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 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 

 

WHAT DOES THE PERSON WITH DEMENTIA NEED?

The person with dementia needs to feel safe, but not in a way that they feel restricted. The person with dementia has a need to understand. The person with dementia has a need to be understood. The person with dementia has a need to be healthy and physically fit. The person with dementia has a need to be spoken to like an adult.

The need to feel safe, means feeling comfortable and accepted. Many times when a person with dementia moves into a nursing home, they will talk about “going home.” Home is where you are comfortable, accepted and you will not be forced into doing something. In the nursing home setting it takes about a month for many to no longer ask to go home. It is not that they are now resigned to being in the nursing home. It is that they finally feel that acceptance and feel at home.

The need to understand, and be understood. Persons with dementia have lost their normal forms of communication. They no longer can communicate verbally or non-verbally their needs. Even the person who still has words has trouble expressing their thoughts and feelings. Misinterpretation of their environment causes more misunderstanding and results in fear.

The person with dementia has a need for nutritious food and exercise.  Nutritious meals, no junk food, supplement with B vitamins for stress and brain health, fresh air and exercise results in better sleep. (B vitamins should only be taken in the morning so they do not disrupt sleep)

The person with dementia needs to be included in conversations. They need to be addressed by their preferred name or title.

The person with dementia struggles all day long to understand their world and make their needs known.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

GETTING LOST IN THE COMMUNITY – WHY DO PEOPLE WITH DEMENTIA WANT TO WALK AWAY?

Harry was out to dinner with his family, and stood up saying he had to go to the bathroom. Soon it was noticed that Harry hadn’t returned. When a member of the family went to look for Harry they discovered he was no longer in the building. Two hours later, and after a search of the neighborhood, Harry was located wandering the neighborhood streets confused and unable to state why he had left the building. Harry has early dementia and had just walked away. Leaving a dinner party and even a restaurant unaccompanied is not a problem unless you are a child or are confused. Harry was confused, alone and quickly became lost in the community.

Current statistics tell us that about 60% of people with dementia will get lost in the community at some point. This includes people living in the community as well as those living in institutions.

Harry might not have been able to locate the restroom, or may have seen the exit and just thought to go home. Perhaps he used the restroom and then forgetting his family having dinner, just walked out the door. However it happened, after wandering the neighborhood for two hours, being tired and scared, he was not in condition once found to state what his actions were.

In this case, Harry was just confused and walked away. Many with dementia who become lost do so because they are actively trying to meet a social, emotional or physical need. As in the case of the woman who always feels her children are needing her, or the man who must get to his job.

Many years ago when Harry and his wife had young children, they had ID bracelets made for their children in case they would ever get lost. Now Harry is wearing his own ID bracelet for the very same reason.

The Alzheimer’s Association sponsors the  “Medic Alert – Safe Return” bracelet.  This  bracelet offers a 24 hour service, national data base and coordination of local support services. Well worth the price, in peace of mind.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

THE HIGH COST OF DEMENTIA TO SOCIETY, FAMILIES AND MOST OF ALL TO THE INDIVIDUAL

There is a high cost of dementia both to society as well as the individual and family. The cost to society through Medicare payments is not only high it is skyrocketing. Currently 1 in every 5 dollars spent is on elderly with dementia. The per-person cost to Medicare for taking care of persons with dementia is 19 times higher than the average per-person cost for all other seniors together. The total spending by families is close to the same as the government spends.

The cost of dementia to society:

  • Alzheimer’s is the most expensive condition in the nation. In 2014 the cost to Medicare and Medicaid was $150 billion with an estimated total cost of $214 billion. Estimates are that 2050 costs will escalate to $1.2 trillion dollars.
  • In 2014 an estimated 5.2 million Americans had dementia.
  • Of the over 5 million people with dementia age 65 and older, 3.2 million are women and 1.8 million are men.

The cost of dementia to families:

  • In 2013, 15.5 million friends and family provided 17.7 billion hours of unpaid care to those with dementia. That care was valued at $220.2 billion dollars.
  • The emotional stress of care-giving for someone with dementia is so high it takes a devastating physical toll. Dementia caregivers, had $9.3 billion dollars in healthcare costs, of their own in 2013.
  • Women are more likely to be caregivers for those with dementia, more than 3 in 5 unpaid caregivers are women.
  • Because of their caregiving duties, nearly 19 percent of women caregivers had to quit work. This causes future consequences, when those women once again want to join the workforce.

The total cost to Medicare is $37 billion annually, and estimated to be $36 billion of cost to families. As staggering as these numbers are, the cost to the individual with dementia cannot be measured. The loss of memory, inability to concentrate, loss of social skills, deterioration in personal hygiene and appearance, difficulty communicating, disorientation and more, how are these costs calculated?

The high cost of dementia is shouldered by everyone.

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

WHY DOES AN ELDERLY PERSON NEED A NURSING HOME/REHAB FACILITY?

Why do people need to go to nursing home or rehab facility?

  • they need nursing help with bathing, eating, dressing, or walking
  • they have just come out of the hospital and are not ready to go home
  • they are unsafe and can no longer take care of themselves
  • they have dementia and and forget how to take care of themselves

Why do these people need so much assistance?

It may be for a medical condition that they are recovering from, or the nursing facility has the equipment or human assistance they need to recover. It can be that they are recovering from an infection and need medications better delivered at a nursing facility. It maybe that they are just too weak to live independently, or they are frail due to advanced age. The elder with poor vision can have a hard time shaving, dressing, even difficulty eating independently much less shopping for food and meal preparation.

The elder with dementia may not even remember how take care of himself, even how to brush his teeth:

  • he may not remember that he needs to brush his teeth
  • not remember that he hasn’t brushed his teeth
  • not remember what equipment he needs to brush his teeth
  • not remember how to brush his teeth, what to do first and what to do next – the entire process of brushing teeth

How much should you help a person with dementia?

“Why do you make my wife brush her own hair?” a husband asks the nursing assistant. “Isn’t that your job?”

  • the confused elder feels better about themselves if they do as much of their own care as is possible
  • the elder who participate in their own care remain healthier and stronger
  • the job of the nursing staff is to teach the confused elder how to take care of themselves
  • it is the responsibility of everyone in a nursing community to help their patients be as independent as possible
  • always support ability not disability, provide just as much assistance as the person needs

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

 

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

 

DEMENTIA AND THE COMFORT OF FAMILIAR WORDS

After Vera first entered the nursing home her daughter’s visit revolved around her mother’s physical progress. Vera had a debilitating stroke and was making very slow progress. It became apparent that Vera would always require the care provided by 24 hour caregivers. So now her daughter’s focus shifted to the quality of her weekly visits.

The daughter brought favorite food items, books to read together, and her Mom’s request – her hymn book. The nursing staff got used to hearing the mother and daughter singing together on Sunday afternoons.  As the years went by Vera was declining in so many ways. Those times together changed as Vera could no longer follow social conversations or books read to her.

But those hymns, those words sung so many times over so many years, those words remained and gave comfort. At the end of Vera’s life she was almost blind, hadn’t walked in the 14 years she spent in the nursing community, and she was confused most of the time as to where she was and what was going on around her. Yet, hearing those so familiar words gave comfort and yes gave joy.

For Vera, this Thanksgiving:

Come, ye thankful people, come – raise the song of Harvest home, – All be safely gathered in, –  Ere the winter storms begin, –  God, our maker, doth provide, – For our wants to be supplied, – Come to God’s own temple come, – Raise the song of Harvest home.

If you no longer have your Vera to read comforting words to, you can find a Vera in your neighborhood nursing home. Volunteer to read.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing