Browsing "Dementia Related Behavior"

Dementia Related Behavior – Entry 2

Dear Diary:

Since we started reducing George’s Seroquel dose, the evening shift nursing assistants began observing him more closely. They recorded their observations and then we met with his wife, Lois. We discovered that George became more agitated in the evenings following large group activities. He was calmer when there was less activity around. He would also react to the TV in the evenings, sometimes even yelling at it, like it was a person. Lois shared that George had little tolerance for the TV in the evenings at home. He preferred to listen to music or play cards, especially solitaire.

George is much calmer now that he has a consistent routine in the evening. Lois picked out some of his favorite songs and we loaded them on an iPod. Lois brought some headphones from home. George loves the music. You can hear George humming along to the songs. He also loves his cards. We have a quiet spot in the lounge where he can sit at the table and play solitaire. Some evenings he plays for hours or just shuffles the cards and lays them out. The nursing assistants keep the TV off in his room in the evenings and he never asks for it to be on. There have been no more outbursts or conversations with the television.

We seem to finally be at a good place with George. He has become calmer in the evenings. The nursing assistants tell me that now when they ask George if he’s ready for bed, he doesn’t resist them. He’s also sleeping better and seems happier. And the best news is, his doctor has discontinued the Seroquel. He even is more alert during the day without the Seroquel. Looking at the behavior logs, he hasn’t had an outburst or resisted evening care for a week now. It’s taken some work to get this far.

We haven’t had this success with everyone. Since seeing the changes with George, staff are more willing to try nonpharmocological interventions and problem solve for other residents. It takes a team effort! I wonder what changes can we make in our workflow to spread this success to other residents?

Signed, Donna

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Dementia Related Behavior – Entry 1

Dear Diary:

We have been steadily reducing the use of antipsychotic medications at River View. It’s been going fairly well. Staff understand the need to do this and our physicians and nurse practitioner are on board. Each person and family has a different journey with a dementia diagnosis. I’m thinking of George, who moved to River View a few months ago at age 85.

George’s wife was caring for him at their home. Even with some assistance, Lois was struggling. She became more fatigued when George was restless at night and her arthritis limits her movement. Concerned about Lois, their family encouraged her to move George to River View. Married 62 years, Lois is devoted to him, making this a hard decision for her.

George has adjusted fairly well and Lois visits daily. Anna, the nurse on George’s neighborhood, talked with George and Lois about reducing the Seroquel dose he’d been on at home to help manage his restlessness. Lois was reluctant at first, but agreed after talking with their physician. The dose reduction has gone fairly well until now.

George had been mild mannered and fairly agreeable. Over the past month, he’s become more grumpy and agitated, especially in the evening. At bedtime, he sometimes becomes distressed and verbally abusive when staff try to assist him. Twice he was shouting loudly, as if he was having an argument with an imaginary person in his room. Anna wants to call the physician and have the Seroquel increased. I understand her thinking but want us to consider other options before antipsychotics.  How can I help Anna think through another approach for George?

Signed, Donna

6 Comments

  • We believe Anna should talk with the wife and find out what kind of routine George had at home during the evening hours. Also, find out what hobbies George has or what he enjoyed doing. Maybe he currently has a TV in his room that is distracting him.

  • Perhaps he is demonstrating sundowners and could benefit from having the blinds closed, all the lights turned on, or perhaps his family could come in during that time to ease him into his routine. Have all the staff been trained for the right approach on how to handle him, does he have consistent staff who are caring for him, is there another medication that is causing the problems, or has he just become more of a night owl and isn’t ready for bed…..Just some questions I would ask.

  • If Anna were to visit George during these bouts of anger, would he take that anger out on her? Or would Anna see this behavior and think it was because she placed him at River View and then become down because of that. I do think it would be a good idea to speak with the family to figure out what his evening routine was at home to ensure staff are following to make George feel more at ease and at home. Also, would George benefit from a “memory box” that he could look through in the evenings? (Have family place some of his favorite things in a shoebox or plastic small tub)

    • Review any recent medicaton changes, ask family about normal routine in the evenings. We would review all of the approaches listed in the previous comments.

      • Most certainly try every approach possible before adding the Seroquel. Is he in pain or is he depressed? I think there is some education about trying Celexa first. Sometimes as we know people who have dementia cannot verbalize their discomfort or even their sadness.

  • Per our PDSA, we would complete a “My Best Day Care Plan”, which is a history of the resident per interview of family/prior care givers looking into life history, likes/dislikes, routines, sleep habits, etc. Once we know the needed information about George, we would further enhance his individualized care plan. We could then look at initiating use of “happy lights”, individualized toileting plan, and individualized activities.

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