by Ann Gordon, via Flickr
For the past few weeks, my family has been living a health care nightmare. My 85-year-old grandmother, physically fit and as beautiful as an old-time movie star, but suffering from the first stages of Alzheimer’s disease, had a major meltdown. Her assisted living facility called to say she was harassing the residents and staff, claiming her belongings had been stolen, shouting at people at random, and even calling the police. Clearly not equipped to handle this level of agitation, the facility turned to us to pick her up and keep her for a few days.
The week that followed proved arduous—nobody seemed to know what to do with her. Her GP was at a loss, suggested that we bring her to the ED. Her neurologist prescribed Seroquel (after having to tackle and physically restrain her from the subsequent episode of screaming and pounding her fists on the wall, we called to tell the neurologist that the pill wasn’t working; he said to give her more; four pills later, she was still mildly agitated.) This went on for over a week. She came to live with us, where we listened, exhausted, to constant chatter that didn’t make sense. The talking never stopped—her voice grew hoarse with it and she didn’t sleep. She couldn’t feed or dress herself. We tried to see a geriatric specialist. He wasn’t available, so we were passed on to his assistant, a PA, who suggested that, at 85, my grandmother had developed bipolar disorder.
We finally brought her to the ED, where she was left alone for eight hours babbling away, only for a psychiatrist to come into her room at night, after she’d finally fallen asleep, to give her Haldol. We refused to let him. The psychiatrist suggested admitting her to the psych ward, but there weren’t any beds. This meant she could be shipped anywhere in New York State. We left the ED frustrated and angry.
What were we to do? A family friend and nurse said we shouldn’t be dealing with this alone, that my grandmother needed to be “controlled.” But nobody else would deal with her. She was being passed around from physician to physician, each diagnosis more outlandish than the last. Nobody believed that despite her dementia, she wasn’t crazy. One physician even suggested perhaps she’d hidden her psychosis all these years with drink. (Problem with that diagnosis: she never drank.)
The last time a similar episode had occurred, a nurse suggested checking if my grandmother had a urinary tract infection. She’d said that these types of infections could affect the mind in older patients. She was tested and bingo, an infection was present. After a course of antibiotics, she’d recovered. This time there was no infection. But two nurses I work with, Shawn Kennedy, AJN’s interim-editor-in-chief, and clinical editor Christine Moffa, suggested several other possible causes of sudden agitation in geriatric patients: electrolyte imbalance, constipation, sepsis. After a particularly rough weekend, we brought her to a new ED. The nurses on duty immediately took charge. They ordered a scan of her abdomen and found a severe fecal impaction with resulting inflammation. They put her in a bed next to the nurses’ station to keep an eye on her. Now that she’s been treated for the underlying condition, my grandmother seems to be returning to normal, the incessant talking and agitation grinding to a halt.
I don’t know how or why geriatric patients are so affected by imbalances such as these, enough to wreak absolute mental havoc. I only know that in my experience, physicians look at an old lady with Alzheimer’s and assume that her babbling and psychotic bursts are part of the package. As an associate editor at AJN, I often come across the term “care at the bedside.” Rather than a catchphrase, this now means something to me. Thanks to some nurses who took the time to look further into my grandmother’s problem, and to actually provide care, there seems to be light at the end of the tunnel.
Wonderful post. Caring for the geriatric individual requires a change in expectations from the provider’s perspective. For instance, beginning pneumonia can also present with a change in behavior or agitation. Many geriatric patients do not mount an immediate white blood cell increase when battling an infection, thus appearing to “not be infected”, when they may have an infected gallbladder, appendicitis, or perforated colon. Then, by the time “the WBC is elevated”, which gets everyone’s attention, the patient is much sicker. Often, the change in behavior IS the presenting symptom. Thank you for this article.
Editor’s note: We appreciate all the comments on this post. One clarification: the blog post is written by Amy Collins, AJN’s associate editor, and the photo is from Flickr Creative Commons and is by Ann Gordon. Please excuse the confusion in the inital layout.
Enlightening and important.
Nice piece of work, Ms. Gordon.
This is a very important article. It’s always good for the lay person to be armed with tools to help the ones they love. I’m very grateful to have this tool in my bag. I had no idea that uti or fecal impaction could cause those kinds of symtoms.
Very important information.
Thank you.
As a student nurse who is currently learning about geriatrics and dementia vs delirium, I was very pleased to read this article. Thank you Ann Gordon for sharing your story. It makes a strong point for us all.
I have seen this happen. My mother had this problem when on chemotherapy. Delirium, confusion. My dad thought it had to be her cancer metastasizing to the brain like the doc had said it might. I come on the scene and my first question was when was her last BM (which she could not remember) and listening to her complain of pain in her upper right abdomen. Again thought to be the cancer as it had gotten to her liver too. I palpated her abdomen and noted it was not soft but hard where her pain was.
Took her to the ED and she was diagnosed with a fecal impaction. When her bowels started to move, she became her old self again.
Though not conclusive, in every case I have seen a change in cognition or behavior it was either a UTI or fecal impaction. I work in home health as a CNA and I am a nursing student.
This is an eloquent and moving testimony on the essence of nursing care. Patients do not fit into “boxes” of medical categories (elderly, dementia, Alzheimer’s). That is simply lazy health care. Every person deserves to be viewed as an interesting case, as someone who might not fit our usual snapshots of illness presentations. I implore nurses in practice to share and discuss this post with their colleagues in light of the burgeoning population of elderly patients with dementia. For a global perspective on dementia, visit Alzheimer’s Disease International at http://www.alz.co.uk/research/worldreport/.