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Aggression and Combative
msbonner92
Posted: Tuesday, April 9, 2019 8:21 PM
Joined: 4/8/2019
Posts: 2


My FIL has become increasingly aggitated, aggressive and combative with my MIL who is his primary caregiver since having a seizure about 7 weeks ago. We have been unable to determine a trigger for his aggression towards her for his attitude changes extremely quick like flipping a switch. You never know how long these episodes will last. His doctor prescribed Seroquel and added Xanax last week. Any advice on how to diffuse the aggression when it starts??
LicketyGlitz
Posted: Tuesday, April 9, 2019 9:47 PM
Joined: 2/3/2018
Posts: 303


Ms, we hit the rage-stage HARD in January of this year. Mom's doctor also prescribed seroquel, and it took a couple of weeks to start to see some relief for her, but it's only been this last week or so that I feel she's back to her pre-January dementia "normal." Her doctor worked with us on adjusting dosage, we started with the lowest dose possible, now she's up to two low dose pills a day.

I bet others will have good suggestions on diffusing the aggression, we didn't come up with much to redirect Mom's anger for a month except chocolate pudding (gawd bless chocolate pudding!). But I wanted to pipe up and let you know the seroquel is working for us.

Good luck!


Stephanie Z
Posted: Thursday, April 11, 2019 5:01 AM
Joined: 12/15/2011
Posts: 4194


Hi msbonner,

     LickityGlitz had the right idea when she tried chocolate pudding. Any particular treat they like has a good chance of calming them down enough for you to move them to another room and change the conversation (if any) to something less threatening.

     I'm an RN with a lot of dementia care experience. I remember one patient who must have done a lot of rock climbing at one point in his life. He would get "stuck" hanging on for dear life to his bureau, or one of the door handles, or even the railing  that ran along the wall. He was genuinely frightened that he would fall and would strike out at any of us who tried to help him.  The only thing that worked was to put a chair behind him and offer him a donut. When he took the donut, we would gently push him into the chair and back him up away from whatever he was hanging on to. He loved donuts so much the distraction helped break his fear of falling and after a few minutes he was able to join the other residents in an activity or go to lunch.

Hard to tell what is going on in their mind. But giving them something they "love". (A chocolate kiss also works well) does wonders.

Hope this helps,

Stephanie Z


Abuela
Posted: Thursday, April 11, 2019 6:18 AM
Joined: 6/24/2012
Posts: 265


Mom was put on Seroquel at the beginning of March.  She gets a small dose in the morning and a bigger dose at night.   It seemed to work for awhile.  It does take a few weeks to really kick in and she takes trazodone also during the day.  But lately she has been having more issues and what you describe... turning on a dime... is also happening.  She is taken to not leaving her room or eating or changing her clothes.  So the nurses are recommending a geri-psych eval for about a week to tweak the meds and find the right doses.  After that she will move over to memory unit.  Good luck.  It's not an exact science, but glad that there are some drugs that can help.  


Jo C.
Posted: Thursday, April 11, 2019 8:25 AM
Joined: 12/9/2011
Posts: 9394


A warm welcome to you, msbonner.   This is indeed a challenge and one that weighs heavily on  those caring for the person who is aggressive and of special concern if the person with dementia is combative and a risk to safety of self and/or others.  Routine and structure and quietness of the living environment is very important as well as are good communication skills.  Still, despite all best approaches, sometimes the anger and aggression continue to be a problem.  The following links may be helpful:

https://www.nia.nih.gov/health/coping-agitation-and-aggression-alzheimers-disease

https://www.alz.org/help-support/caregiving/stages-behaviors/agression-anger

You mention your father's doctor; is this a primary care MD, or is it a dementia specialist?   Hopefully, your father has a good dementia specialist.  Our primary MDs are wonderful at so much, but they are not on the cutting edge of dementia dynamics management, especially in a situation such as this.  Of special interest is that this behavior surfaced after a seizure, was any of this cause and effect explained by the doctor(s)?

Since the medication has not made a difference, it seems that addressing this with the physician is warranted; especially a dementia specialist.  I would ask the specialist to confirm the actual type of dementia that is present once again.  Sometimes, as time moves forward, the diagnosis for type of dementia, (of which Alzheimer's Disease is only one type), can change.   This is very important because meds used in one type of dementia can be contraindicated in another and sometimes can cause a worsening of symptoms. It is also not unusual to have a dual diagnosis made for more than one condition.

When a Loved One, (LO), is started on a med, it sometimes takes some adjustment to find the right timing and dosage.  My LO was prescribed Seroquel at bedtime, but it wasn't highly effective.  The Neurologist then prescribed a lower doseage twice a day, but found that a slighty higher dose was required at those times and that made a significant difference. 

There are times when a LO is so dreadfully compromised and aggessively combative, that there is an actual danger lurking.   In such instances, the physician will sometimes recommend a short term admission to a Geriatric Psych Unit. It MUST be GeroPsych rather than an ordinary psych setting as GeroPsych is capable of managing dementia dynamics.

These admissions are covered by most insurances and will usually be for about a week or a couple of weeks depending on medical necessity.   The patient can be assessed on a 24 hour continuum and medications adjusted while observing for effectiveness and possible side effects.

Sometimes this works well, but there are times that it is not appropriate to have the patient return home, and if this is the case, then the patient is transferred to an alternative care setting right from the GeroPsych setting.   This will be the family's decision.

NOTE:  Your mother's safety is of prime concern.  If there are any guns in the house, they must be removed immediately.   All knives and scissors need to be locked away in a drawer or cupboard; same with other items that can in a moment's fury be used as a weapon; hammers, wrenches, bats, etc.  

It would be best if your mother carried her fully charged cell phone on her person at all times and that she keeps in mind a room she can get to with a locked door if she finds the situation out of control.

In such a circumstance, it is necessary to call the police department.  There is no shame in this, it is keeping everyone safe.  If it is necessary to make such a call, let them know that the person being called about has Alzheimer's Dementia and is agitated and combative.  They need to know that.  If he is still acting out when the police arrive, they can be asked to call for an ambulance to have your father transferred to a local ER where one can make a request that your father be admitted to a GeroPsych Unit at whichever local hospital has such a speciality.

So wish there was an easier way, but this is one of those situations that are on the more difficult end of the spectum in dementia.    I so hope that there will be an answer soon, please do let us know how you are and how your parents are, we will be thinking of you.

J.


Mimi S.
Posted: Thursday, April 11, 2019 10:08 AM
Joined: 11/29/2011
Posts: 7000


As usual I urge you to ask at your library for a copy of any book by Naomi Feil with the word, Validation, in the title. it's not an easy read but will be time well spent.

I also urge you to call the non-emergency police line and give them a heads up on what's going on.

 

Good luck!
jfkoc
Posted: Thursday, April 11, 2019 7:02 PM
Joined: 12/4/2011
Posts: 16582


ditto to Mimi.....sooooooooo important
msbonner92
Posted: Friday, April 12, 2019 10:07 PM
Joined: 4/8/2019
Posts: 2


Thank you all, for your responses, encouragement, and advice. I will be sharing this information with my family. 

To update you, on Wednesday, my FIL had an extremely bad day of very aggressive behavior. It began by attempting to hit me that morning, progressing to attacking my MIL multiple times, him falling 3 times during his aggitated behavior, and under the advice of her police officer neighbor and their PCP, my FIL was transported to the hospital Wed. night to be evaluated due to his falls. He continued to be combative in the ER. From the ER early Thursday morning, my FIL was transported to a behavior/psych unit out of town. We were told they are going to keep him at least 72 hrs for evaluation. Within the first hour after his arrival, they notified us he fell again. This time he hit his head on the floor. He was transferred to the hospital associated with the behavior/psych unit. for a CT. After a long day of the runaround from the hospital, my husband and MIL found out they transferred him back to the behavior/psych unit. They finally got to see  my FIL very late last night for a brief period. He was calm, alert, ate, and expressed affection. We went to see him during visiting hours today, and we were not allowed to see him. We were told he did not sleep at all last night, and he was aggitated, aggressive, and verbally abusive to staff today. The doctor apparently made the decision to give him meds to calm him not long before visiting hours began, and he was asleep when we arrived. We have not  been given the opportunity to talk to the doctor,  so we don't know fully what is going on with my FIL nor the plan of action. We have yet to get the results of the CT, and everyone we ask doesn't have any answers. It has been very frustrating to say the least. We are very concerned about our LO and if they will be able to help get his behavior under control. We know very little about this evaluation process and what to expect.

In the meantime, we have decided it is time to place him in a MC facility whenever he is discharged and began looking for one today. We found a facility all of the family liked, and we have him scheduled for an assessment on Monday. We pray he will show signs of improvement soon and won't be deemed too aggressive so he will pass the assessment and be accepted into the place we have chosen for him. 

This is all so scary, overwhelming, and stressful!! And not having adequate communication with the hospital and doctor makes it all worse. We are not familiar with this hospital and do not know anything about this new psychiatrist. This evening we were able to get a  contact number for the new psychiatrist who is currently treating him during evaluation and the number for his assigned therapist. We plan to call first thing in the morning to see if we can get the information we need and see if we can schedule a time to visit him tomorrow. 

Notes: My FIL is under the care of a neurologist for his AD. He is in stage 6. We are concerned about this latest fall and head injury at the behavior/psych unit and the effect it will have on him. We are concerned because this injury happened out of town in a different hospital network and hasn't been reviewed by his neurologist (that we know of).

When my FIL began showing signs of aggression toward her, she made a safety action plan which included notifying her police officer neighbor about his behavior, finding out they him who is best to contact  during emergency, and keeping him updated on behavior changes. She also put away weapons and items that could be used as such, and had a safe room she could escape to. She also made a plan of when and how to evacuate their home if needed. She always carried her phone on her and a key to the house in case my FIL locked her out. 


MacyRose
Posted: Saturday, April 13, 2019 12:24 AM
Joined: 12/15/2011
Posts: 3849


msbonner92, a geriatric psychiatric evaluation can take several weeks - I believe 26 days is not uncommon.  The goal of the process is to use a cross discipline approach to determine what is wrong with the patient and, if warranted,  find a psychiatric medication and level of dosage that is beneficial to the patient.  This may involve removing unnecessary medications and/or adding new ones.  Most of these medications take anywhere from 2 to 6 weeks to achieve efficacy so that they can be evaluated as either being beneficial or not and if not, a new medication must be tried.  I do agree that placement after this hospitalization is the correct decision, but it may take a few weeks before your FIL is discharged from the hospital.  That's OK.  They are doing what is right and best for him.  The last thing you want is for your FIL to go into Memory Care and be evicted due to behavioral issues that could have been controlled if he were put on then right medication prior to moving into Memory Care.  

Here is detailed information on all that is involved in a Geriatric Psychiatric Evaluation:

https://www.aafp.org/afp/2011/0101/p48.html 

https://www.merckmanuals.com/professional/geriatrics/approach-to-the-geriatric-patient/evaluation-of-the-elderly-patient 


Jo C.
Posted: Saturday, April 13, 2019 8:07 AM
Joined: 12/9/2011
Posts: 9394


Hello again, I am so very sorry for what has happened and can well imagine the stress and concern everyone is feeling.  I have had such an experience with my LO.

It is difficult for families to traverse the unfamiliar Psych dynamics.  Visiting times are far more strict than on medical units.  It is important that there be a scheduled time so as not to interfere with the care needs and to not cause focus for the patient to be compromised. That was difficult for me when I first encountered it.

NOTE:  One thing I strongly recommend, is to call and ask to speak to the Psychiatric Social Worker.  Every unit has one or more of these individuals; they can be very helpful in many ways and can also assist with getting one in touch with those who can address what is happening.  When my LO was in GeroPsych, I made a new "best friend" of the SW as that cleared the way for so much and clarified matters.  Since placement is desired, this Social Work contact would best be made asap.

I would also find out if a multidisciplinary care plan meeting with family can be done; this can be very helpful, but it is good to be aware that laws governing confidentiality on a psych unit can often make things a bit more difficult. 

One can also have a note with your contact information placed on your LOs record at the nursing station asking for the psychiatrist to contact you; there should be one person who is the primary contact.  The licensed nurse on the unit can be helpful in getting access to the psychiatrist.

NOTE:  If you wish, you can also request that your LOs Neurologist come in to see him on a consultative basis.  The psychiatrist will need to write the order for that consultation, and a licensed nurse on the unit can contact Psych to get the order.

Some GeroPsych stays are very short and do end at the 72 hour involuntary admission period. Others may extend to a week or a couple of weeks.  Secondary to strict laws covering psych hospitalizations, any continued stay will have to be certified at intervals by multiple members on the unit's care team as medically necessary.   Once the person is seen as stable, discharge will the take place.  Stable does not mean perfect, so keep touch with that Social Worker.

NOTE:  You CANNOT be forced to take him back home again.  Let staff know, including the Social Worker that home is NOT an option; then discharge will take place once your LO is deemed stable, and an accepting facility is found.  The family is expected to do much of the contact with NHs or whatever type of facility will accept him and be safe for his transfer.

It does not take weeks for many of the medications to take effect, so if one is to err on the side of caution, it is best to think on the shorter end of the timing spectrum so that if the length of stay is shorter rather than longer, you are prepared.

I send you best wishes for all to go smoothly; please do let us know how you are and how things are going.

J.


 
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