Course content – PFLEGE-16
The modules of this course – work through them in order.
9. Module 8 · Dealing with specific situations
9.1. In depth: delusions, delirium, aggression and exit-seeking
Delusions, delirium, aggression and exit-seeking
Specific situations
| Situation | Approach |
|---|---|
| Exit-seeking | Understand the need, safe movement |
| Aggression | Cause (pain!), de-escalate |
| Delusion/hallucination | Do not argue, take feelings seriously, distract |
| Night-time restlessness | Rhythm, causes, safety |
Do not confuse delirium with dementia
An important, often overlooked distinction is the one between dementia and delirium (acute confusion). Whereas dementia is a chronic, slowly progressive illness, delirium is an acute, suddenly occurring state of confusion, usually with a treatable cause (infection – e.g. urinary tract infection, pneumonia; dehydration; medication/side effects; pain; metabolic disturbance such as hypoglycaemia – Course 13; after surgery; and others). The insidious thing: people with dementia are particularly susceptible to delirium, and delirium is easily overlooked in them (people think ‘the dementia is getting worse’). But that is a dangerous mistake: delirium is a medical emergency with a treatable cause that must be found and treated (otherwise it can become life-threatening). The decisive distinguishing feature is the time course: a sudden deterioration/confusion (over hours/days) in a person with dementia is suggestive of delirium and must be investigated – in contrast to the slowly progressive deterioration of the dementia itself. Other signs of delirium: fluctuating attention, altered consciousness (drowsy or hyperactive), new/increased hallucinations, disturbed sleep–wake rhythm. For care staff the rule is important (also from Course 10): with a sudden deterioration/confusion in a person with dementia, do not simply assume ‘the dementia’, but think of delirium, look for a treatable cause (infection? dehydration? pain? new medication? hypoglycaemia?) and inform the doctor. This vigilance can save lives, because delirium that is recognised and treated in time usually resolves, whereas delirium that is overlooked becomes dangerous. Distinguishing dementia from delirium is thus a key competence that links the dementia course with clinical observation (Course 10).
Remember: sudden confusion is always a warning sign whose cause must be sought – also (and especially) in people with dementia.
Hallucinations and delusions: what to say
A hallucination is a perception without an outside source, such as seeing a person who is not there. A delusion is a fixed belief that does not fit the facts, such as the belief that a carer is stealing. Both feel completely real to the person. The aim is neither to confirm nor to dispute. It is to acknowledge the feeling, to offer safety and to change the situation around the person. Figure 8.2 contrasts typical responses to an accusation of theft. Acknowledging a feeling is not lying: “That sounds frightening” is true whatever the person has seen.
Note what the right-hand column has in common. Each response keeps the person’s dignity, offers an action and avoids a debate about facts. If a hallucination is not frightening, you can leave it alone. If the person is afraid, you can say what you are doing to help, such as switching on a light or sitting close. If the content of the delusion is the same every day, such as a missing purse, a “safe place” for the valuables and a note of what is where can help.
Aggression: protect, then understand
Aggression in dementia is usually a reaction to fear, pain, being overwhelmed or being cornered. In the moment, your own safety and that of others comes first. Keep an escape route behind you, avoid standing in a doorway that blocks the other person, keep your hands visible, speak slowly in a low tone, give space and do not argue or touch without warning. If you are in danger, step back and call for help. After the situation has calmed, look for the cause: pain, thirst, toilet, noise, a stranger, an intrusive task. Report the incident according to your organisation’s procedure, and note triggers and what helped. This is a team task, and nobody should be alone with an escalating situation.
Exit-seeking and walking with purpose
People walk for many reasons: a need to move, a search for a person or place, a habit from working life, boredom, pain or restlessness, or an attempt to escape an unpleasant situation. Many of these reasons can be addressed without any restriction. The goal is to turn a risky walk into a safe one. Accompany the person for a stretch, ask where they are going and listen to the answer, and then offer something that honours the intention, such as a walk in the garden loop, a task (“I need to check the shopping list”) or a cup of coffee. Where there is a real risk of leaving the building, the team agrees on a plan: who can notice, how the person is brought back, what the person wears and what information is on hand if they go missing. Do not make promises you cannot keep, and do not tell untruths that you will have to defend later.
Night-time restlessness and sundowning
Restlessness in the late afternoon and at night often has several causes working together: a disturbed body clock, too little daylight and activity during the day, pain, a full bladder, hunger, noise at night and a room that is unfamiliar in the dark. Review the day as well as the night. More daylight, a walk after lunch, a calming evening routine, a warm drink, and a quiet room with a low orientation light often help (Modules 6 and 7). Sleeping tablets are a medical decision, not a care routine, and are not part of this course.
Who decides what in your setting?
- Section 240 of the Criminal Code (StGB), the offence of coercion (Nötigung), punishes using force or a threat of serious harm to make another person do, accept or omit something unlawfully (Bundesministerium der Justiz, n.d.-a). Forcing a person to be washed, to stay in a room or to take something is not a legitimate response to resistance in care.
- Section 1831 of the German Civil Code (BGB) governs deprivation of liberty in accommodation and in facilities. Paragraph 4 applies where a person in a hospital, care home or similar facility is deprived of liberty over a longer period or regularly, for instance through mechanical devices or medication. These measures need the approval of the custodianship court (Betreuungsgericht) in line with the section (Bundesministerium der Justiz, n.d.-b). Short-term emergency situations are handled through your organisation’s procedures and with the doctor. This course does not give legal advice for individual cases.
- Section 14 of the Social Code Book XI (SGB XI), the law on social long-term care insurance, lists behaviour and psychological problems among the six areas used to describe the need for care. They include night-time restlessness, aggression, resisting care, delusions and anxiety (Bundesministerium der Justiz, n.d.-c). Careful records therefore also support the person’s access to the right level of care.
- If location devices or cameras are considered for a person who walks out, GDPR Article 5(1)(c) requires that personal data are limited to what is necessary (European Union, 2016). This is a question for management and the data protection officer, together with the person’s legal custodian (rechtliche Betreuung) where there is one.