Q: I have a patient with dementia who falls frequently. He can ambulate with the assistance of two people and propel himself in a wheelchair using his feet. He is taken to the bathroom regularly. He will transfer himself from a bed to a wheelchair, from a bed to ambulate, and from a wheelchair to a regular chair, but he states no purpose. He is offered snacks and activities, which he will remain at for only a few minutes. We have tried tab and seat belt alarms—both of which he will turn off or take off. He does not complain of hunger or pain and we offer him food and pain medication. He has not yet been injured, but he has had as many as five falls in one day. What else can we try?
A: Very often the answer to why someone does something lies in his or her social history. For example, if this patient was a busy carpenter or plumber during his working years, he may feel the elemental need to move. Although he is offered an activity, it might not be one that makes sense to him. Try something reflective of his occupation that he is capable of doing, such as using a small wrench to loosen a bolt or hammering a large nail. If he was an office worker, he might appreciate a clipboard or a keyboard. Even with dementia, people look for purpose in life. The hope is that you can find his personal reality and figure out what it is that he feels he needs to be doing.
Keep a log and record what time of day his behavior is the worst. Generally, there is a pattern to the behavior. It may appear random at first, but keep track for a few days and see. A sense of urgency to get up and get going may be associated with old habits (e.g., getting up and going to work or taking the children to school). See if the time log correlates with facts from his social history. Family members can be helpful if a social history doesn’t exist in the medical record. If this behavior occurs later in the day, it may be associated with sundowning. If you can determine a correlation and provide an appropriate activity at those times, the propensity to get up can be reduced.
Hydration may also be a concern. Individuals at this stage of dementia may feel thirst but not be able to express it. Sequencing how to perform the task of drinking may be another problem. Straws or specially-made sippy cups can be helpful. You can determine hydration status with a simple urine dip by looking at the specific gravity and concentration (dark color) of his urine.
Also, look at his medications. The side effects of certain drugs may cause him to be restless.
Finally, consult a physical therapist (PT) for ideas for safety. From a risk perspective this is a wise move. While the patient can’t cognitively respond to therapy in the traditional sense, the PT can suggest safe ways for the patient to move and devices to help prevent fall-related injuries, such as hip protectors. If all else fails, in the interest of safety you may elect to get a companion for him during peak problem hours.
—Sandra Petersen, DNP, APRN, GNP-BC, program track administrator and assistant professor at the University of Texas Medical Branch School of Nursing in Galveston and Carole Eldridge, DNP, RN, NEA-BC, dean, campus director, and associate professor at St. John’s College of Nursing and Health Sciences at Southwest Baptist University in Springfield, MO