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

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 

SUDDEN CONFUSION DUE TO TOXINS – Part I

Sudden confusion due to toxins may be expected and at times unexpected. Ralph was 86 when he decided that he was finished with dialysis. Ralph had end stage renal disease related to diabetes, and was on dialysis for over 10 years. Now Ralph decided that enough was enough and he wasn’t going any more. Ralph understood that this would be the end of his life. Without dialysis toxins would build up, and he would become very confused before those toxins would end his life.

Mike arrived at the nursing home due to extreme sudden confusion, related to alcohol abuse. A very long history of alcohol use and abuse. When Mike arrived he had been begging for money from strangers on the street in order to go to a hotel, because he was sure someone had put cameras all over his house. He thought he could no longer live in his home because there was a bomb, and he was being watched.

Many elderly suffer from sudden confusion due to medication mistakes. When the elder is managing their own medications and do not have a good reliable system in place, mistakes often happen. The elder then is admitted to a hospital where lab tests are run, and the medication is identified. However it might then take some time for that sudden confusion to resolve.

People as they age begin having more and more difficulty with toxins. This is due to the lifetime of environmental toxins their brain has been subjected to. Just one example is the history of using leaded gas, and the toxic effects due to use of that gas. Research studies have shown that older Americans have much higher levels of lead than younger people who were not exposed.

As the elder ages, they have a reduced brain capacity due the shrinkage of the brain. The combination of reduced brain capacity and that lifetime of exposure to many environmental toxins, put them at higher risk for sudden confusion. The elderly brain just has less to work with and at the same time more to deal with. (see also delirium)

Virginia Garberding RN

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

 

ALCOHOL RELATED DEMENTIA – THE DR. JECKEL & MR. HYDE STORY

Howard was a particularly difficult new patient in the dementia unit. Howard was young – only in his mid fifties, strong and very fit at least physically, not mentally.  Howard was easily upset, especially if a staff member told him “No”. And Howard presented us with many opportunities for saying no, as he literally ran through the unit. Having seen other patients like Howard, I asked his wife if Howard had had a drinking problem. She looked very surprise at the question, and yes Howard had been in the habit of drinking daily.

I then asked her if Howard had shown a significant change in personality when drinking, yes he did.  His demeanor changed and she remembered him having almost a “day and night personality change”. Eventually a Dr. Jeckel and Mr. Hyde personality switch was going on. Howard being normally a happy person, when starting to drink would soon become excessively friendly and happy to the point of being obnoxious. He would be very social and then become almost celebratory in his mood. When guest were over frequently jumping into the pool fully clothed.

After a seemingly shorter and shorter time of drinking,  Howard would literally check out, having a flat expression and appearing somewhere else.  His expression would then become very dark and scary while his vocabulary became suggestive and often he was vulgar.

Fortunately  Howard hadn’t been the drinker who becomes immediately angry, aggressive, rage-full and ready to fight. Of the two personality shifts the happy drinker is easier on the family, but maybe makes it harder for them to identify a drinking problem earlier.

So how much is too much, when it comes to drinking? Moderate consumption of alcohol is considered 1-2 drinks a day. A significant history of drinking is 35 or more drinks a week for a man and 28 a week for a woman.  Alcohol is quickly absorbed into the blood stream and goes directly to the neurons in the brain. Alcohol causes an increased release of dopamine in the brain (the pleasure/reward neurotransmitter), and over time you need a larger and larger amount of alcohol to realize the same effect.

When caught early, brain damage due to alcohol can be reversed. Alcoholism is caught too late when long term excessive consumption has been a toxin to the brain, resulting in neurological damage and changes to the brain including brain shrinkage.  Drinking to the point of drunkenness is particularity harmful to the brain.This was Howard’s story, and is he now is at the point where Dr. Jeckel is gone and all that is left of Howard is Mr Hyde.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

BUILDING BRAIN HEALTH PROTECTS AGAINST DEMENTIA – DON’T PERFUME YOUR OXYGEN PART III

Whether it is bath soap, air freshener, laundry products, scented candles, or the cologne on the check out clerk at your local grocery, we are surrounded by scented air. While it is law to list ingredients on these products, there is a significant loop-hole. The word “fragrance” in so many products used every day, represents many substances the average person would not consider a pleasant odor. These chemicals masquerading as a fragrance, are for the most part derived from petroleum and coal tar products.  These chemical concoctions are found is products all around us, and are directly related to many health concerns.

These chemical mixtures are protected under a misconception that they are “trade secrets.”  There might have been a time in years gone past that the combination of certain essential oils and flowers were highly protected secrets. However these days, the secret that is being protected, is where these chemicals come from and what they do to human health.

Current research is telling us compared to other senses, the sense of smell is directly connected to brain health. That smells are able to pass the blood brain barrier, that protects the brain from many other forms of attack. These hundreds of fragrances created in laboratories, with many times banned chemicals, are responsible for many disorders. Surrounding ourselves with all of these scents is leading to negative emotions, irritability, brain fog, fatigue, headaches, dizziness, tremors, convulsions, and the list is growing.

There is recently even a new term for that person, who through the use of strong smelling products, intrudes on others. It is “second hand fragrance” similar to second hand smoke. It is when one person makes a decision to use several strong smelling products (shampoo, deodorant, hair spray, perfume, laundry products) and by doing so contaminates the air quality of others. There was a recent report on the news regarding sunscreen products, and they found many people bought a product not on how effective it was for sun protection, but because of the way it smelled.

The elderly as well as the very young are at increased risk for neurological problems connected to fragrances that pass the blood brain barrier. Yet many times the offender is an elderly person who has become so addicted to their fragrance, that they literally no longer smell it.

If you have been guilty of second hand fragrance, do what people did years ago, put a little vanilla extract behind your ears.

Suggested reading: “Get A Whiff of This” by Connie Pitts

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

8 QUESTIONS TO ASK WHEN CAREGIVING FOR THE PERSON WITH DEMENTIA AND DIFFICULT BEHAVIORS

The person with dementia no longer reacts the way they used to, many times resulting in problem behaviors. When you have identified a problem behavior, which can be anything from the elder spitting, to striking out at a caregiver, or even becoming sexually inappropriate, start with identifying exactly what is happening.

8 Steps to understanding difficult behaviors in the person with dementia:

  1. Identify the problem or behavior. Make sure you are clear as to what the problem is, and whose problem is it. In the case of the elder with dementia who spits; it is embarrassing, someone has to clean it up, and many times it is hard to find a caregiver for the elder.
  2. Identify when this behavior occurs. Does this behavior only happen during times of direct care? Such as the elder who strikes out during times of dressing, bathing, or brushing teeth.
  3. Identify how often this behavior happens. Does this behavior only happen occasionally, as during a large holiday get together? Does this behavior happen only later in the day when the elder is tired?
  4. Identify how long the behavior lasts. Is this behavior of short duration, and once the incident is over it is quickly forgotten by the elder?
  5. Identify what is going on in the environment when the behavior happens. Is the environment understandable to the elder? Remember the elder with dementia needs a time of transition between activities. He can no longer just switch from one conversation to another, or do several things at the same time such as eating and watching TV.
  6. Identify who is present when the behavior happens. Does someone present tend to startle or surprise the elder? Does someone seem to not know how to approach the elder? Is someone asking a lot of questions the elder is no longer able to understand? Does someone have expectations of the elder that they are no longer able to meet? Does someone present seem to be critical of the elder.
  7. Identify how intense the behavior is. Is this behavior of such intensity that is scares the elder as well as all who are present?
  8. Identify if there is more than one thing contributing to the problem. Especially if the elder has been having trouble sleeping and may be suffering from sleep deprivation. If the elder’s behavior becomes more difficult in the late afternoon, see if the elder has an problem with oxygen deprivation. Many elders who are more agitated later in the day may benefit from a sleep study.

Finding out what happened right before, or what is happening during the behavior, is of the most importance, when care giving for the person with dementia.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

EXERCISE LIKE YOU ARE IN GRADE SCHOOL AND YOU WILL HAVE BETTER BRAIN FUNCTION

Remember when you were in grade school and you went out for recess three times a day? Well research now tells us that having those short bursts of exercise will support brain health. Over 25% of the oxygen in your body is in the brain. Increasing the percent of oxygen to the brain increases alertness, supports increased focus, is calming, and will even regulate behaviors.

When children are going out for recess, people will frequently say, “Its good for them, gives them a chance to run off their energy.” What those children are really doing, instead of running something off, they are taking in more oxygen through exercise. All the while improving their oxygen supply to the brain. Short bursts of exercise have been shown to be beneficial for brain function in all age groups. Everyone is able to benefit from increased oxygen through exercise.

There are very positive effects to periodic physical activity.  Short bursts of exercise have been shown to especially bring more oxygen to the frontal areas of the brain. Increasing oxygen to the frontal lobe of the brain helps with increased self control and emotional control. The ability to self regulate behavior is important whether in a social, academic, or religious setting, as well as just sitting on the couch at home.

Finding those opportunities for oxygen promoting exercise throughout the day are so necessary. Whether just stepping outside for a quick walk around the parking lot at work, opening a window while you vacuum for 15 minutes,  or popping in a short exercise video, whatever, call it your “recess.”

For the student studying, the restless child on a long car trip, or the elderly person with dementia who is getting agitated. Everyone it seems can benefit from a regular recess.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

5 REASONS THE PERSON WITH ALZHEIMER’S DISEASE CAN HAVE BAD BEHAVIORS

When life begins to be a mystery and the person with Alzheimer’s disease no longer understands what people say, the meaning of words, and he no longer understands the environment, he can react with anger. That anger can lead to his being restless or even combative. Sometimes striking out at caregivers, strangers and even those he loves.

What causes bad behaviors in Alzheimer’s disease:

  1. His short term memory is affected, so no he doesn’t remember what he just had for lunch. And furthermore all of those questions, about things he can’t remember are getting on his nerves.
  2. He has poor judgement, so even though he has always been a cautious person he now is very impulsive. Even possibly having inappropriate social behavior, because he no longer exercises good judgement in actions or what he says.
  3.  He now is making poor decisions, due to Alzheimer’s disease and no longer understanding the environment. Spontaneously walking outside alone, to take a walk in winter without coat, hat gloves, etc.
  4. He now has an obvious short attention span, becoming impatient, fidgeting, having difficulty sitting still, becoming easily distracted or easily bored.
  5. He is losing verbal skills and having difficulty expressing wants and needs. So becomes angry when people do not meet those needs because of poor communication.

It turns out not to be such a mystery as to why the person with Alzheimer’s disease can have bad behaviors. The person with with Alzheimer’s disease is living in on ongoing mystery.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

WHY YOU DON’T ARGUE WITH A PERSON WITH DEMENTIA OR DELUSIONS

The elderly person with dementia, who has a persistent fixed incorrect idea or delusion, is literally unable to change their mind. The idea might be harmless, as in the case of the elderly woman who insisted she was always on a train. Or it might be dangerous as the person who is insisting he has to leave and go to work, when he hasn’t worked for many years. Harmless or not, these ideas frighten the family or caregiver because it demonstrates irrational thinking.  Using rational explanations or arguing doesn’t work when the person is unable to change their mind.

5 ways to address delusions without arguing:

  1. Let it go if at all possible. If the idea is not dangerous, doesn’t bother the person or others, let it go.
  2. If the idea or delusion is frightening, such as the woman who thought people were living on her patio, give reassuring , comforting words. “I am here and will stay with you,” while you use a distracting activity.
  3. A delusion might be an expression of some fear. Look to the environment. Are there shadows, do you need more light, are curtain or shades open at night creating reflections on a window?
  4. Support the feelings the person expresses, not the delusion.
  5. Ask the person to show you what they see. The shadow on a wall, when reality is distorted, may become a ghost to the confused.

Many delusions are just plain hurtful, as with the spouse who is no longer recognized and is accused of being an impostor. Some delusions are very embarrassing for the family, and require understanding and the education of others.  Well meaning friends and acquaintances may intercede and begin arguing the irrational  idea or delusion. Look at this as an opportunity to educate other people, so that they may support you, in creating your plan of care for this person.

When caring for the individual with irrational ideas, you never argue these thoughts away.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing