How to help husband that has become combative in memory care?

Bring him home if you can.

J, any update on how it is going for your husband in his memory care? Combativeness in these situations is such a problem. Often it comes down to a good neuro-psyc consult and that often ends in various medication cocktails to try out. This is difficult for memory care, especially when a lot of facilities are now dealing with Covid-19. Problem with med cocktails is that it is difficult to find that magic formula that keeps a pt. medicated, but not over medicated and asleep in the chair 24/7. Certain dementias have more episodes of acting out than others. I would certainly caution you against any attempt to bring your husband home. If this facility cannot accommodate your husband they and the Social Workers they have access to will have to find other placement; this is something that would be nearly impossible for you to do.
Hoping to hear any update from you and wishing you well. You're in our thoughts.

NHWM

To answer your question, Yes, I always recommend people to care for their LO in their home.

You can best believe if it were "left up to me", I would bring my husband's brother home "in a heartbeat." However, it is not left up to me, "it's left up to my husband."

I "LOVE CARING FOR PEOPLE," for that reason I "BEG" my husband to let me care for his brother but "HE THINKS" (not what I think) I am caring for too many already.

I don't understand why this facility doesn't already know what to do for patients like this. that is their job.  Unless the family does NOT want any medicines to be given, then there probably isn't much they can do.  However, there are meds that can be put in applesauce, pudding, etc that will help him to stay calm.  Facilities are not allowed to restrain them due to law.  Have you asked why they haven't given him some medications to help calm him?  It sounds like they just don't want to be bothered, which is not good for anyone.  Wishing you luck

JMarie: I did see your update. Prayers sent.

Hi find out how his hydration is. My dad would become agitated if he was dehydrated. The first time this happened he had to be hospitalized at my insistence. The doctor was leaving him get worse and not giving him more fluids
Another thing is that the staff forces themselves on them and doesn’t
give them time to understand what they’re doing and then take it personally when they become combative.
I used to ask them to please not start trying to give him care when he got like that since it would only get worse. Leave and come back later.
Like some commented in snigger post , they act like this never happened before.
Sedatives should only be low doses and done carefully with medication he’s on. This can lead to more problems if he’s drowsy and doesn’t eat and interact normally.
Best to you

Talk to the charge nurse to find out WHEN he is being combative and if it is with all staff or just select people. This will help you to identify if he is scared/anxious, seeing a "type of person" as somebody he disliked from his past, if staff is "rushing him" or not explaining while doing. or Sundowner's Syndrome. After figuring out the cause of the problem (besides he has Alzheimer's disease), then you can decide on solutions with the help of charge nurse, administration, and his doctor.

FYI - in LTC facilities. the majority of care is performed by CNAs who have six months of training to provide safe care but not a lot of education about disease processes. Most of the nurses to care for the clients are are LPN/LVNs who can administer medications and treatments but do not have a lot of training in problem solving for different patient diseases/conditions. Usually the chief nurse and assistant chief of nursing are RNs who can do all that CNAs and LPN/LYNs can do AND are trained in problem identification and resolution. Unfortunately, they do not get to interact with all the clients regularly to identify problems early and recommend solutions.

So contacting the RN is the lowest level to resolve most of your problems. He/She will need to contact the LPN/LVNs and CNAs who care for a client to be able to implement changes in care.

Right now, things must be horrible for residents and skilled staff. I almost lost my husband last week. He was in the hospital for a sharp pain below his collar bone, we figured a pinched nerve by the excruciating pain he was having. 911 took him and they tested him for Covid, he was positive...lung infection was causing the pain. Fast forward a week and he was discharged to the BEST rehab center on the Covid floor. I have not seen him, spoke a few times on the phone. The last time a nurse came in and he was begging her to help him, said he felt like he was sliding off the bed and that he was dying here with no help...I heard her say, she would be back in a minute...he replyed NO, I need help now!! He was very agitated and angrier than Ive ever heard his tone. He was telling me they would bring his urinal and sit it down, or his food tray and sit it down...he’s blind and was so lost in that room and was terrified in his situation. I went that day and picked him up...he was only there two days for rehab...when I got there they had me sign a AMA form and wheeled him to the curb...said they needed the wheelchair but would not help me walk him down the curb and into the car. His back was covered in feces and his face was hallow with dark circles around his blind eyes. He was totally unaware of what was happening and couldn’t hold his legs under him to bear weight. A week and two days ago he was walking pretty good without a walker at home. I physically lifted him and put him in the car by myself! A week later at home...he is wearing Depends because he still can’t walk good enough with a walker to go to bathroom, he sleeps almost all the time and complains of a sharp pain in his stomach but won’t let me call 911. His doctor nurses and therapists make home visits and they are all sad at how far he has declined in such a short time. My prayers are with you... Go get him if you must. My best friend would be dead right now if I hadn’t. (((Hugs)))

The only time my father became agitated and upset was when he was afraid or having hallucinations. I would guess that the staff in trying to get their work done are rushing him in the process. He doesn’t understand what they are trying to do, therefore he gets upset and becomes combative with them. While meds may help this what really needs to be done is for them to slow down in their approach to him and what needs to be done.

INatalie a camera in his room and see what really is going on because you never know.

Speak with his Dr about it but there are always meds to give a person but that doesn't mean it's good for them

Why can't the administrator or charge nurse call his doctor and ask for anti anxiety meds?? Why do the always act like they have no idea how to treat this? Luke they have never seen this before and don't know what to do. Ive heard about this over and over. Then threaten the family the person must leave. As if they can control the resident.
All they have to do is say he is getting combative so we have to adjust his meds to keep him calm and everyone safe.
Instead they turn it into a very distressing situation for the family.
Someone needs to pick up the phone and call the doc. I believe they have a doc at the home on call. I dont know why they have to turn this into a catastrophic event. So the family will have to call the doc and say his meds need to be adjusted. That is done to keep him free from distress and anguish. He's not happy either. Its not that hard of a fix.

Yes, there are meds for him. Speak with his doctor. My dad was very difficult and down right mean until I talked with his doctor and got him on his "bedtime pill". He asks what it is and that is what I say. The meds help him sleep through the night too. Talk to his doctor soon.

My Dad has Alzheimer’s, is wheelchair bound and can still talk, though he doesn’t always make sense. He’s in an apt. with 24/7 care. Lately he’s been sundowning and becoming verbally and sometimes physically aggressive. He threatens to hit someone or swats at them. His hospice nurse has him take Ativan at bedtime and another dose 4 hours later. It’s helping. I’ve asked his cg to gently rub his shoulders and talk with him about whatever is going on. Remind him he’s safe, they’re there together and they’re ok.Touch works as well or better than Ativan. This is a new problem for us and we’re only a month into this, but it seems to be helping. Good luck and am praying for you. This is tough- esp. with Covid keeping lo out.

When my Husband was on Hospice I asked the CNA about things like this (just in case this happened) She told me that often with patients that experienced pain when being moved they would pre medicate them so that they would be in less pain, or no pain when the CNA would begin her duties.
I always made a practice of telling my Husband what I was doing or going to do BEFORE I did anything and I would talk to him throughout the task. For example when I was going to move him I would tell him I was going to move him over to the other side of the bed, then I was going to take his arm and bring it over his chest to the other side of the bed and I wanted him to hold onto the bed rail....and on it would go so he knew what I was doing. I never had a problem with him resisting me or the Hospice staff.

Are the caregivers talking to him or do they just come into the room, grab the gait belt and hoist him up? Maybe if he knew what they were going to do, where they were going to put him he would be more cooperative.
My guess is 2 of them come in and they are talking to each other about what they did last night, about a movie they saw and they are not talking to him or treating him as a PERSON but an object to move, like you would move a dresser or table.
If talking to him and explaining what they are doing does not work then pre medicating him might.

Thank you for all your responses and I am reading thru them all. One thing I should clarify is that he is not violent, he is resistant when the MC staff is trying to do care and "bucks" his body when they are lifting him to the bed or to the wheelchair. He can not verbally express his pain or discomfort and I have talked to his doctor about this and she will be trying some pain medicine to see if that makes a difference since he does experience back pain at times. Also due to Covid I can not be in his room or see him in person for more than 3o mins once or twice a week which is heartbreaking. My husband is now under hospice care so maybe the addition of the hospice nurse can help with this. Thank you.

The OP's husband can't get out of his wheelchair without assistance - he becomes combative when the staff attempt to transfer him.

If there is a silver lining, it's that it makes the threat he poses to other residents really very limited indeed.

I would like to assume that the staff are establishing full communication with him before they move his wheelchair and again before they begin the transfer process. Normally, one would place oneself on a level with the person - at a distance, because we're all maintaining distance anyway - make eye contact, engage, and wait for the person's response. One then explains what is about to happen (this can be difficult when the person is very deaf and you are wearing a mask, but you have to Find A Way).

You do NOT, for example, cheerfully wheel somebody off in his wheelchair and manhandle him into bed without so much as a by-your-leave.

I am pretty sure they wouldn't be doing anything of that kind, of course.

I recently read an article about the importance of physical contact for dementia patients, especially if they can’t talk. Spouse laying in bed with him, holding him, rubbing his back, brushing hair, lotion on hands, etc. Basically, showing them love. The article said it can change their behavior for the better and made a good case for it. Look at how babies will fail to thrive if they aren’t held and talked to. Same with us at any age!

Ask social services in his facility to recommend a psychiatrist that will be qualified to manage aggressive behavior.

There are several medications that can reduce negative behaviors without being too sedating.

If his facility has no psychiatrist on staff, ask for their recommendation for an independent practitioner. His insurance should cover the work up and prescription.

This is so sad. You can’t care for him at home. You are relying on their expert care.

I can’t imagine how frustrating this is for you and your husband.

Have they said if they will consult with others about his situation since they are not able to resolve these issues?

It’s disturbing to read about these situations because this could potentially happen to anyone that is a resident in a memory care facility.

It really does boil down to having the proper staff on premises to address the concerns of it’s residents.

Please keep us posted and I hope that his facility will find a viable solution so you won’t be faced with finding another place for him.

Having said that, violence is never acceptable anywhere and has to somehow be managed so all staff members and other residents can be in a safe atmosphere.

My godmother was a fighter at her facility. She had ALZ, plus macular degeneration and was blind. I am sure she was scared and would fight the staff throughout the day and night.

A Memory Care ALF, or any other residential care community where elders live, has to be safe for EVERYONE. If a resident becomes violent and cannot be controlled with medication, then he or she presents a problem to ALL of the residents *and caregivers* who can be harmed as a result of their behavior. This is common sense. Anyone saying that a facility 'should know' how to handle violent residents does not understand that community safety is, and SHOULD BE, their top priority, and should go work inside one of these ALFs to see what life is all about inside one. When a violent resident hits another person, the police is called; the victim's POA then has the right to file a complaint against the violent resident or not. So, you can see how such situations can get out of hand in a hurry and present problems for innocent residents who deserve to live in peace.

That said, your DHs Memory Care facility does have the right to ask him to leave for combative behavior if they are unable to keep him calm. His doctor is the one you would need to speak to about possible medications to calm his agitation...........if the doctor prescribes him something, THEN the caregivers at his MC can dispense it directly to him. It can be a trial and error type of thing with different meds and trying different doses before hitting on the right one.

Wishing you the best of luck getting this all sorted out.

That's a tough situation. I'd explore a few things, including those that others have posted here. I'd also explore why he's getting that way when being transferred to bed. Can they do some detective work? Does he have pain that he's expressing? Are they touching him somewhere that is painful? Is the bed uncomfortable and he doesn't want to get into it? I'd also find a geriatric psychiatrist to see if medication could help. Is he a hospice candidate? Hospice nurses are trained in detecting pain in nonverbal patients. Also, in my state there are a few long term facilities designated for people with dementia who are have behavior issues. I'd explore that, in addition to asking the MC he's in now to find him a place. I think they have some duty to assist in finding new place for him. You can also contact the Ombudsman for that facility. Most states require long term care facilities to have one. It is usually posted on the wall at the facility. Not sure if you have access to get in, due to covid, but, the facility may be able to provide the name and phone number OR the state regulating agency for long term care facilities. You might also have an attorney review your contract and options. I hope you can find some help.

I'm sorry you and your husband are going thru this. A major question the family fails to ask when placing a LO in a care facility is “What is your discharge policy?”. That is, under what circumstances would you discharge a resident? Your story strikes a nerve with me. It is a shame when MC facilities cannot properly address residents behavior. The problem? Training! These are dementia facilities for God's sake. Does the staff not expect combative, resistive and standoffish behavior? The problem is not with your husband but with the facility. The first line caregivers (usually nurses aides) are typically trained by watching a 4 hr video and told to “have at it”. They should at the very least spend a week viewing Teepa Snow videos and have hands on training. It is rare to find a staff person certified in dementia care. The resident care mgr in my wife's facility was fired for being “too close” to the residents. She was the only one in the facility certified in dementia care and training. My wife was combative to the extent of trashing family pictures, tearing the thermostat off the wall and damaging the Venetian blinds. With the families OK she spent 12 days in a psychiatric ward to address her behavior. Returned to MC a different person where she spent her remaining 14 months.

Does the staff know what triggers his behavior? Much of the LOs behavior is a reaction to the caregiver's actions. Many states are addressing caregiver training thru legislation. I hope yours is one.

I am sorry you are going through this.

Memory Care Unit's are suppose to be specialized in caring for people with behavior issues.

Sadly they are not.

My LO has been dumped here and there by facilities bc they don't know how to care for him.

Hope you get some answers. So sorry

There are several techniques, but the right one to use depends so much on what *exactly* happens when they try to transfer him that it's impossible to guess what might work best for him.

But I can't help thinking - for heaven's sake! This is a specialist memory care facility, yes? If they aren't already using a range of different approaches to reassure and help him, what are they for???

Are you able to visit your husband, or are you only hearing about this over the phone? It must be terribly worrying for you, either way; I just wondered if you would be able to say when he began to do this, whether it's with any particular individuals or with everyone, whether they've checked for possible problems such as pressure sores or overgrown toenails which might be hurting him and making him afraid to be mobilised...

It's so hard to know when you're not right there, is the thing.

Medicating him to make him more compliant would be an ethical no-no, at least until everything else has been given a fair trial. It would also probably make him even less able to mobilise.