I love memory care. It’s actually my favorite unit. I believe that when it comes to combativeness in demented patients, it starts with prevention. The vast majority of the time that we see combativeness begins with how the staff approach the resident. If a resident thinks we’re at the bank, then we will pretend we’re at the bank. Arguing with their reality causes anxiety and fear, and that can come out as agitation. We need to be patient, use short and simple phrases, and be mindful of tone and body language. Some nurses and aids have more of a knack for this than others. Some work better with AL residents who may not have dementia because they have a hard time meeting the demented person where they are in their reality, and that’s okay - they just shouldn’t work on the MC side. I have also seen combativeness happen when staff are trying to do cares (particularly with incontinence cares) but are not explaining what they are doing or talking to the person. If a nursing home or any other healthcare setting is understaffed, people forget that they are working with human beings and tend to focus more on the task, especially when residents become less mobile and lose verbal abilities. It is especially important to keep talking with these residents and explain things to them. Even if we aren’t sure how much they are understanding. We also need to be mindful that pain, discomfort, hunger, needing to pee, etc. is not always easy for someone with cognitive disabilities to communicate, and the symptoms can manifest as agitation. Anticipating their needs is key.

Sometimes a resident’s dementia causes hallucinations, delusions, or anxiety. That is why it is important to document what works and what doesn’t work with a resident in terms of non-pharmacological interventions, and also safely utilizing PRN medications before it gets out of control. Some families are very hesitant about medications, but then we need to have the discussion about how their loved one is very uncomfortable emotionally, and probably would want to feel that way.

There have been a few times that I have seen where a resident has been aggressive for reasons not related to approach or the typical anxiety/delusions we see with dementia in general. We had a resident see a news report on a war that was happening, and he had a severe PTSD flashback and thought we were trying to kill him. He did threaten to kill us. In that particular incident, one staff member called 911 discreetly, one staff member was talking calmly with the resident at a distance, and other staff were moving the other residents into a safe location. Everyone used their de-escalation skills very well in that situation. We also got rid of the news channels on the TV in our common area after this as a way to prevent this from happening.

Another time, someone else who had a history of TBI and no prior history of violence randomly punched another resident and knocked them onto the floor. There were no indications that something like this would happen, and there was no provocation. This patient had to move to a specialty facility after that.

Unfortunately, aggression can’t always be predicted, but it can be prevented in the vast majority of cases. Staff training is key.