Tuesday, 2 October 2007


I have a few beds on an "organic assessment" ward where patients with dementia can be assessed and treated.

Few patients are admitted.

The diagnosis of dementia is made in the community, the treatment is implemented in the community, why should a patient need hospital in-patient care for their memory problems?

They don't.

They're not admitted through memory problems, such folk would be placed in urgent respite care within a specialist (charmingly classified as EMI, Elderly Mentally Infirm) care home.

So who is admitted?

Usually it's folk with dementia who have behavioural disturbance. What is behavioural disturbance in my world? Mostly it's someone who, through their impaired concentration, memory, information processing and temprement misconstrues circumstances and acts aggressively.

You're sitting down minding your own business. Someone you don't know looms over you and starts undressing you. What would you do? Most of us would resist, and resist pretty assertively. Folk with severe dementia can't appreciate the hands on personal care so even if told they're being undressed to get in to a bath as their top is being taken off, a few minutes later will have forgotten and wonder why some strange folk are hauling their trousers off. Sensory ambiguity and misperceptions (seeing curtains blowing in the wind then thinking they're moving 'cause an intruder is there in their room), commensurate increases in paranoia, it's unsurprising that such an individual is feisty when a carer discreetly pads in to their room in the night to check they're alright.

Most folk with severe dementia are impaired but are fine to be around. Some folk will be aggressive and although it's not acceptable it is often understandable (when you start to think of their experiences from their impaired perspective). I don't like care home staff being battered. Such folk are admitted to my "organic assessment" beds.

They have Behavioural and Psychological Symptoms of Dementia (BPSD).

Despite comiing from an EMI Nursing Home, most (in fact, a review of the last 4 years shows all of them) are then are discharged back to an EMI Nursing Home. What magic do we work?


Medication is optomised but in fairness the Care Home team and I will have done this well before they were admitted, anyway. Stopping medication that could aggravate symptoms, starting and titrating helpful medication, we've fiddled with the chemistry in the community and it's still unmanageable in the EMI Nursing Home, so in they come to the ward.

Occasionally I find a medical condition exacerbating their distress and disturbed behaviour, occasionally I find a change of medication that I'd not explored in the community and initiate in hospital with benefit . . . but mostly I have, in truth, little to offer.

Nursing care

Nurses do it all. They assess what the patient finds distressing, what provokes distress of confrontation and what is helpful. Some distressed folk need their hands held, eye contact, calm speech, soothing touch, close proximity and reassaurance and all this support and reality orientation can keep them in the here and now, coping. Other folk find this claustrophobic and intense and intrusive and are wound up big time, favouring space and solitude and a desire to pace, pace, pace endlessly around the garden or ward (that's a huge circular building, for this purpose).

As well as gleaning what winds patients up and what is helpful, nurses then can implement an informed behavioural approach sympathetic to the person's presentation. Having sussed out how they can get dressed or bathed or fed without provoking hostility this is done each and every day, establishing a routine and habituating behaviour.


After a few weeks behaviour settles. The person's stable and then we're able to be discharge them to a care home.

What's worked?

So many folk are full of praise for what I've done to "help their mum" or "get their old dad back" or "stop Mr X battering my staff" and, no matter how many times I tell folk, they continue to say this. But it isn't me. It's the nurses. Not nurses doing doctor's roles. Not nurses doing extended roles. It's highly skilled nurses doing highly skilled nursing.


Dr Andrew Brown said...

"Highly skilled nurses doing highly skilled nursing"

An interesting concept, but it will never catch on.

The Shrink said...

They'll spank you for such impertinence, Dr Brown!

Seriously, my nursing colleagues on my in-patient units are highly skilled nurses and they do highly skilled nursing.

I concede it can be an oasis in a desert of desolation, and indeed may never catch on. But for anachronistic folk like me, it's cheering to see such dated practice of nursing staff nursing and the whole thing going swimmingly well.

Calavera said...

I think that this is a wonderful post, and beautifully written.

I admit, I didn't know that nurses played such a key role in this department. Thanks for the enlightenment.

Elaine said...

It is really good to see an appreciative comment about nurses by someone in the medical profession. Thank you:-)

Spirit of 1976 said...

I must confess, just lately since moving from being a student nurse to being a staff nurse, I've been developing a new appreciation of the importance in nursing of getting the basics right - making sure you set aside time to spend with patients, working to ensure that therapeutic work doesn't get swallowed up by the hurly-burly of ward business, eliminating problems in communication so as to reduce the risk of clinical errors. All those little things that can make a big difference to patients if they're done well, and can be catastrophic if they're done badly.

I'm not opposed to extended nursing roles (so long as they're nursing roles rather than cheap doctor-substitutes) but it's vital to look after the basic principles first.

The Shrink said...

Cal, they do pretty much all the hard work, yes!

Elaine, credit where credit's due :-)

Zarathustra, as usual, we find ourselves violently agreeing ;-)