Course content – PFLEGE-16

9. Module 8 · Dealing with specific situations

Situations

Managing difficult situations

Certain situations are particularly challenging in dementia care. With a exit-seeking/walking with purpose (Weglauf-/Hinlauftendenz: the urge to leave/walk about), there is usually a need behind it (urge to move, searching for something/someone, wanting to go ‘to work’/‘home’ – Module 2, anxiety, restlessness): you understand the need, enable safe movement (circular routes, accompanied walks, movement activities), design the environment (Module 7), and avoid locking in/physical restraint (Module 11). With aggression (Module 4): look for the cause/need (pain!, anxiety, being overwhelmed), respond calmly and in a de-escalating way (do not confront, Course 23), provide safety, protect yourself and others. With delusions/hallucinations (the person sees/hears/believes things that are not real, e.g. ‘being robbed’, strangers in the room): do not argue/contradict (for the person it is real!), take the feelings seriously (fear, mistrust), provide safety, distract, and check for triggers (e.g. mirrors, shadows, misperception – Module 7; or a physical cause/delirium).

Other situations: night-time restlessness/disrupted day–night rhythm (daily structure, activity during the day, calm/safety at night, checking causes), ‘sundowning’ (restlessness in the evening – adapt the environment, calming rituals), resistance to care (Course 06 – familiarity, calm, no coercion, understanding the cause), eating problems (Course 07). The common denominator: understand the cause/need, respond calmly and empathetically, provide safety, no force/physical restraint.

What this module is about. Why people walk, accuse, shout or sleep badly, and a simple frame for responding with calm, safety and dignity, including the one question that can save a life: is this sudden?

What you will be able to do afterwards. You can respond to a person who heads for the door, answer a delusion without arguing, de-escalate in an aggressive moment while protecting yourself, and recognise when a sudden change needs a doctor.

Think about it first. Mrs Adler (fictitious), 82, has lived in a care home for two months. Every day at about 4 p.m. she puts on her coat, takes her handbag and heads for the front door. She says, “I must fetch the children from school.” Yesterday she shouted at a carer who stood in her way. What need could lie behind her walking? What would you say, and what would you avoid? Write down two ideas. You will compare them with Figure 8.3 and with the worked example on page 3.

Learning objectives of this module

You deal with exit-seeking, aggression, delusions and more.
You understand the need/cause behind it.
You respond calmly, in a de-escalating way that provides safety.
You avoid arguing, coercion and physical restraint.
You can respond to a person who heads for the door, using a calm, stepwise approach that offers a safe alternative (apply).
You can tell a sudden confusion that suggests delirium from a slow change, and decide whom to inform and when (apply, analyse).

Responding to delusions and mistrust

A common, distressing phenomenon is delusion – especially the delusion of theft (‘Someone has stolen/taken something from me’) or mistrust of people. For the person this belief is real and frightening – often it is an expression of loss of control (the person cannot remember where they put something and ‘explains’ its disappearance as theft) and of insecurity. The wrong approach is arguing/contradicting (‘Nobody has stolen anything from you, you have mislaid it’) – this reinforces mistrust and conflict and hurts. The right approach: take the feelings seriously and validate them (acknowledge the fear/mistrust/loss: ‘It’s annoying/worrying that you can’t find it’), provide safety and relationship (build trust), help search together (instead of contradicting, support the ‘search’ for the missing item – often the item turns up, or the person is distracted/calmed), distract and reduce triggers. It is also important to consider possible physical causes: new or increased hallucinations/delusions can also be signs of delirium (acute confusion due to infection, dehydration, medication – Course 10) and must then be investigated (do not simply accept them as ‘dementia’!). For care staff it is important to respond calmly, patiently, non-confrontationally and empathetically, to take the feelings seriously, to provide safety, and, with newly occurring/increased symptoms, to think of delirium and have it investigated by a doctor. Dealing with delusions/mistrust requires a particular amount of patience and the ability not to take it personally (the mistrust is not really directed at the carer but is an expression of the illness/insecurity).

These situations exemplify the principles of dementia care: understanding (inner world, need), validating (accepting feelings), providing safety, not confronting, considering causes (including physical ones). Those who master these principles can handle even difficult situations with dignity and effectiveness.

One frame for many situations

The situations in this module look very different, but the same four questions help in each of them. What is the person trying to do or say? What might be behind it: a need, a fear, a pain, a habit from earlier life? What is happening around the person, in the room, the time of day and the people present? And is this new, or has it been there for a while? These four questions turn a behaviour that feels like an attack into information. They also protect staff, because a carer who is looking for the meaning is less likely to take the behaviour personally.

The last question matters most. A change that comes on over hours or days is handled differently from one that has built up over months. Figure 8.1 shows the fork. It does not diagnose anything. It tells you where to look first and who to tell.

Figure 8.1: A first question when behaviour changes (general professional knowledge; not a diagnostic tool). Source: own illustration.

Read Figure 8.1 from the top. If the change is sudden, the left-hand path applies, and the next step is to report it rather than to manage it alone. If it is slow, the right-hand path leads back to the approach of Modules 4 and 7. If you are unsure which path applies, treat it as the left one and ask. A report that turns out to be unnecessary costs little, and a missed delirium can be dangerous.