Lilly sits in in front the nurse’s station in a nursing home. She is seated in a wheelchair with a lap tray to prevent her from getting up. She pounds the tray repetitively with a tight fist and mumbles angrily between clenched teeth. Her caregivers report that she is difficult to care for- she punches, pinches, and bites when they try to get her dressed and transfer her to and from her chair.
I have met countless Lillies, and plenty of intermittently physically aggressive folks who were not as far long in the degenerative process. Caregivers providing personal care to these individuals face a real risk of injury.
In Lilly’s case, her disease has probably advanced to the point that her communication (temporal lobe), judgment and reasoning (frontal lobe), and sensorimotor cortex are no longer viable. Her interactions with the world are quite primal- she lives in protective/survival mode. Because of the difficulty in caring for her, Lilly has essentially become “shunned from society”… or at least from her small place in the universe.
The aides in Lilly’s nursing home dread working with her. Sometimes she is medicated for her behaviors, which essentially knocks her out. Lilly is at risk for dehydration, malnutrition, skin breakdown, contractures, and falls.
Here are some tips for caregivers:
1. Physically aggressive people are usually defending themselves. They are not actively seeking opportunities to hurt caregivers. Your job is to decrease their perceived threat of harm that is making them defensive.
2. Do a sensory evaluation. Look at the world through Lilly’s sensory organs and try to figure out what triggers her. Do bright lights, loud noises, and position changes agitate her? Does she tend to panic more when she is left alone, or does she calm down? Is she hypersensitive to tactile input?
3. It’s safe to assume Lilly is in pain- she is older, rigid, and doesn’t get the opportunity to move much. Deterioration of the sensorimotor cortex can cause a person to perceive pain more acutely and not be able to shift body positions to relieve pain or discomfort.
- Talk to the physician about pain management medication (even just routine Tylenol) and see if her symptoms decrease.
- Make sure her wheelchair is comfortable and passive position changes are possible (tilt-in-space wheelchairs are ideal).
- Digestive discomfort is an overlooked cause of agitation in the dementia population, particularly when they cannot verbalize the discomfort. Watch for food triggers, constipation, bloating…
4. Communication techniques:
- Approach Lilly in her visual field- one to two feet directly in front of her face.
- Don’t touch her until she sees you.
- Smile, use your kindest voice.
- Use short sentences.
- Touch Lilly with firm pressure on her large body areas- upper back, upper arm, thigh just above the knee
- Positively react to all Lilly’s attempts to communicate. Help her see that you understand her.
5. Transfer techniques:
- Demonstrate the action before you touch her.
- Put balled up socks in her hands to occupy her hands so she can’t pinch or grab the caregiver. Primitive reflexes sometimes re-emerge in late stage dementia. Use the palmar grasp reflex to your advantage.
- Use calm voice.
- Move slowly, give her a chance to adjust to position changes. Lilly may have an impaired ability to recognize an upright position. She may be dizzy or nauseous after changing positions. Resistance to position changes is probably a reaction to a perceptual problem, not an intentional behavior.
- If Lilly can bear weight, allow her to pull to stand by stabilizing the walker or using a grab bar or super pole. Do not let her pull on a caregiver.
- Lilly is probably terrified of falling. Her ability to judge the distance to the floor or understand where she is going is impaired. Expect resistance and try to reassure her.
6. Bonus tip:
- Pets and dolls are a great way to decrease combative behavior. By tapping into instinctive nurturing tendencies, placing a baby doll in Lilly’s arms may, momentarily, stall her physical reactions. A friendly dog or stuffed animal may also provide a calming effect.