Few years ago, while I landed as a foreign Physical therapist in the
USA, I was assigned to work in a geriatric nursing home by my employer
in the heart of Detroit,Michigan. At least for me the interior of the
nursing home was an unusual sight and frightening too. While the other
staff  walked casually besides me, I couldn't  ignore those patients
walking towards me,as I felt it was my duty to smile back and answer
them. They were in-patients who would stop and ask me repeated questions
or phrases, some meaningful & most of them delusional and hallucinative.
Some were aggressive to the point of kicking, scratching, hitting and
even spitting at me. Looking at them during my brief encounter, I had
absolutely no knowledge as to what to say & what not to say. I would
stand there blank minded and struggle with all my fresh Indian accent
and pity myself with the poor outcome. Sometimes I even wondered who
exactly lost their minds in that crowd !

It took months to learn a little  about Alzheimer's disease and it's
dementia. As I learnt I realised that almost every single nursing home
in the United States  would present such a scenario.This article aims to
analyse the key issues binding the agitation and aggression of demented
patients, primarily the Alzheimer's kind, as it is the most common form
of mental degeneration , described as the " Mind Robber" affecting more
than 4 million of the US population.

Agitation is the most common precipitant of a nursing home
admission.Examples of Physical agitation are Pacing, Wandering,
repeating apparently meaningless gestures, clenched fists, etc. Verbal
agitation includes screaming, complaining, crying, repeated questions,
etc. Aggression is a violent form of agitation which may include verbal
ones such as threats, accusations, cursing and obscenities.Physical
forms of  aggression include scratching, pinching, biting, hitting ,
spitting and kicking.

It took several months of experience to learn to not take these
accusations personally.  It was several months ago in a nursing home of
Wayland, Michigan, there was this elderly female resident whom I had
approached to perform a wound dressing. To my outrage, she said " Dont
touch me. I know you come from a Land of Sin ". The same woman was nicer
when I had brought a PTA who re-assured and calmed her to explain that
this "sinner" is actually a clinician.

Any frustrating situation to a patient  can lead to agitation. ex: when
he or she can't get dressed.. In nursing homes, sometimes this behavior
is re-inforced by the staff, when they provide extra attention. Some
even misbehave to get this  special attention .

Wandering is yet another physical agitation which puts every staff in
action as they spring on their feet once in every hour. As per
healthcare guidelines, nursing homes are prohibited to use physical
restraints without a potential cause.Observational studies reveal that
use of restraints does not decrease agitation in any means.The level of
agitation is either the same or more. I have known a variety of
residents who wander aimlessly. They range from those who shuttle the
whole nursing home block numerous times to the ones that leave the
nursing home out to the bushes and surrounding yard. Often the staff
have a little fun in ending this " hide & seek " game as they also get a
chance to go out  for a breath of fresh air. Rarely this type of
situation has turned out to be tragic as I had worked in one facility,
where a wandering female resident left the nursing home late night
crossed the road and got killed by a speeding motor vehicle.

Nursing homes generally operate activities to keep these demented
population busy. Some have special designated areas for them to confine
their wandering.Some nursing homes have a   "Walk me" programme where
caregivers & volunteers spend some time  in walking and talking to these
residents which is a proven benefit. Other measures include putting stop
signs on a door, tying ribbon across a door, placing personal and bed
alarms ,etc.

Physical therapists require  a great deal of understanding of  treatment
strategies in dealing agitation  and combative behavior. This difficult
task of having an agitative patient comply to  treatment is only by
considering what internal and external stimuli preceded,accompanied and
followed  the behavior.  Verbal agitation and aggression may be handled
by 1)  Remaining calm.2) Giving one direction at a time.3) Speaking and
moving slowly & calmly.4) Moving the patient to a quiter environment 5)
To explore what the patient is really seeking 6) Face the patient on the
patient's level and avoid speaking loud as the sensory and cognitive
impairments complicate and compromise the patient's ability to
understand. 8) Be clear about what kind of behavior to expect.9) Be
brief and concrete and reward good behavior.10) Use "please" and
"thankyou " often.

Physical agitation may require the following 1) Re-direct .Use silence
to help diffuse the patient's anxiety.2) Use nonthreatening body
language with a soft voice. 3) Use supportive words to comfort the
patient . Physical aggression requires reduction of overstimulation from
the environment Knowledge of patient's past aggressive behavior helps
for predicting the future behavior. ( Courtesy : The Brown University
GeroPsych report )

For all of us who claim to be normal , the truth is that "  it is we who
confuse our minds often in our daily life ". But  it's the opposite for
an Alzheimer's patient. " It is the mind which confuses them ."  "
KINDNESS AND CARE IS ALL THEY NEED " Let's give it in abundance.

Raveendran Thangavel PT
Rochester, NY.