Mrs. Smith kept getting up during her meals. The nurse decided she wasn’t eating enough of her meals and contacted the doctor to get her some Ativan. That way she’d stay in her seat and get her to eat at least
75% of her meals. Good idea, right?
Mrs. Smith fell. Then she kept falling. Then she couldn’t stay awake for her meals. Then she aspirated
enough to require speech therapy for a swallowing problem she didn’t have before she got the Ativan.
This happened. I didn’t make this up.
The nurse defended the choice to change her meds because “She needed to eat.” Then she said, “she
was driving me crazy because she just wouldn’t stay in her chair and I couldn’t keep track of her. She
needs to eat.”
Does this sound like a chemical restraint?
The initial motivation was good, but it resulted in injury and didn’t solve the problem of Mrs. Smith not eating enough. It had the opposite effect.
The Physical Therapy Assistant who was treating this patient was incensed (I love our therapists and
assistants who get incensed because they care.) She tactfully reminded the nurse that a resident who
gets up a lot during a meal gets up for a reason.
Does she have to use the bathroom?
Does she remember something (real or not) that she had to do?
Is she having pain? (remember our dementia residents may express pain differently than others)
Instead of Ativan, someone could have offered to take Mrs. Smith for a walk. If she wants to walk, go with her and see where she’s heading. If she’s heading to the bathroom, she needs a new toileting program to change her schedule and keep her at her meals.
Is she heading to the door because she thinks she has to go to work? Talk to her about her job and whether she can have lunch first and then head to work. Simple, right? But this works every time.
As she’s walking, is she limping? Is she grabbing the hall rails? Ask her if she hurts, and get her something for pain. Those who are constantly in motion are going to have hip, knee, ankle, and foot pain.
Sometimes I wonder if what we’re calling “sundowning” is actually the result of pain after putting in 10,000-plus steps per day.
I know that all of these interventions take time away from overseeing the dining room. It’s important to acknowledge the value of that time that it takes to walk with Mrs. Smith and understand why she won’t sit and eat.
But medicating for agitation without attempting to understand the cause of the agitation will result in physical, psychosocial, and emotional issues. It may result in falls. It may result in falls with injury.
As we know, a fall with injury in a geriatric resident has a 60% higher rate of mortality within one year. We see it all the time, and we frequently know that that hip fracture may be the end of the line.
Let’s use all the tools in our toolbox, and look past medication to see how we can decrease agitations without compromising the health of our residents.
Jean Wendland Porter, PT, CCI, WCC, CKTP, CDP, TWD is the Regional Director of Therapy Operations at Diversified Health Partners in Ohio.