6 WAYS TO MANAGE ANGRY OUTBURSTS BY THE ELDER WITH DEMENTIA

Mike was visiting his daughter Marge and her family for the 4th of July holiday. Mike had called ahead and insisted he was bringing all the food. He arrived during a heavy downpour, and Marge standing on her porch urged him to stay in the car till the rain stopped. Mike proceeded by demonstrating an inability to reason on something so simple as staying out of the rain, and then immediately becoming angry, thus began the unhappy holiday.

Mike stated “No one was going to tell him what to do.” And he proceeded to get out of his car, struggling with his walker as he tried to carry his groceries to the porch. Mike not only wasn’t going to be told what to do, but he very much wanted to direct his daughter. When Marge said she would be waiting for the rain to stop before moving groceries, Mike went right into his now frequent response of “just do what I tell you!”

Starting the visit all wet did nothing to improve Mike’s mood. From this unfortunate beginning, Mike proceeded to engage his teenage grandchildren in conversation regarding the dishonesty of the healthcare industry.  Saying everyone in healthcare is crooked and only in it for the money. Mike’s son-in-law a dentist, quickly became frustrated with Mike’s outrageous behavior and soon was asking Mike to leave.

6 Ways to manage angry outbursts by the elder with dementia:

  • realize that this is an episode of agitated behavior and that in order to manage this well you need to be in control of your own emotions
  • take care of yourself first – whether it is with taking some deep breaths or whatever you normally do that helps you to remain calm
  • be aware that arguing or trying to reason with the unreasonable person with dementia is not possible
  • remove the “audience” it is harder for Mike to back down from outrageous things he says if the whole family is there, and seeing himself as the father figure, he wants to save face
  • instead of several family members entering into this argument making Mike think everyone is against him, only one person should engage in de-escalating the situation
  • be respectful and avoid becoming defensive, the angry words even if directed at you are not about you

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

REASONS FOR SUDDEN DEMENTIA – DELIRIUM AND DEMENTIA Part III

As stated in Part I of this series on Sudden Dementia, the key here is to have the diagnosis, of delirium. Once the patient has the diagnosis, the nursing home is mandated by Medicare to investigate all of the previously mentioned  probable causes. The nurse or nursing assistant may be very concerned, and listen to the story of how rapid this change came over this patient, but there will be little follow though with this information. Only physicians, and nurse practitioners are able to write a diagnosis,and the delirium diagnosis is what drives the investigation.

As well as the previously mentioned possible causes in part I and part II, there will be attention given to the circulatory system, the respiratory system and metabolism. Circulatory – did the patient possibly have a stroke, are they in congestive heart failure, have they had a heart attack, or are they possibly suffering from severe anemia?  Respiratory – does the patient have asthma, emphysema, or is in respiratory failure? Lack of oxygen to the brain caused by a circulatory or respiratory condition can cause confusion.

Does the patient have a metabolic problem – diabetes, or thyroid disease? Anyone familiar with and experiencing these disease processes knows how they can impact so many other areas of the patient’s health. Ruling out these very significant  disease states is extremely important.

The center for Medicare Services has created this special focus for delirium showing how seriously this condition is viewed. When a patient in a nursing home, covered by Medicare, the patient’s power of attorney for healthcare is able to ask to see the patient’s diagnosis. Reviewing the diagnoses and making sure that someone who doesn’t know the patient’s history has called this sudden confusion, Alzheimer’s disease, is very important. Once the patient has the diagnosis of Alzheimer’s , the healthcare community finds no need to look any further.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing 

AGGRESSIVE DEMENTIA BEHAVIORS PUSHING, YELLING AND SPITTING

Persons with dementia may at times have difficult behaviors. Behaviors that may cause harm to themselves or others. Aggressive dementia behaviors, apply to pushing, yelling, hitting, grabbing, spitting or even trying to bite the caregiver. Persons with dementia who have these combative or harmful behaviors are considered to have aggressive behaviors. Some aggressive dementia behaviors are predictable and follow a pattern of actions or events. While other aggressive behaviors are isolated one time, events.

There are three basic types of aggressive behavior triggers:

  • Something is affecting the person with dementia internally such as a medical, social or psychological cause. This could be anything from pain, fear, frustration, hunger, thirst, unable to communicate, or needing to go to the bathroom.
  • Environmental triggers have to do with items, actions or events that cause over stimulation which turns into aggression. It might be that the environment is too noisy, temperature is too hot or cold, lighting is to bright or too dark, or maybe the person just doesn’t recognize any of the people around him.
  • The “caregiver trigger” applies to whomever is providing care for the person with dementia. It could be that the caregiver is tired or over stressed and not using the best communication techniques. They might not be providing care the way the person prefers or they just don’t know the likes and dislikes of the person they are caring for and, because of their poor care,  cause the behavior.

Knowing the person you are caring for can prevent those aggressive behaviors that follow a pattern and are predictable. Observe  the person’s body language, watch for wringing of the hands, rubbing their body, clenching fists, gritting teeth or the person can become extremely quiet before an episode of aggression. Knowing the person can prevent injury from aggressive dementia behaviors.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing 

DEMENTIA FROM ALCOHOL AND THE FAMILY IN DENIAL

Long before experiencing dementia from alcohol, the alcoholic has spent a life time trying to hide his alcoholism from family, friends and even medical professionals. So when the illness progresses to the dementing stage the  family who is in denial, now takes over not only the feelings of guilt and shame the alcoholic experienced. But also the active role of concealing the real cause of the dementia.  Dementia from alcohol doesn’t come on rapidly, but after a long time of alcohol abuse.

During those years of alcohol abuse the family maintains a code of secrecy, looking away and in so doing gives the abuser little reason to seek help. Family and friends are referred to as “co-alcoholics” due to their role in maintaining the alcoholic’s excuses, thereby promoting continued abuse.

Enabling, references the families efforts to protect the alcoholic from the consequences of their drinking. Supporting statements of needing “something to unwind,” ignoring odd or inappropriate behavior, and not identifying times when the alcoholic is not physically or emotionally available, are ways in which families protect the drinker. By not addressing the abuse the family gives the alcoholic little reason to seek help.

The alcoholic most likely, because he is enabled, will not seek help until he hits rock bottom. However more often than not, the abuser experiences dementia from alcohol and long term placement becomes necessary before he has the opportunity to make that choice. Once in long term placement the family and friends then continue the charade by finding a diagnosis of Alzheimer’s disease more acceptable than dementia from alcohol abuse.

The true numbers of persons with dementia from alcohol will most likely never be know because of the family continuing their role of “co-alcoholics.”  While healthcare professionals avoid questions about alcohol consumption so they are not seen as being “intrusive.”

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

DEMENTIA STAGES – TIME LINE

While every person with dementia has a different experience and progression. For dementia symptoms that follow the decline due to Alzheimer’s disease, these changes can be tracked in the following way.

Mild Cognitive Impairment: Very early changes noted in areas of forgetfulness, problems in locating lost/misplaced objects and loss of words. Changes cause concern yet mild cognitive impairment does not always progress to dementia. Many elderly people never experience an increase in this level of confusion. (this lose can occur very gradually over up to 10 years)

Very Early Dementia: No longer able to be gainfully employed, may becoming lost in familiar community, experiences anxiety due to having trouble always understanding environment.   Very important at this time to have hearing and vision checked to support the elder in understanding the environment. (2 years)

Early Dementia: Now diagnosed with dementia, possibly of the Alzheimer’s type, no longer able to handle finances, trouble identifying money, no longer able to do meal planning, no longer driving, unable to live independently, flattening of expression  (most noticeable in family group photos), emotional problems, withdrawn, tearfulness and sometimes anger. Starting to have problems with appropriate clothing choices and hygiene. (2 years)

Mid-Dementia Stage: Now need caregiver support for hands on assistance in hygiene, bathing, dressing, toileting, brushing teeth, significant problems with communication uses few words, is now incontinent of urine and beginning to be incontinent of bowel as well. Continues to be able to eat independently but totally dependent in all other areas of eating even cutting food and pouring beverages. (2 years)

Late Stage Dementia: Total care in all areas of life, need to be physically fed all foods, non-verbal, few people can walk at this point,  and requiring to be re-positioned when in bed, no longer moves independently.

Dementia stages vary depending on the disease causing the dementia, most notably in dementia caused by delirium or early onset dementia. The person with early onset dementia who is diagnosed at a young age goes through the dementia stages at a much faster pace.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing 

 

DEMENTIA BEHAVIORS – WHAT IS THE FIRST QUESTION TO ASK

To know if this is really a dementia behavior, ask the question, “What if this person was 20 instead of 80 years old?” This is a question I frequently ask caregivers when they report a elder with dementia as having “behaviors.” Because if this activity or response wouldn’t be a behavior for someone 20 why should it be for someone 80.

“Mary keeps standing up.”  That is the behavior the caregiver reports about her patient Mary. Well, I asked the caregiver,  “do you keep standing up?”  “Of course I stand up, all day I am getting up and down,” the caregiver shared.  While it is more than normal to want to stand and walk. The caregiver being afraid the elder will fall if walking unattended, will often standing up to be a dementia behavior.

Just standing up, might mean the elder needs a meaningful activity and she is bored. It could be that the elder wants to get away from something such as; too much activity, too much talk, too much stimulation. It could be that all of a sudden the elder realizes she is hungry or thirsty, and just stands up to get something for herself. Or what is frequently true in Mary’s case, she just has to go to the bathroom.

Rose was over 100, and really looked good for her age. She was cared for by a live-in caregiver, and Rose always looked company ready. But once ready in the morning, Rose was seated on the couch in the TV room. The caregiver enjoyed spending her day watching daytime dramas and game shows.

Rose had vision and hearing problems, and couldn’t follow these shows. Rose wasn’t even a fan of such programming, she was too polite to say she didn’t like the caregiver’s programs.  So Rose would often just stand up to go do something else. The day was spent with Rose standing and the caregiver telling her to sit down.

For a behavior to be a dementia behavior, the question to ask is, is this activity trying to tell me something? Is there a need that is not being met? Is the elder trying to fulfill an emotional need? Is the elder trying to fulfill a physical need? What is being sought? And in the case of Rose, is the elder trying to get away from something?

Whatever the dementia behavior is, first stop and think of that question, would this be normal for a 20 year old?

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

EARLY STAGE DEMENTIA – SYMPTOMS OF EARLY CONFUSION

Harry has currently un-diagnosed early stage dementia. How can he be so happy and content, seemingly unfazed by his confusion. All due to his wife Ann’s attention.

Harry’s wife of over 45 years was at his side while he greeted friends outside of church. Harry loves to talk and has many friends. These friends don’t seem to notice that Harry is having memory retrieval problems.  And that is all due to the wife at his side who is seamlessly providing words and cues to Harry. Harry never seems to be stumbling in his conversation or  searching for words. Ann knows Harry so well that she just fills in for him with the right word at the right time and he accepts her help.

At this point in time Harry might not even be aware of his memory loss, his wife makes no effort to point it out to him. Harry drives the couple around but you know it is Ann who is navigating because Harry would be disoriented without her.

This partner in life, is now the decision maker, for today deciding where the couple will go for lunch. Because of their warm trusting relationship, Harry trusts Ann to now manage their finances.  When shopping he might just joke that the “little lady takes care of all of those money things.” This saves Harry the stress of trying to pay bills, balance the checkbook, and make poor financial decisions, all signs of early stage dementia.

Emotional outbursts and anger directed at others and situations come from anger at oneself. The person who has early stage dementia and rejects any help or assistance from others may be a risk to himself and others. The inability to change a bad behavior is a symptom of early stage dementia.

For Harry, the frustration that accompanies trying to understand where he is, what is going on, and what might be expected of him is all reduced because of his partner, and yes now his caregiver, Ann.

Virginia Garberding

Certified in Gerontology and Restorative Nursing  

DEMENTIA – BAD BEHAVIOR AND HOLIDAYS

Children act out in the days leading up to holidays and parents shake their heads and say ” he has had too much sugar.” That may very well be true, yet children are certainly impacted by the hustle and bustle of holidays. And just as children are overwhelmed by the activities and anticipation, even more so is the elder with dementia.

However when the elder with dementia becomes angry and uncooperative, no one says “he has just had too much sugar.” And very often the solution proposed is some form of isolation, where what the elder may need is just the opposite. The elder with dementia may push family away with angry behaviors such as yelling, screaming, even pushing and at times throwing things.

There are also behaviors that are not as physical but equally as troubling such as, pacing, complaining, repeating themselves and general restlessness. What is important to remember is that the elder with dementia is not acting this way on purpose. The elder with dementia is always trying to understand his environment. Where he is, who is there, what is going on and most of all what might be expected of him.

While holidays are great is so many ways for the person with dementia, the music, colors, food, smells and decorations reinforce what is happening. The increase in  people, excitement, noise can push an already stressed elder over the edge. This is a good time for old fashion remedies. Activities that are calm, quiet and one on one.

  • a hand massage helps with anxiety, worry, sadness, and fearfulness
  • the old fashion back rub works wonderfully for those  in chronic pain or exhibiting irritability and anger
  • a foot massage provides calming for those with hyperactive behaviors, restlessness and pacing
  • massaging the forehead, temples and scalp help with tension and headaches

Added to the calming effect of the physical-therapeutic touch, some light smelling aroma, and you might be giving the best gift.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

HOLIDAYS A GOOD TIME TO HAVE THAT FAMILY TALK ABOUT GRANDPA’S DEMENTIA

Grandpa still lives alone in the family home and his daughters keep in constant communication with him by phone. Getting ready for the family holiday get together, required several phone calls to Grandpa to remind him of where and when they were meeting. After the big event , the daughters used their time with Grandpa to compare notes on how well their Dad is still able to function.

What they found:

  • Dad needed those frequent phone reminders – he had a 15 minute chat with the oldest daughter and the next day didn’t remember she had called
  • Dad had been mentioning that neither of his 2 hearing aids still worked, yet he was wearing both
  • Dad was now making strange and inappropriate comments to strangers, he asked a man in a restaurant if the design on his shirt was Nazi swastikas
  • Dad’s personal hygiene was in question, even though the holiday event was for an entire weekend at a hotel, Dad was wearing exactly the same clothes every day and on arrival it was apparent that Dad hadn’t bathed for some time
  • When asked what he has been eating, even though the daughters kept him well supplied with grocery delivery, he was choosing to eat all of his meals at the local fast food carry out
  • Dad had been asked to bring his latest report from his physician, after reviewing the doctor’s findings and recommendations, it was clear that Dad not only had no intention of following the doctor’s advise but didn’t understand most recommendations
  • Dad asked one of his daughters for a type of first alert button – in case he was taken to a hospital he could push the button and an ambulance or “someone” would come and take him out of the hospital

On the positive side, all of the daughters are on the same page, that Dad has dementia and needs their monitoring any changes. It is terribly hurtful and lonely to be the  only member of a family seeing signs of dementia. When even some of the family members are in denial of signs of confusion, it delays solutions. These daughters are realistic and pro-active trying to get ahead of future problems and support for their Dad.

Now after this holiday, they know that Dad might be needing some house help if the reason he doesn’t make meals is that he no longer can put a meal together. Some home help might be also needed for hygiene. One of the daughters needs to get involved in going with Dad to have his hearing aids taken care of as well as accompany him to his physician.  Dad probably would benefit by having a calendar to write down appointments and events. This way the daughters could check, just by calling and asking Dad what he has written down for a certain date.

The daughters know that as Dad continues to decline, (and they realize he will) he will be a candidate for an assistive living facility. When that day comes they will have to be united, it really helps to start now.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

IS DEMENTIA THE SAME AS MENTAL ILLNESS?

Mental illness is a broad term for disorders that affect thinking and behaviors. That, at first glance, can sound like dementia. However, there are known causes for many forms of mental illnesses. Also, strong effective treatment programs will include cognitive behavioral therapy, which is not used for persons with dementia.

Mental illnesses range from mood disorders; major depression, anxiety disorders, panic disorders, personality disorders, obsessive-compulsive disorder, to psychiatric disorders; anti-social, narcissistic, schizophrenic, and so many more.  These conditions are traceable to poor parenting practices, childhood trauma, bereavement, unemployment conditions, social stresses including cultural stresses, as well as abuses; drug abuse, cannabis, and alcohol abuse.

Cognitive behavioral therapy involves helping the individual in identifying their distressing thoughts, while seeing how realistic these thought patterns really are. This therapy, stresses working on distorted thinking, and coming up with positive problem solving techniques. Consistently focusing on how valid the person’s thoughts are, as well as examining how useful this thinking is to the individual. Cognitive behavioral therapy when successful will change troubling behaviors.

In order to be successful with this therapy the person has to possess the ability to reason. Loss of reason and judgement are early signs of dementia. As well as loss of the ability to focus, persons with dementia due to Alzheimer’s disease, are very easily distracted.  Persons with dementia, due to Alzheimer’s disease, will have short term and eventually long term memory loss.  Memory loss not a symptom of mental illness.

Above all, despite the changes seen in the individual with a dementing illness, he is not really distressed by his losses. For the most part his frustration is due to misunderstanding the environment and cooping with the loss of communication skills.  In contrast, persons with mental illness are very much distressed by their thoughts and behaviors.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing