Course content – PFLEGE-16
9. Module 8 · Dealing with specific situations
9.3. Case, consolidation & transfer
Two cases and what to take away
The delirium that was recognised
Mrs K. (dementia, otherwise calm) suddenly becomes severely confused and restless over two days and has new hallucinations. The team could think ‘the dementia is getting worse’. An experienced carer recognises the sudden deterioration as suggestive of delirium and looks for the cause: Mrs K. has cloudy urine and a slight fever – a urinary tract infection. The carer reports it; the doctor treats the infection, and Mrs K.’s acute confusion resolves. The case shows how recognising delirium (instead of accepting it as ‘dementia’) uncovers a treatable cause – distinguishing dementia from delirium is vital.
Mr Nowak and the thief
Mr Nowak (fictitious), 80, has had dementia for four years. For several weeks he has told staff that a night carer takes his watch and money. He becomes loud and refuses care from that carer. A colleague says he is “paranoid”, another suggests that a doctor should “calm him down”. Tamara (fictitious), a carer, sits with him in the afternoon. She says, “It is awful to lose things. Shall we look together?” They search the wardrobe, and the watch is in a slipper. Mr Nowak is relieved, then angry. Tamara responds, “I understand, it frightened you.” The team agrees that the watch has its place in a box with a lid, labelled with a photograph, and that the night carer will not be the one to look for it. The son brings a spare watch. The accusations become rarer. The team also asks the doctor to review Mr Nowak because the change is persistent and may have physical causes, such as pain, a sensory problem or infection.
Analysis. (1) The accusation expressed loss of control, not malice (Figure 8.2). (2) Arguing would have confirmed his mistrust. (3) Searching together and giving the watch a fixed home addressed both the feeling and the object. (4) The carer who was accused was protected from taking it personally. (5) The team did not treat the behaviour as only “dementia”: a long-lasting or worsening change deserves a medical review (Figure 8.1). (6) Medication was not the starting point; any such decision belongs to the doctor, after review and with the legal custodian or the person, as appropriate.
What is the first question when behaviour changes?
How do you respond to a delusion of theft?
Why is delirium dangerous in dementia?
What comes first in an aggressive moment?
How can you respond to exit-seeking without restriction?
What does section 240 StGB say about coercion?
Key messages
- Behind exit-seeking, aggression and delusions there is almost always a need, a fear or a cause.
- Do not argue with a delusion. Acknowledge the feeling and offer safety and a search.
- In an aggressive moment, protect yourself and others first, then look for the cause.
- Sudden confusion is a warning sign. Think of delirium and tell the doctor or the nurse in charge.
- Walk with the person instead of blocking the way, and offer a safe alternative.
- In Germany, coercion and long-term deprivation of liberty are strictly regulated (sections 240 StGB and 1831 BGB).
- Which situation in this module do you find hardest, and what do you feel in your body when it occurs?
- When did you last correct a person with dementia, and how might you have responded to the feeling instead?
- Who would you tell if you saw a sudden change in someone, and have you ever hesitated to do so?
- ☐ I ask whether a change is sudden or slow, and I report a sudden one at once.
- ☐ I look for the need behind walking, shouting or accusing.
- ☐ I respond to the feeling and do not argue about facts.
- ☐ I keep distance and an escape route when someone is aggressive, and I call for help.
- ☐ I record triggers and what helped, and I share them in the team.
Exercise: Choose a difficult situation (exit-seeking, delusion, aggression) in your area. How could you understand the need/cause and respond with dignity? Commit this to memory: with a sudden deterioration, think of delirium and have it investigated!