10. Focus on vocally disruptive behaviour

Case study: A woman, 80 years old with vascular dementia is living in a nursing home. Staff, other patients and visitors see her as being ‘disturbing’ because of repeated periods of screaming. She is also sometimes aggressive towards the staff. The problem is repeatedly discussed with the physician, who prescribes different sedatives without any effect on the behaviour. She has lost most of her ability to communicate and has impaired motor and cognitive functioning. Systematic observations show that she screams mostly when the nurses help her with personal hygiene and at mealtimes. She often refuses to eat and turns her head away. She is mostly lying or sitting huddled up. The screams are described as being unarticulated, heart-wrenching or groaning and one can sometimes hear the word “ow!”

Task: Consider what you would do or how you would respond if you were a member of staff in this nursing home.

Write down your responses in your notebook.

When the woman suddenly dies, her medical record is reviewed. It is discovered that five years ago, her ovaries were surgically removed due to cancer. Post-mortem examination reveals widespread spread of the disease. At the time of her death she had no prescribed painkillers (analgesics).

Note any thoughts from this further information. Would you respond differently had you known this?

Comment: This is a real case that was reported to the Swedish National Board of Health and Welfare (International Psychogeriatric Association, 2007). The woman was labelled as being ‘disturbing’ by the nurses and even though systematic observations were made, the nurses did not recognize the signs of pain.

Consider reasons for vocally disruptive behaviour?
Some people with dementia may suddenly begin to swear when upset, insult family and friends for no obvious reason or start shouting and be verbally aggressive. Other difficulties can be loud noise making – this is persistent vocalising which is often unintelligible and resistant to requests for silence such as yelling, groaning, disruptive talk and calling out.

It can be difficult to tolerate, however it should not be seen as a nuisance and ignored and isolated as there is usually a cause through an unmet need.

For example verbal/vocal behaviours have been shown to increase in frequency when nursing home residents were alone and decreased when with others or staffing levels increased (Cohen-Mansfield and Werner 1995) suggesting loneliness or need for social contact may be at the root of verbal or vocal behaviours that distress others.

Possible causes may be unmet physical needs such as:

  • Pain.
  • Needing to go to the toilet, constipation, incontinence.
  • Feeling too hot or too cold.
  • Physical discomfort due to sitting or lying position.
  • Limited freedom of movement.

Psychosis
For some people who experience hallucinations this can lead to them responding to the images/people that are real to them.

Psychological distress
Calling out may be the only way that the person is able to communicate sadness, frustration or distress. Vocal disruption may indicate;

  • Anxiety – the person may be seeking comfort.
  • Feelings of anger, frustration, resentment, hopelessness etc.
  • Feeling abandoned and calling out for someone indicates feelings of insecurity. Sometimes people with dementia cannot recognise faces and this may heighten feelings of aloneness.

Environmental factors
Over stimulating environment – an environment that is cluttered and noisy will lead to agitation, irritability, stress and confusion not only for the person but also for carers and families. Unpleasant aromas can add to a person’s distress and agitation. Also if the person feels they are being bombarded with questions.

  • Lack of stimulation or social contact – if the only contact patients have with staff is when they are providing specific and basic nursing care then people will become distressed and feel isolated and lonely. Sensory deprivation through poor sight or hearing can also lead to lack of stimulation. Shouting often occurs at night if the person is lying awake in a frightening silence.
  • Not being able to see and watch what is going on around can contribute to a person’s sense of isolation, loneliness and fear.

What might help?
Look for underlying reasons of what might be causing the shouting and for any patterns with the behaviour For example, if someone always starts yelling when you sit them in a certain chair, they may do so because they are uncomfortable, don’t like the people around them, can’t see what’s going on around them, can see too much of what’s going on around them etc.

One to one social contact and communication-based activities related to the person’s past interests have been shown to reduce significantly verbal disruptive behaviours and agitation, resulting in an improved quality of life for the person with dementia.

Interventions really depend on the cause. Remember there is a reason.

Other ways to help can be:

  • Distract the person by introducing other enjoyable activities.
  • Increase social contact and meaningful activity based on past history and occupations. For example, if the person with dementia enjoyed housework encourage them to help fold the laundry or place a basket of towels and dusters in their room. Encourage a walk in the garden if this was an area of interest.
  • Talk to the family and friends
  • Use sensory techniques such as massage; provide visual cues through touch.
  • Encourage light exercise.
  • Encourage the family/friends to create a video of conversations and reminiscing about special events, or a memory book of photographs and special memories to help with conversation.
  • Calm the environment down if over stimulation: lower lighting, turn off loud music, take to a quieter environment etc.
  • If under stimulation may be the cause increase stimulation eg singing, a gentle hand massage, take to a busier place such as a lounge room.
  • Communicate continually with the resident during the task at hand.
  • Provide adequate meals/snacks/fluids to prevent hunger and thirst.
  • Initiate an individual toileting regime and change promptly after incontinent episodes.
  • Allow/encourage rest periods to prevent fatigue.
  • Provide frequent positioning changes/massage for people who are immobile.
  • Check environment and maximise cognitive capacity through orientation cues such as notes, signs, diagrams, calendars and personal items of significance.
  • Consider language barriers
Task: Take a few minutes to close your eyes and identify the sounds and smells around you. Think about how they make you feel and then imagine them from the perspective of a person with dementia.

Think about different settings eg a care home, a busy hospital ward and what sounds and smells may be present. Make a note in your workbook of how you could change the environment to make it more comfortable for people with dementia.

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