Dementia and Aggression

Sunday evening was pleasant.  I was enjoying a glass of wine with my brother when my mobile rang.  It was Mom’s residence.  I answered fearing something was wrong - after all, she’d not really been much of herself.  It was the med-aide.  She informed me that Mom had punched her.  What?!  Mom hadn’t had any incidents for a while - usually it had something to do with being agitated and cornered by another resident - but that was very infrequent.

Apparently, the aide had come to give Mom her meds, left the door open and another resident poked her head in (and Mom is not fond of this resident - not at all!).  The med-aide turned, asked that another aide come and take the peeping resident away, and when she turned Mom swung and connected.  Wow!

Gratefully, the staff member was unharmed, but needed to alert me.  This had me thinking - I’d known of other residents having troubles restraining themselves - one night I returned Mom from dinner to find a staff member fleeing a resident who was pinching, scratching, and biting her.  Knowing the resident and watching the staff, I stifled my laughter, but knew it was probably a veritable issue.

And right I was!  I received yet another call explaining to me that she had punched one of the administrators, and then on yet another day had punched the lovely busy-body lady she was beginning to loathe.  The staff who phoned with the second bunch of assaults and I spoke at length about the problem.  It seems, though, Mom isn't the only one who is acting out at this time, and the residents I named as being likely suspects were <da-ding!> the ones who were also without blame.  All of these residents seem to be about the same stage as ma mere.  Hmmmmmm.

So the question is:  “What causes dementia patients to lash out if they’re typically mild-mannered?”

According to WebMd.com,  and DementiaToday.com, there are three typical factors in causing aggressive behaviors in dementia patients:

1. Discomfort from lack of sleep, medication side-effects, or indescribable pain;
2. Environmental  - loud noises, clutter, or too much activity occuring in or around the space;
3. Confusion from not understanding questions, directions, or frustration from not being able to comprehend the situation.  (Alzheimer's Violence, Aggression, Anger: Causes …)
4. Feeling frightened or humiliated;
5. Feelings of frustration at not being able to be understood or not understanding;
6. Physical effects of dementia which have eroded their judgment and self-control;
7. Loss of inhibitions and decreased awareness of appropriate actions learned in childhood. ( Dementia and Aggressive Behavior)

Many times, it is difficult to understand the root of the aggression, and it may simply be that the patient cannot recall what they believe they should know, and they know they knew but too much has vanished.  (Alzheimer's Aggression: Causes & Management)

It is important for everyone to feel independent and able to fend for themselves, but when the realization slowly creeps in that this is possible less and less, this could also complicate the psyche of the patient.  

Therefore, it is imperative we understand that the aggression isn’t necessarily directed at us, but there seems no where else to point that frustration and anger; also as the physical capabilities break down it becomes tougher and tougher to work out those aggressions in physical activities.  

Speaking in calm tones, creating a safe and normal environment in which routine provides stability, and giving patients the assurances (through deed and word) that all is well, seem to be the greatest gifts in helping prevent the outbursts.  

Also, Don’t argue with the patient.  This is a battle that need not be fought.  Who cares they think you’re Uncle Lemuel or Aunt Emertina.  You are for them, and that’s all that matters - you won’t be able to snap them out of it, and even if you did it would last moments and you’d be right back to square one!  So, be reasonable and rationale.

Forms of Aggression tend to be:

1. Verbal or Threatening Abuse;
2. Kicking or Punching/Slapping, Pinching, Biting, Stomping on Feet;
3. Lashing out at People and Property;
4. Overreacting or Becoming Quite Agitated Over a Minor Situation.

Dementia and Aggressive Behavior

It is said that when a patient begins exhibiting these signs more frequently they tend to be in the later stages of their disease.  However, as the disease progresses, there may be instances for the aforementioned reasons due to the loss of memory and abilities.  

For Mom, it would seem that this was an isolated case as she becomes aggressive out of frustration and feelings of being cornered - or not understanding.  Perhaps there was more activity aurally, visually, and orally, than she could handle in her room, and she felt threatened and violated because of this.  I’m not sure I really know, but at least this has allowed me to process and learn a bit more.  

Articles for Further Reading and Discussion:

Hagen, Brad F, and Dorie Sayers. "When caring leaves bruises: the effects of staff education on resident aggression." Journal of gerontological nursing 21.11 (1995): 7-16.

Jeanblanc, William, and Yvonne Battey Davis. "Risperidone for treating dementia-associated aggression." The American journal of psychiatry 152.8 (1995): 1239.

Chrzescijanski, Deirdre, Wendy Moyle, and Debra Creedy. "Reducing dementia-related aggression through a staff education intervention." Dementia 6.2 (2007): 271-286.

Dementia and aggressive behaviour

Aggression and Anger | Caregiver Center

When Aggression Follows Dementia

Aggressive behaviours

Coping with the behavioural changes of dementia …

Dementia Care Dos and Don'ts: Dealing with Dementia

Alzheimer's Aggression: Causes & Management

MIsDiagnoses of Dementia....Huh???!!!

It came as a message on facebook.  Someone I knew spoke of how their mother had passed due to Alzheimer’s Dementia (AD), and yet, now, years later, they began to realize it was Lewy Body Dementia (LBD).  It had me thinking:  ‘How prevalent are these misdiagnoses  between dementias?’  And, ‘What are the real causes of the symptoms, if they aren’t dementia, or if they’re another type?’

Well, the second question could be answered quite easily, as stated in A Startling Cause of Misdiagnosed Dementia, from the webpage Aplaceformom.com.  What the author asserts in this article is that too many seniors are prescribed medications and they can abuse those doses - from either side effects or simply forgetting they took or didn’t take them.   The diagnosis, after assessing the same symptoms as differing forms of dementia is that they do have dementia - until they come under some form of structured observation and the realization that the meds were to blame appears.    But that’s just one.  

The next article I found, Misdiagnosis of Dementia, from Rightdiagnosis.com, has a great number of reasons for the misdiagnoses:  Tumor, Adult ADHD, Stroke, Medications, Thyroid Disease, Vitamin B Deficiency, among others.  There are also the mistakes made when looking at the patient and believing that many of the causes for the symptoms may be related to aging (this is what we assumed with Mom, along with her medications).  This is, indeed, an interesting and vital article to investigate if you have any curiosity on the topic.

Another article, Reversible dementia and the misdiagnosis of dementia: a …, published by the National Institutes of Health, announces that 10-33% of patients diagnosed with dementia have some reversible form - due to medications, or other cause for the symptoms, from medical to psychiatric.    How’s that!  

Now, Lewy Body Dementia (LBD) may take 18 months and 3 doctors to reach a diagnosis - and this usually happens when the patient is in the severe stages of the disease, according to the LBDA.org in the article Most Misdiagnosed Form of Dementia Leaves Patients ….  This piece of literature gives us the awful feeling that the patient and the caregiver or family needs to do their homework, as most physicians haven’t a clue as to what LBD is (such as it was with Mom’s primary after her diagnosis - so we fired her and found someone who had done their homework).  

There are many other articles available, and I’ll try to put them at the bottom of this post.  But it is really intriguing that as the population ages that medicine is trying to catch up to the needs and problems that will be quite widespread in only a few years.  

I suppose this may bring more questions than it answers, so this could become something that propels me further along.  So, until next time, keep reading and learning!

Articles:

Rabins, Peter V. "Reversible dementia and the misdiagnosis of dementia: a review." Psychiatric Services 34.9 (1983): 830-835.

Ryan, DH. "Misdiagnosis in dementia: comparisons of diagnostic error rate and range of hospital investigation according to medical specialty." International journal of geriatric psychiatry 9.2 (1994): 141-147.

McKeith, Ian G et al. "The clinical diagnosis and misdiagnosis of senile dementia of Lewy body type (SDLT)." The British Journal of Psychiatry 165.3 (1994): 324-332.

The Treatable Disease That's Misdiagnosed as Alzheimer's

Dementia Misdiagnosis and Hearing Loss

Dementia DES will result in widespread misdiagnosis …

Dangers of dementia misdiagnosis highlighted by 88-year …

Most misdiagnosed form of dementia leaves patients ...

The Games Lewy Plays - OR The Week Ending 11/08/2015

The Freesias from Anonymous - sent as Mom is in hospice.

This has been somewhat of an odd week, but then, it’s also been a normal one for Mom.

Tuesday, the hospice nurse came to bathe Mom.  It took 3 people.  Mom is quite the fighter!  She screams and pushes back no matter what they tell her.  She does not want to take a bath - until she is in and under the water, then she’s in heaven.  But, the nurse is absolutely exhausted after this, and it has become, I gather, a bit of an issue - you see, they’re not supposed to force anyone to bathe - that includes Mom.  So, it seems a phone call and some conversations need to be had.  

There is also an issue that seems to be making a resurgence - constipation.  Mom is having more issues with her intestinal tract, again.  She eats most of her meals, ingests plenty of fluids, and does some reasonable amounts of exercise (she follows Leddy around the cottage - that’s her exercise, as she is unwilling to participate much in anything else).   Fortunately, they do her laundry twice a week, but Mom seems clueless as to what’s going on.  

Her thinking is also becoming muddled again - as it was when we first placed her in hospice - but then it sparks back!  

This morning, she arose perky and rosy.  She ate breakfast (yes, she was appropriately garbed) and read her paper.  She was in the dining hall for quite some time, then retired to her room.

Mom after a tumultuous struggle to take her shower

When I arrived she was asleep in her recliner.  I turned on a light and this seemed to really bother her.  She then demanded I turn on another while turning off the first.  She kept dozing off.  Finally, she agreed to come out of her chair.  She arose and complained of pain - she seemed dull-witted and unsteady.  Her eye had a bruise-like mark (which had just appeared after breakfast - probably due to her scratching it), and she held on to the dresser as she made her way to the bathroom.  

When she finally came out, she decided she needed a sweater, and then we went to lunch.  Even while eating she did not seem to be the person described to me earlier.  The staff mentioned this was on/off again and again.  However, for some reason this seemed very much unlike her in the past weeks - I’m not really sure where this leads, if anywhere, but I’m on guard, just in case.  

I did bring in a puzzle, as promised in Thursday’s post, but it seemed so out of touch with where she was today.  There will definitely be more visits this week, as well as calls and conversations - just to see where we actually do stand.  

On a lighter note, The RLC (Connie & Jean) came to pay their weekly visit to Mama earlier this week.  And here is their report:

It was a cool, sunny day today, just right for a visit to Norma at St.Anthony's.

Connie signed us in at 1 pm, and we found Norma finishing her lunch.  She always looks happy to see us; we sat at her usual table, the one closest to her room. We put Connie's walker in the room, and our coats.

Some ladies do stop by to chat; we are polite, but do not invite them to join us.

Norma was interested in the Wall Street Journal Connie brought for her.  She glanced at the articles, reading a few captions (perfectly, of course) and beginning sentences.  Connie commented on one that had a good cartoon with tips on how to know what a man or woman is really like, no matter how they present themselves at first.  Norma read to us the numbers on the graph describing different positive and negative traits, and which gender considers each important.  Some typical male and female traits made for a 3-way conversation.  Of course, we are all amateur experts, with our limited experience.

Norma's speech, as always, showed she believes strongly in some ways to behave, and what is appropriate. She reminded us that we need to consider what might be responsible for what some people do. Her sentences start out strong, but the thought is not always completed.  We just continue as if she had finished her thought.  She did not mention that you and Lawrence interrupt your work days to shower with her.

Morina made coffee for us, and Jean paid attention, so she’ll be able to do that instead of asking the workers.  Elsa brought Norma her dessert--two pastry goodies with an apricot (?) filling.  She offered one, but we said it was for her.  When, after a while, she urged Jean to eat it, she took a bite, was about to devour the rest of it, when Norma moved the dish and said, "I'm saving this for Tom." Gracious ladies that we are, we asked her to say Hello to Tom for me.

Those freesias are beautiful!  I forget the name of the group that sent them; the card said they send flowers to those in hospice and something else. Bend, Oregon was on the card.

We stayed at the table all our time there, just chatting and watching what was happening around us.  Liana (sp?), the very slim, beautiful dark-skinned young woman, put two tables together, brought in Bingo materials and called the numbers for six residents.  We saw chocolate bars there for prizes.  They had Bingo for quite a while.  Neither of us  heard anyone call "Bingo!" but maybe they did, quietly.

A lady came in with a cute little dog, a Sheltie named Spencer, she told us. She walked around the room, stopping to let people see the dog and pet him.  When she passed by us, Jean asked if she had a trained "visiting" dog. She said the dog was not trained, but she had training.  She asked Connie and Jean if we lived there. Jean told her they  were visiting Norma, whom we have known most of our lives.  She introduced her friendly mother, Shirley, in a wheelchair, and herself, Nancy. Shirley's room is the one just East of Norma's.  We hope Shirley and Norma can be friends.

We saw residents there new to us, at least two using wheelchairs. Lucille marches along confidently with her walker.  Connie and Jean each greeted her with a hug when we first saw her, but she did not speak--a little smile, maybe.

We said our goodbyes and left at 3:45.  Norma had her WSJ to read until Tom showed up.  It was already looking gloomy outside.

Not an exciting time, but time well spent with old friends.

 And so it goes.

Puzzles and Dementia...

There was a thought in my head - but it came too late.  

Last Sunday I was going to bring a jigsaw puzzle with me on the visit with Mom.  Unfortunately, I had left it behind and being in a hurry, forgot to find one at Costco.  Doggone it!  I’ll have to bring it this next time!  

In doing some research, I found many articles that stated puzzles and card games can help stave off the onset of dementia - and it might also delay its impact.  Perhaps I’m in the wrong here, but Mom was doing crosswords until July of this year - and she was pretty adept!  Cards she hadn’t played in quite a while.  

They also state that writing was very good at helping the brain work - Mom slowly began not writing any more letters, cards, notes.  In fact, last year on my birthday, she wrote her condolences after she began to celebrate the occasion in ink.  This was with some prompting, as she had decided she wasn’t going to write anyone anymore.  

Her good friend, Nadya, explained to me that when Mom was first placed in Memory Care she had written over 40 letters and cards.  Within a year that had dropped to 20 or so, and then to 10, and finally to nothing.  This was tragic, in her eyes, as they considered themselves sisters - but now they were separated by 250 miles, and neither could navigate the journey.  Writing was the only connection.

There are sites where you can buy puzzles and games for dementia patients!  Whether they truly work to stimulate the brain’s workings is probably (in my opinion at this point) rather individualized; if it can trigger something with Mom, then, perhaps, it could become something we consider to be a regular thing - even bringing in the RLC (her friends, Connie & Jean, who comprise the Retired Ladies Club).  It’s less arduous than Scrabble, but one can have a jolly time chatting while figuring the pieces.  

It would be interesting to hear from those who have used puzzles and what they found.    I’ll continue trying to figure out the puzzle of LBD and Mom in the meantime.

The Alzheimer’s Store

Puzzles and Brain Games

8 Brain-Training Games for Memory

Memory Jogging Puzzles

Mind Start

Puzzles for Alzheimer’s

Moments of Moments

I remember when Mom was first diagnosed - it had been quite a wild ride those few weeks prior and after.  I was riddled with guilt, exhausted from all the travelling and paperwork, and there truly seemed no end in sight.  

At last, things seemed to calm down a bit - but there was still the demand on my time; never knowing what might pop up at the next bend, and trying to figure out what the best tactics would be for whatever came next.

Then, it seemed as though we were entering the final stages.  Hospice came and began working with Mom.  Her dilemma, it was discovered, was constipation, and it seemed to be cured with active culture yogurt!  Go figure!  Something that simple!

Mom began eating, again, and participating off and on in the activities of the cottage.  She could no longer venture out as it seemed a cause of great stress and confusion for her.  The doctor stated this could be a turn for the better before it went downhill; and so the waiting planning for that moment is ever present.

However, there are those times when it would seem Mom just wants someone to be next to her - someone who might bring a presence that means security.  There may be no real reason to speak, but to be - there - in the moment; and then fetch her coffee when she wants it.  No conversation but the silence.  

Relationships evolve, change, rotate, you name it.  There doesn’t seem to be any need to express what happens - it just does; no matter how you try to force it or put it into place - that’s artificial.  That’s not a relationship.  

And so, as Mom continues on (with whatever you might call her health, at this time),  there is another person emerging with another mindset.  It’s still the woman who raised us and drove us crackers; but it isn’t.  

She has evolved - for better or worse - she is a person who has a world unlike ours and cannot express it as simply as you or I.  

Sometimes appreciation is difficult; sometimes it’s harder to find the humor; but it’s all there for the taking.  An acquired taste for the menu of life.  

The Week Ending 11/01/2015

Interesting.  That’s the best word to sum it up.  Interesting.  Why?  Because it is, that’s why!  

Now, I had been under the impression that Mom was a more than willing participant in her showering.  HA!  Apparently, Tuesday, it was as though WWIII was in the making.  She threatened to summon my brother, the attorney;  call the police as well as city hall!  But they still managed to get her into the stall and she calmed right down, enjoying the water and being cleansed.   

She walked every day for about 10 minutes.  She was quite conversant - one day she went on for nearly 2 hours!  And, she did play BINGO (even yesterday, as my brother discovered when he dropped in to visit).

Her eating habits are decreasing, though.  On two days she ate but one meal, others two, and some three  - it’s very inconsistent.

Connie and Jean popped by earlier in the week, and here is their account:

We were lucky not to be rained on today.  Lunchtime was over, and we found Norma at her table, reading The Oregonian. We talked a bit about the different headlines, and Norma perused each large sheet of ads that came with the paper.  It's nice to have a discussion almost as we have done other times.

Norma was wearing a nice white sweater, dark blue pants, and a lovely Pendleton Wool dark gray jacket.

We asked if she cared to take off the jacket; no, she was fine with wearing it.

Then she read aloud the advice column, "Ask Amy." Perfect reading, with understanding, we thought, even keeping her place as she stopped to say something then go back to the column.  She reads as well as ever. We talked about the problem presented, with our various ideas about a proper answer.  It was a good 3-way conversation.

Connie is good about introducing a new subject any time Norma starts to express a thought, then drifts off.  Mom was in good form today generally.  As you might guess, Jean tends to speak with other residents and even "help" them move away from our exclusive property.  Norma discourages this, but Jean does it anyway.  (They have already been "invited" to go "over there" or anywhere but at our table.)

Norma asked Connie where her car was.  She said Jean's car was in the parking lot.  Usually she follows that question with saying she would go with us; We think she did not do that. As we said, Connie is good about bringing up some interesting subject.  She said she was gifted with a copy of "The Romanov Sisters" by Helen Rappaport.

Morina was working with a few ladies, carving a pumpkin.  We think she was the carver, they, the audience. She put a big piece of black plastic on the table before starting.

Hair-fixer Barbara stopped for a few minutes to chat.  Norma said that Barbara was a good hair cutter; Barbara thanked her.

We had coffee; Jean told Norma she would get her a cuppa after she drank the juice in her glass.  It was red; when she was ready for more juice she specified not the red kind. She found apple juice in the refrig, gave it to her,and she said something about wine..did not catch what she meant.  Jean said maybe there was a bit of wine in it, but did not really know.  We reminded her that she has wine with dinner,and that the ladies keep her own bottle for her.  She seemed to deny that this was true, just a kind of poo-pooing the thought. (Mom hasn’t had wine for a few months now)

Jean asked Norma if she could check out her bathroom, and she asked, "Where is it?"

Jean answered that it's right next to her bedroom, a few feet from her bed. There were no towels on the racks, so Jean got an orange towel from the cupboard.  Her bathroom looked nice and clean, as always.

jean brought Connie's walker and coat from Norma's room, then we walked to her room.  She sat in her recliner, the room was rather dark, and I suggested she might have a nice nap before dinner.  No comment from her; I'm guessing she did nap.  It was a bit after 3 pm.

We said our goodbyes and left. We had been visiting for two hours; it never seems that long.

So, today, I popped around for the morning visit (as I am prone to do).  I had received a text from Leddy that she was in a very bad mood - Leddy surmised it could have been because they told her her breakfast was on the table and they would like her to come out.  Who knows?  Another aide told me she knocked on Mom’s door and Mom told her to wait a minute.  When the aide finally opened the door, Mom was putting on her shirt, pants and socks.  However, five minutes later, when she returned to see if Mom was alright, Mom had taken off the shirt and pants and had replaced them with her nightie, then put sandals on over her socks.  She did put on her own compression stockings, though, too.  

When I arrived, Mom was sitting in her room dressed in what I thought was just her nightie.  

“Don’t you want to get dressed?”

“What do you mean? I am dressed”

“I mean put a shirt and some pants on.”

“There’s nothing wrong with what I have on!  Some people wear only their bathing suits, and some less!  Stop being so rude!”

Deep intake of breath here.

Mom did mention she was feeling a chill (even though it was 74 in the room and I was feeling rather comfortable).  So, I helped her put on a sweater and out we went into the dining room where she supposed she would have her breakfast (only 3 hours late!).  

As we sat down, another woman came to sit with us.  Mom tried, tactfully - for once, to ask her to leave us alone.  In truth, we tried many strategies, but she woefully couldn’t take the hints - even when we said she needed to go!  At last, Leanna came and tried to move her.  This didn’t work, either.  Mom was rolling her eyes and glaring at the woman (“There is really something wrong with her!”).  At last, we were able to move her to another table and she was content.  

Mom began reading her paper, and we talked about some of the articles.  Of course, we repeated many of the conversations as they seemed to have flitted away in her mind.

At one point she turned to me and stated, “You really have no shame, do you!?”

“What’s that about?”

“I do not like you trying to shower with me (gug!)!”

“Did I try that this week?”

“Duh!  You did it this morning!  Your father was very upset.”

“Oh.  Did you win at BINGO! yesterday?”

“Of course.”

“You know, Lawrence tried to visit with you, but you were off playing.”

“Well, he needs to stop that disgusting shower stuff, too - I’ve had it with both of you!”

Apparently, we are both taking showers with her on a daily basis…...gug gug ugh!

I was to leave, only to return later after a hike, bearing flavored creamers with me (she had asked, and I figured ‘What the hey!’  I know what I’ve stated about the brain and sugar and insulin, but at this point…..).  She loved it.  She was still involved with her paper, and then, finally, she stated we needed to get going.  She believed we were going somewhere, but had to wait for someone to take the cups and napkins.  I took them and she began to throw a fit.  I returned one napkin, and she found a piece of rice on it -which she flicked off and then folded it up to reuse at another time.  

Upon my departure, she began lecturing me on collecting children.  She reprimanded me for having too many and feeling smug about it as though it meant something.  “Well, it doesn’t! It just means you’re a creep!”  Where this came from, I imagined, was the same wonderful world that gave her showers with us.  Oh well.  

I then left her with music after I filled up the vase filled with fresias someone had brought her (beautiful!  I wish I’d been able to snap a photo!).   She was weary and ready for a nap.  After all, she’d had one very trying day.