Caring for Patients With Dementia in the Acute Care Environment

Rose M. McCloskey, RN, MN


Geriatr Nurs. 2004;25(3) 

In This Article

PLST Model

According to the model, patients with dementia experience difficulties receiving, processing, and responding to environmental stimuli. These difficulties are the direct result of the progressive deterioration in cognitive, affective, and functional abilities that accompany dementia. The model asserts that individuals with dementia exhibit behavior that can be described as baseline for the individual, anxious, or dysfunctional. The behavior demonstrated at any given time varies and depends on perceived environmental stimuli and stage of the disease.

For example, baseline behavior is generally a calm state where the individual is capable of functioning within the limits of any cognitive impairment. Anxious behavior, such as avoidance, may develop when the individual feels stress or perceives a loss of control. If the anxious behavior continues, or if excessive stimuli are present, dysfunctional behaviors such as aggression or verbal outbursts can result.[6] Similarly, when demands on the individual are removed or adjusted to a level at which he or she can adapt and cope, functional behavior is likely to occur.

According to Gerdner, Buckwalter, and Reed,[7] six main groups of stressors negatively affect individuals with dementia and may accelerate the transition from baseline to anxious and dysfunctional behavioral states. These groups include fatigue; changes in routine, environment, or caregiver; demands that exceed functional capacity; multiple and competing stimuli; affective responses to perceptions of loss, including anger; and physical stressors, such as pain or medications. These stressors cause the individual to become anxious or stressed and may trigger dysfunctional behaviors. Over time as the disease progresses, the individual's ability to cope and adjust to these stressors may progressively diminish. As a result, baseline functioning behaviors decrease while disruptive behaviors increase, reflecting a decreased ability to adapt and understand stimuli.[7] Interventions that decrease environmental stimuli and individual stressors will reduce stress and promote appropriate behavior.[6,7]

In the acute care setting patients are exposed to environments they are not familiar with. These environments are busy and noisy. The constant sound of telephones and call bells, overhead announcements, equipment being moved, other patients, visitors, health care professionals talking back and forth, and numerous unfamiliar staff can all be very overwhelming for the patient. Patients also are exposed to changes in daily routines and social milieu and periods of activity fluctuating between overstimulation and sensory deprivation. The patient with dementia may have a difficult time adapting to this environment and experience significant stress. This stress may be exhibited as behavior that is disruptive or challenging for the acute care nurse. Nurses, who are very familiar with the hospital environment, may not even be aware of the excessive stimuli the patient is receiving.

Careful assessment of the patient's environment may help identify factors that contribute to his or her stress and need to be modified for future care. Lack of understanding of behavioral outbursts in this population may lead to inappropriate care and frustration for both the patient and nursing staff. For example, physical restraints continue to be used in acute care despite the overwhelming evidence of their negative consequences, which include increases in nursing workload and patient mortality.[4,8,9] Too frequently, nurses apply restraints while keeping the patient in a highly stimulating environment, thereby increasing the patient's stress level and placing him or her at risk for injury. Table 1 lists alternatives to physical restraints.

The PLST provides a framework for understanding patient behavior and directing patient care. Table 2 provides some specific interventions that can help the nurse minimize patient stress and provide quality care to demented patients in the acute care environment. Interventions must be individualized for each patient. Something that works with one patient may be ineffective for the next patient. Likewise, a strategy that is successful at one time may be unsuccessful the next time it is implemented.[10]

Patient Factors

Before attempting to intervene, the nurse must first rule out a physical cause for the behavior. Because patients with dementia have difficulty expressing themselves, they may be experiencing some discomfort that they are incapable of communicating. Agitation can be precipitated by an array of undiagnosed health conditions, such as pain, constipation, hypoxia, infection, drug toxicity, or renal or liver insufficiency.[11] A complete assessment, including a medication review and laboratory studies, can rule out a physical cause for the behavior.

Patients also may become agitated when their personal space—the distance required between themselves and others—is invaded.[12] Older people who are predisposed to aggression, such as patients with dementia, have a personal space that is an average of four times larger than that of those not prone to aggression. In fact, studies have demonstrated that assaults are more likely to occur when caregivers are in close proximity to patients, such as when prompting patients to eat, dress, bath, reposition, or move from one area to another.[12,13] These patients may not understand what is happening to or around them and may strike out in an attempt to protect their space or personal belongings.[12] Attempts to stop this behavior may only create further stress and escalate the agitation.[13] This reaction can be problematic in the acute care setting as staff attempt to care for patients, particularly when providing basic care or performing invasive procedures, such as caring for tubes and drains or changing dressings.

Managing these behaviors is a priority for nurses as they struggle to deliver care, facilitate patient recovery, and prevent complications, such as infection, malnutrition, and functional decline. Whenever possible, nurses can respect the patient's personal space by prompting him or her to complete the task independently using simple one-step instructions,[14] such as during bathing, feeding, or repositioning. During more complicated procedures, such as wound management or tube care, the nurse can encourage the patient to grab the bed rails instead of striking out.

Minimizing distractions can prevent excessive stimuli and prevent agitation. This can be accomplished by closing the door to the patient's room, having as few people present as possible during procedures, being organized and completing the task in a calm and efficient manner, speaking softly to the patient throughout the procedure, and explaining what is being done in simple language. Flexibility and creativity may be required to discover a strategy that helps the patient feel safe while allowing procedures to be performed efficiently. Music also has been found to be effective,[15,16,17] helping to create a soothing and relaxing environment.

The presence of tubes and drains, such as Foley catheters or intravenous lines, may be irritating and should be avoided if possible. If their use is necessary, they should be removed as soon as possible. Frequent monitoring of patients with tubes is necessary to ensure they do not pull at the tubes, disrupt treatment, and injure themselves. Nurses also can attempt to "hide" the tubes with cloths or linen or ask family members or institutional companions to sit with confused patients to distract them and prevent them from disrupting therapy.[9] Although using restraints to prevent disruption of treatment is common in the acute care setting,[4,10,18] no evidence exists to demonstrate their effectiveness in preventing disruption in treatment or maintaining the safety of patients.[8]

Given the dangers posed by the restraints themselves,[4,9,18] using them should not be an option. Restraint-free care can be achieved through an individual plan of care: knowing your patient, recognizing what precipitates stress and agitation, acknowledging the patient's right to refuse care and make choices, establishing relationships with family and other informal supports, collaborating with other health care professionals, and exercising creativity, flexibility, and patience.[4]

Environmental Factors

As previously discussed, the acute care environment, with its multiple and competing stimuli, can be very stressful for patients with dementia. These patients have limited ability to process and understand what is occurring in their environment. Nurses need to be aware of environmental cues and, when necessary, modify the environment to control the information the patient is receiving. Odors, noise, and décor contribute to the information the patient is required to process and should be included in the environmental assessment.

The impact the environment has on patient behavior may fluctuate, depending on the degree of activity occurring at any given time. Research has shown that disruptive behavior is more likely to occur during periods of high activity. A landmark study[19] identified three peak times for disruptive behavior: between 7 and 10 AM, noon and 2 PM, and 4 and 7 PM. In an acute care environment, these times represent periods of high activity: shift changes, meal times, sending and receiving patients from operating rooms, doctor rounds, and visiting hours. Understandably, placing additional demands on patients during these periods, such as by performing procedures, may perpetuate their anxiety and result in unpredictable behavior. Carefully planning activities to minimize these demands during peak periods may prevent unnecessary stress and behavioral outbursts.

Lighting in the patient's room requires careful consideration. Shadows created by dim lights may confuse and frighten patients with dementia and set off aggressive behaviors. Bright lights, such as fluorescent lights, although helpful to staff in completing assessments and making astute observations, are problematic for older adults because their eyes are sensitive and may become irritated. Lighting should be kept free of shadows and glares with low lighting restricted to sleep time.

Staff should be careful with mirrors. Patients with dementia may not recognize their own reflection and feel threatened by the person looking back at them. Similarly, reflections seen through windows may be disturbing.[20] Covering mirrors with a blanket or drawing curtains is all that is required in these situations to prevent aggression or difficult behaviors.

If the patient wanders, the environment should be modified to accommodate this behavior by removing clutter from the patient's path, such as in hospital corridors and around the patient's room. Keeping main doors closed will prevent patients from wandering away from the nursing unit. Hiding the doorknob by covering it with a cloth or towel has proven effective.[21] Patients also can be provided with opportunities to engage in purposeful, work-related activities, such as sweeping the floor, folding laundry, or "working" alongside supportive staff, if possible. Recreational therapists, if available, can be consulted to provide diversionary activities. Family or volunteers can be asked to accompany patients on walks to ensure they are safe. Attempts to restrict movement in patients who routinely wander will only frustrate and agitate them.[22,23]

Sensory deprivation is common in patients with dementia and may contribute to increased confusion and agitation.[24] Unfortunately, patients with dementia are often left alone.[2,14] This may be a coping mechanism for caregivers, particularly when patients exhibit difficult behaviors and the caregivers feel burdened. Yet research has demonstrated that demented patients are more likely to exhibit disruptive behaviors when they are unoccupied and alone.[25] For this reason, patients should not be assigned to private rooms, which can lead to feelings of isolation and loneliness and exacerbate difficult behaviors. Conversely, hospital wards may overstimulate the patient; multiple patients sharing the same room generate numerous and competing simultaneous stimuli, which may be overwhelming. Accordingly, a semi-private accommodation, where the patient shares a room with one other person, is preferable. However, Gilster et al[24] cautions that roommates must be carefully selected. Ideally, the patient should share a room with someone who can provide social interaction and is sensitive to the demented patient's level of cognition.

Caregiving Factors

Many of the day-to-day caregiving responsibilities for individuals with dementia are performed by either family or staff of long-term care settings.[26,27] Admission to a hospital often means a change in caregivers, which can be stressful in itself.[28] Nurses should actively seek input from informal caregivers to understand their usual behaviors. Involving people who are familiar with the patient in the development of an individualized plan of care will help maintain a consistent routine, maximize strengths and abilities, and identify any potential needs that may arise in the hospital.

Although it is unrealistic to expect the usual caregivers to remain with the patient at all times, they may be happy to learn that they can participate in some level of the patient's care. This assistance may be particularly helpful during the first few days of hospitalization when the patient and nursing staff are attempting to develop familiarity. Family members may be able to help keep the patient calm and reduce the sense of insecurity. Families should be asked to help maintain home routines and rituals, which are very important for people with dementia.[28] For example, if a patient does not receive medications at home until after breakfast, the nurse can modify the regimen to help maintain this routine and avoid stress and agitation. If necessary, the nurse can ask the caregiver who is responsible for the medications at home to assist the patient with scheduled oral medications. If medications are to be administered by other routes, the nurse can seek input from the caregivers regarding how best to approach the patient.

With adequate knowledge regarding dementia and agitation within this population, nurses can better respond to their patients' needs. Nurses should be open to new strategies in managing behavioral problems and be willing to share ideas among themselves. Emotional support has also been found to be helpful because demented patients can be stressful and emotionally exhausting for the nurse.[11,27,29] Research and commentary on managing this population should be posted and shared. Available resources, such as gerontologic nurse specialists, should be consulted regularly.

Patients with dementia respond better to routines and often become agitated and stressed when approached by people with whom they are not familiar. Whenever possible, patients with dementia should have consistency in care providers. Assigning casual or float staff to patients with dementia may create undue stress and perpetuate disruptive behaviors.

When possible, procedures should be performed by one health care professional. Although nursing staff frequently work in pairs to complete specific tasks, such as complex dressings or complete bed baths, patients with dementia may become overwhelmed when a number of people approach them. If more than one person is required to accomplish a specific task, it should be performed by the least number of people possible. In these cases, one staff member should approach and engage the patient before other professionals enter the room.

The attitude and manner in which the nurse approaches the patient can impact his or her response. People with dementia are extremely sensitive to the nonverbal cues of those around them and mirror their affective behavior.[23] Patients will sense a nurse's apprehension and respond negatively. Likewise, the patient may emulate the nurse's patience, calmness, and gentleness and remain relaxed.

Patients with dementia need to be spoken to directly, even if they are unable to talk back. Nurses should approach patients in a calm, slow manner, look directly at the patient when speaking, and avoid moving or walking around during conversations. When patients are approached abruptly or unexpectedly, they may become agitated and stressed. If the patient does become agitated when spoken to, it is important for staff to remain calm and repeat the sentence using the same words. If possible, bring the patient to a quiet area or remove excess stimuli during discussions or when making requests. The use of short, simple sentences and a soft tone are also effective. If a patient does not understand what was said or does not respond, it is important to repeat the sentence using exactly the same phrase. Because their thought processes may be delayed, it is important to allow ample response time before repeating the request/phrase.

Nurses should resist asking the patient for information. Questions such as, "How are you feeling today?" or "Can you tell me why you are upset?" can be overwhelming. Provide patients with information by saying, "You seem to be having a good day," or "You are upset, but I will help you." The use of memory aids, such as directions, pictures, or symbols, also can be effective when attempting to explain procedures.

Implications for Practice

In keeping with the PLST model, the nurse can minimize stressors and agitation in individuals with dementia by modifying or controlling any factors that increase stress. For example, if the patient consistently becomes agitated during a dressing change, the nurse can critically examine the circumstances surrounding the procedure. Specific questions nurses should ask themselves include: Is the procedure painful? How many people are present during the procedure? Does the discharge from the wound have a foul odor? Is the procedure being done at a time of day when a lot of activity is taking place on the nursing unit? Can family members be present during the procedure? What does the patient normally do during that time of day? What other procedures or demands have been placed on the patient before the procedure? Answers to these questions may provide an awareness of the stimuli the patient is receiving and help direct nursing care.