Upon entering the nursing facility one afternoon you encounter Mrs. Jones, an 84-year-old woman with a history of dementia, who propels her wheelchair toward you screaming, “Help me get out of here! Mama is trying to come get me, but they won’t let her in!” Moments later a staff member approaches from behind Mrs. Jones, grabbing her wheelchair and saying, “Mrs. Jones, you need to come back to your hall. No one is coming to get you.” Mrs. Jones becomes visibly upset and reaches back to strike the staff member. She cries out, “You’re lying! You are one of them. You won’t let me go home.”
This scene may seem all too familiar for those who have spent time in nursing facilities. What many refer to as “agitation,” including verbal outbursts or aggressive behaviors such as hitting, kicking, or biting, can often be a reflection of one’s environment. Environmental triggers may include loud noises, unfamiliar faces, and social isolation. We commonly see these behaviors toward the end of the day as adults grow tired and as the shift change brings about a new set of caregivers.
We will share tried-and-true, person-centered strategies for decreasing agitation in older adults with dementia and for providing a comfortable environment for residents, their loved ones, and staff. By partnering with older adults and connecting with them, we can develop a better understanding of where their behavior is coming from and how best to avoid it in the future.
Creating a Safe Environment
When approaching agitated older adults, first make sure they are in a safe environment and they feel safe. Approaching from the front is best because they may not hear you coming from behind. Introduce yourself using a calm and soft voice, adjusting for hearing loss if needed. Ask them if you can take them to their room or to a quieter area to reduce overstimulation. Ask permission to turn down the TV or radio volume. Get to the eye level of the person, acknowledge their distress, and support their feelings. Don’t challenge them or their perceptions; instead, attempt to redirect or distract.
Looking for Underlying Cause “ABCs”: Antecedent, Behavior, Consequence
Once you’ve helped the older adult feel safe, look for unmet needs. This is a common reason for agitation: older adults are unable to effectively communicate their needs, which compounds their frustration and distress.
Look for signs of acute illness such as a low-grade fever, cough, or change in bowel or urinary patterns, including incontinence. Next, consider their medications. Have any new medications been added to their regimen, or were there any recent dose reductions? Has there been a change in renal or liver function that may affect their medication clearance? If not, consider unrecognized pain. A trial of routine acetaminophen could be helpful.
Finally, consider hunger, thirst, or boredom. One of our residents, who was agitated daily, calmed down by eating a packet of graham crackers and then smoothing out the wrapper over and over. Sometimes interventions can be this simple.
Connect to the Moment
After making sure a resident is safe and all needs have been met, try connecting the older adult to the moment by using the five senses. Food is a great tool because this can also work toward meeting an unmet need. Pick something with a strong flavor, perhaps something they can connect with on a cultural level. Use smells such as essential oils, stickers, or even scented stuffed animals. For some older adults, holding a doll or stuffed animal may be soothing. If the facility has a garden or outdoor area, a walk outside can help the resident connect with nature. If these ideas don’t work, try breathing deeply together.
Do Something They Enjoy
When an individual’s memory is impaired, the environment may seem unfamiliar, leading to fear and anxiety. In these situations, you can try reminiscence therapy or connecting the adult with familiar memories. Memory books with pictures of loved ones are a great way to comfort someone in distress.
You can also connect with people by talking about your own family or pets or sharing your own photos. Humanizing ourselves to the people we care for helps establish trust. Telling a joke or watching a funny video can trigger laughter, replacing negative emotions with positive ones. Similarly, listening to familiar music and dancing can create a positive emotional response.
Do a Meaningful Task
You may have witnessed an older adult with dementia sitting at a nurse’s station folding a towel, just for the staff member to unfold the towel and hand it back to them. While the idea of distracting a distressed adult with a task is a good one, the task should have purpose and be something the person wants to do. Wanting to find meaning in one’s work and feel a sense of purpose are normal human emotions. Getting to know individuals and their hobbies and previous work may help you identify activities they will enjoy, which then can be incorporated into their care plan.
Choose Your Battles
Finally, choose your battles. Staff often try to redirect adults who are wandering, which can lead to acute agitation. Ask yourself how you would feel if someone was repeatedly preventing you from exploring and kept forcing you to sit still. In a controlled setting like a nursing home or a memory care facility, allowing safe wandering may reduce agitation in adults with dementia as well as ease the burden on staff. Similarly, some older adults may have different sleep cycles or bathing routines and respecting their preferences may prevent a battle and lend to a better quality of life.
If the staff member working with Mrs. Jones had used these tried-and-true strategies, she may have been able to redirect Mrs. Jones and avoid her aggressive behaviors. Person-centered care strategies can reduce agitation and improve quality of life in adults with dementia (Clin Interv Aging
2017;12:381-397). Individual strategies may not be effective 100% of the time, but consider these strategies as potential tools to help alleviate behavioral symptoms. Striving for consistency in routine and caregivers also can reduce the likelihood of agitation. For more information on these strategies, visit the Nursing Home Toolkit at http://www.nursinghometoolkit.com/
One final tip to keep in mind is to never take these behaviors personally. Unfortunately, it’s not uncommon to hear from staff that “she does this on purpose” or “she just wants attention.” It’s vital to educate families and staff that at the heart of behavioral symptoms there is a cause or unmet need, and our responsibility is to help identify it. When we recognize signs of caregiver fatigue, it’s appropriate to take a break or rotate staff in order to better care for ourselves and our residents.
Dr. Rust is an assistant professor of geriatrics at the Florida State University College of Medicine in Tallahassee, FL. Ms. Villegas is a physician assistant who works in Denver, CO, with Longevity Health Plan. Ms. Coniglio is the president, CMO, and a founding member of Psych360 (http://Psych360.org) and a member of the AMDA Behavioral and Mental Health Advisory Council.