Signs that something is wrong

SIGNS THAT SOMETHING IS WRONG – IMPORTANT

1) Dehydration

2) Urinary Tract Infections (UTIs)

3)  Agressive Behavior

DEHYDRATION

Water is needed throughout the day to help prevent constipation, dehydration and to plump up veins for blood drawing, I.V therapy, etc.

Dehydration can occur for many reasons in the older adult population and those with dementia.

9 Signs of Dehydration in Someone with Dementia

People with advancing dementias are vulnerable to dehydration for several reasons. Mainly, they may forget to drink or to express thirst. Dementia can also alter signals of thirst and hunger to the brain, so your loved one may not even recognize the usual physical cues that tell the rest of us to drink some water. Medications and bouts of vomiting or diarrhea can also lead to dehydration.

What to look for:

• The person feels warm to the touch.
• There’s an increase in confusion (although by late dementia, this can be hard to detect).
• Lips are cracked and dry.
• Skin is drier than usual.
• The person may complain of headache.
• Urine is dark and strong smelling.
• Eyes become sunken.
• The pulse is faster.
• Blood pressure is lower
• Decreased skin elasticity

https://www.caring.com/articles/9-signs-of-dehydration-in-someone-with-dementia

Sign of dehydration – Pinch the skin on the arm above the wrist. If the skin does not bounce back–that is a sign of dehydration.

Many older adults deliberately restrict their fluid or beverage intake if they are suffering from incontinence or are embarrassed about having to use the restroom many times a day. They also may be confused and/or suffer from dementia and not be able to remember if they’ve consumed any beverages in a given day. Also, older adults living alone at home or in nursing facilities may not have the mobility to get beverages by themselves and may be embarrassed to ask for help. What’s more, some medications may affect fluid status or intake, and healthcare professionals may be unaware that a patient’s fluid intake has declined. An older adult taking diuretic-type medication and not replacing the extra fluid lost also is at higher risk for dehydration.” – per Kelly O’Connor, RD, LDN, CDE, of Mercy Medical Center in Baltimore, http://www.todaysgeriatricmedicine.com/archive/110310p24.shtml

URINARY TRACT INFECTIONS – also known as UTIs

Agingcare.com offers excellent advice on the effects of UTIs and people with dementia:

UTIs, Dementia and Delirium: Impact and Treatment Options

Urinary tract infections in elderly people with dementia are a complex issue. The first thing to understand is elders with UTIs may have different symptoms compared to young or middle aged adults. The elderly, particularly those with dementia, may not be able to tell you about urinary burning, increased urinary urge, or lower abdominal pain that is often reported in younger adults with UTIs. Furthermore, fever might not occur in the elderly.

Sometimes, the only thing noted for urinary tract infections in the elderly is an acute change in mental status, which is known as delirium. It is important to distinguish delirium from dementia, because delirium involves a short-term mental status change (over the span of hours or days) that is caused by a potentially reversible condition (such as infections, hypoglycemia, medication side effects, etc). On the other hand, dementia represents a more chronic mental status change (over the span of months to years) that may or may not be reversible, depending on the cause (e.g. Alzheimer’s, Parkinson’s, B12 deficiency, hypothyroidism, etc).

It is possible to have UTI-induced delirium on top of preexisting dementia, and it would be characterized by a sharp decline (within hours or days) in mental status from the patient’s prior baseline mental state. Of course, in a person with dementia, it can be challenging to figure out what the baseline mental status is. To do so requires someone who is in frequent contact with the person with dementia and spends enough time to determine the baseline mental status so that delirium can be detected when it occurs. Otherwise, the elder may be presumed to have chronically altered mental status from dementia when they actually temporarily altered mental status from a UTI-induced state of delirium.

On the flip side, there is a subset of people (such as diabetics, patients with indwelling catheters, etc.) who may have chronic bacteria in the urine (bacteriuria) that generally has no visible symptoms and does not typically require antibiotic treatment. However, these people may get constantly treated for “UTI” that seems to return all the time after the short-term antibiotic course is finished.

A key distinction in determining whether altered mental status in an elder is caused by UTI is whether treating the UTI results in any improvement in mental status. This helps distinguish whether the elder is having recurring delirium from UTI versus something else (e.g. delirium due to another cause or chronic dementia.)

If the elder (with or without dementia) is getting recurrent delirium from UTIs, there are some things that can be done to minimize the recurrence of UTIs.

• Ensure good hygiene, especially if the patient suffers from urinary incontinence. Staying in a soiled diaper for too long or wiping the wrong way (in a female patient) can result in stool bacteria going up the urethra to cause a UTI.
• Make sure urinary retention or obstruction is not an issue. An elderly male may have enlarged prostate, or a diabetic may have neurological impairment of the bladder, resulting in urine stagnating in the bladder, which will eventually result in bacterial colonization (bacteriuria) and possibly UTI. This can be checked by a nurse obtaining a post-void residual, which is the amount of urine left in the bladder after urinating. Low dose antibiotics can help significantly reduce the recurrence of UTIs. What antibiotic to use depends on the situation, such as what type of bacteria are frequently recurring and what antibiotics are the bacteria already resistant to. Commonly used preventative antibiotics include Bactrim, nitrofurantoin, cephalexin, or fluoroquinolones. The limitation of the low dose antibiotic strategy is the bacteria potentially becoming resistant to the antibiotic over time. BE SURE TO CHECK THIS WITH YOUR PHYSICIAN.
• Consider topical estrogen creams for post-menopausal women. There is evidence of usefulness in this strategy by preventing vaginal dryness and positively reshaping the vaginal flora to help prevent recurrent UTI. It is not as commonly used for various reasons, but unless the elder has had breast cancer, it is a possibility to consider.
• You may have heard that drinking plenty of fluids and urinating frequently can help reduce recurring UTIs. While this can help “flush out the bladder” to help prevent UTIs (and especially useful to prevent kidney stones), liberal fluid intake may not be safe for all elderly people – especially those with one of two conditions: congestive heart failure or advanced kidney failure. In these people, drinking too much fluid can result in excess fluid buildup in the body, known as a volume overload. The extra fluid could build up in the legs and even the lungs. Furthermore, an elderly person may be too far demented to be able to drink plenty of fluids anyway. There are a number of practical considerations that could make this option impractical for the elderly patient with dementia.
• Cranberry juice is touted as a preventative measure against recurring UTIs. The jury is still out whether this actually works or not to prevent UTIs. In other words, it may or may not work, and if it does, it may just have a modest effect; but for some, it’s worth a try.
• Probiotics may help in women if they are administered vaginally (oral versions have not proven effective for UTI prevention), but the studies are limited on the use of vaginal probiotics to limit UTIs. Again, for some, it’s worth a try, but ask your doctor about this option before trying it.

The best strategy for each individual’s situation can vary, and any of these ideas should be discussed with one’s medical providers. Hopefully, this article helps give you an idea of what to talk to your (or your loved one’s) health care providers about, regarding the issue of frequent UTIs in the elderly patient with dementia.

https://www.agingcare.com/Articles/urinary-tract-infection-dementia-155344.htm

AGGRESSIVE BEHAVIOR

Aggressive behavior is one of the most upsetting and difficult symptoms of dementia.  Dealing with it can be really tricky. However, once you begin to understand the reason behind the behavior (which is often totally out of character) you can start to make sense of it and learn to respond in a way that helps to stop it.

Aggressive behavior can be either verbal, such as swearing, screaming and shouting, or physical, such as hitting, pinching, scratching, hair-pulling and biting.

It’s important to remember that aggression isn’t a universal symptom of dementia – some people will get it, and some won’t.

Causes of aggression

1. physical discomfort
   2. the environment
   3. social issues
   4. psychological problems

Physical discomfort

If the person you’re caring for is ill or in pain, they may lash out because the pain makes them feel confused or frightened – they simply don’t understand it.  It could be down to illnesses such as a bladder or throat infection, or they may feel uncomfortable because they’re constipated or thirsty.  And don’t forget about any long-term health issues which could be causing discomfort, such as arthritis, or the affect that medications could be having on their mental wellbeing.

The environment

Is the room too bright, noisy, crowded, hot, cold or just generally over-simulating? This could make someone with dementia feel lost or overwhelmed and then lash out in fear or frustration.

Social issues

Find out if the person you’re caring for is lonely, bored or lacking social contact. They may need some sensory stimulation.  If other people are involved in their care it’s worth finding out if there’s been any changes recently. For example, if a favorite caregiver is on vacation it might make someone with dementia feel unsafe, and start acting aggressively.

Psychological problems

Dementia affects your perception and understanding of the outside world. If you feel as if your rights are being ignored – as some people do – it can make you want to lash out.  Changes in the brain can also make people living with dementia feel more extreme reactions than they used to. So whereas before they might have reacted with frustration if they felt someone was being rude to them, now they respond with violence.

Dementia can also cause hallucinations, delusions and paranoia which can lead to aggression, as they don’t really understand what is going on. If the person you’re caring for doesn’t recognize where they are, or who you are, they might think you’re a stranger trying to hurt them. So it makes sense that they might lash out and hit you – wouldn’t you do the same?

How should you respond to aggressive behavior?

Being on the receiving end of aggressive behavior caused by dementia is undoubtedly difficult and often traumatic. However there are steps you can take to manage it both now and in the future.  There’s no ‘one size fits all’ answer, but generally speaking it’s best to:

1. Try to stay calm

While this might seem easier said than done, an angry or defensive response could make the situation worse. Try not to show any fear or alarm, take a deep breath and step back to give them some space to calm down.

2. Identify the cause

This won’t always be obvious, but think about what happened immediately before they became violent and ask yourself if that could have triggered it. For example, could they be in pain or uncomfortable and can you remedy it?

3. Step into their shoes

Try to look at the situation from their perspective. If they’ve reacted strongly after you’ve tried to bathe them or helped them use the toilet, it could be because they feel embarrassed or ashamed. Even though you know you’re only trying to help, dementia can mean the person you’re caring for no longer has the same level of reasoning or logic.

4. Reassure and listen

Once they have stopped acting violently, and are willing for you to approach them, maintain eye contact and talk in a low, soothing (but not patronizing) voice. Explain calmly that you want to help and listen if they’re able to tell you what the problem is.

5. Use distraction tactics

Try shifting the focus to another activity if you think this is what is causing the aggression, or pick a pastime that is more relaxing, such as listening to music or going for a walk with them.

6. Don’t punish them

It can be easy to feel like you want to scold the person like a naughty toddler when they’ve been aggressive, but they probably have no real concept of what they’ve done wrong, or why it’s inappropriate (and may not even remember the incident the next day).

7. Talk to a friend

Try to avoid unleashing your frustrations on the person you’re caring for. Make time to meet with friends who understand your situation, talk to your GP, a counselor or a dementia support worker, or a support group. There will be other people out there who are in the same boat.

Per:  https://www.unforgettable.org/blog/agitation-aggression-whats-causing-this-behaviour