pulled our lone NA.

The resident was not willing to give Benadryl 25 mg.

So then I was wondering how to effectively manage this situation?

[casi, ASN, RN]

Toss them in a recliner or w/c at the desk until they are ready to fall asleep.

[Fiona59]

Call a family member in to sit with them.

[VivaLasViejas, ASN, RN]

Give 'em something to do---let them fold towels and washcloths (over and over again if they choose), bring them a simple jigsaw puzzle to put together on their overbed table, or offer them a portable CD player and headphones so they can listen to music (ask your SSW to have some CDs available with music appropriate for different age levels, e.g. Glenn Miller and the Andrews Sisters for the elderly).

FWIW, if an older patient has his days and nights mixed up, it's best to accommodate him rather than try to 'force' him to sleep. Benedryl is a terrible drug for the elderly (causes nightmares and additional confusion), and sedatives/hypnotics only increase fall risk.

[natalia13]

Toss them in a recliner or w/c at the desk until they are ready to fall asleep.

Yup! thats one of the best things to do. but be careful that the pt doesnt start getting aggressive and tries to slide out of the seat belt or tray thats placed on top of the w/c . also, check your PRN's also ( prob a given)

[EmergencyNrse]

In order:

After lights turned down and limited noise/stimulation

1) Sitter

2) Medication (Benadryl, Ativan)

3) Posi-Vest

4) Soft wrist

5) Wrist & Ankles

Ultimately it's determined by policy/protocol but it's no easy task.

Good Luck...

[loriangel14, RN]

Yeah we usually put them in a geri chair and park them where we can see them.I have one patient right now that never sleeps in his bed.He stills causes a ruckus until his prns kick in though.We get an extra staff member on nights to sit with as well.

[Moogie]

The resident was correct in not wanting to give an order for Benadryl. Benadryl can be a very dangerous drug in elderly persons and can exacerbate behavioral symptoms of dementia. The patient could have become much more confused and agitated.

Behavioral and psychological symptoms of dementia such as wandering, pulling at things, being non-cooperative in care, yelling, or trying to ambulate without assist can be increased when the patient's routine is disrupted and he/she is hospitalized. The hospital environment is stressful for anyone, but particularly so for the person with dementia. The noise, the lights, the presence of nurses walking into the room, and the disruptions in the night can exacerbate these behaviors. One approach, therefore, is to decrease the environmental stimuli that may be causing an increase in the patient's stress. Can the lights be dimmed? Can noise be controlled? Can the nursing staff minimize the number of disruptions and allow for uninterrupted sleep?

Try to avoid the use of physical restraints. Studies indicate that physical restraints do not sufficiently decrease the risk for falling and may contribute to increased injury and mortality from a fall. Chemical restraints such as BZDs and atypical antipsychotics should be used sparingly, as a last resort, because of side effects including increased risk of falling and sudden death.

In addition to soft music and giving the person something to do (as Viva said, fold towels---research indicates that this does help decrease agitation among persons with dementia) you could try gentle hand massage, possibly with a non-irritating lotion. Aromatherapy (lavender oil) is sometimes used but it may not be effective in persons who are severely demented due to impaired sense of smell. Avoid the use of "elderspeak", that is, talking in childish tones to the patient. Use a soft but direct tone.

Make sure to address the reasons behind the behaviors. Does the person have a UTI or an indwelling urinary catheter and therefore feels an urge to void? Does the patient have pain? Is he/she having discomfort due to the presence of tubes or IVs? Look at behaviors as a way of communication---behaviors are often the only way that a cognitively impaired person may be able to communicate his/her needs.

Redirecting doesn't always work but you have already discovered that. Sometimes it's better to try to figure out where the person is emotionally and mentally and work from there.

If a sitter is unavailable, try to get a family member to stay with the patient at all times. Keep the bed alarm at all times and put the bed in the lowest position when the patient is alone. If your facility will allow it, put a mattress on the floor to help cushion a fall. In some facilities, the use of a geri-chair with a tray and/or seat belt is considered a restraint so check with your facility's policy and procedure manual or the night shift management before you put someone in this sort of chair.

Also, watch for any changes in the patient's behavior. This is challenging when you don't get to know someone well as in an acute care setting because you might not notice a change right away. If the person becomes aggressive, you may need to walk away for his/her safety and yours.

Hope this helps!

[Chin up]

Give 'em something to do---let them fold towels and washcloths (over and over again if they choose), bring them a simple jigsaw puzzle to put together on their overbed table, or offer them a portable CD player and headphones so they can listen to music (ask your SSW to have some CDs available with music appropriate for different age levels, e.g. Glenn Miller and the Andrews Sisters for the elderly).

FWIW, if an older patient has his days and nights mixed up, it's best to accommodate him rather than try to 'force' him to sleep. Benedryl is a terrible drug for the elderly (causes nightmares and additional confusion), and sedatives/hypnotics only increase fall risk.

This approach is the responsible thing to do in LTC. Remember, this is their home and they are adults. They may be night people having worked nights for years. They may be bored and want something to do or a snack. How many times have you woken up at night, unable to sleep and thirsty? Or just aren't tired and get up to read, clean house or watch a movie? The same applies to the resident. Just because we want them in bed, or think they should be doesn't make it so. I have given residents towels to fold and they settle down and get to business. I have had music on at the nurse station, and the resident and I would sing to the oldies or they would clap hands, or just relax and listen. Do all this after toileting them, sometimes this is all they need. But medicating and forcing them back to where they don't want to be is never a good solution. Be creative and try things adults do, when they either can't or don't want to sleep. Peace!

[Esme12, ASN, BSN, RN]

Sometimes you have to take your paper work to their bedside and do your chart checks at the door or in their room. Sometimes they just want to feel someones there. I take it this its acute care because there is a resident....

[StrwbryblndRN]

In our hospital we will take turns sitting with them at the nursing station and talk while we computer chart. The capabilities of the pt and the depth of their dementia fine tune what we need to do.

Unfortunately if you are in a hospital there is the issue of sick pt's to take care of so there is not much time to sit with them.

[joanna73, BSN, RN]

As many others have said....we usually get them up, put them in a geri chair, give them something to eat or drink, and keep them up until they start to get tired. I don't use medications or restraints at night for our residents. It's more effective to just get them up for a while, especially if they're a fall risk. Sometimes they might need to sit on the toilet for a bit and then go back to bed. Just depends.