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


  • 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.

Share your nursing home perspective on this quality improvement issue.