Residential aged care psychiatry

Meet the resident

An 84-year-old woman with moderate Alzheimer disease has lived in the same facility for two years. The night nurse rings the on-call doctor at 11pm: she is "aggressive at shower time", has hit a carer, and the request is for "something to calm her down". The last entry in the chart is from three days ago.[1][4]

Nobody has taken her temperature, asked when she last opened her bowels, or checked whether her hip replacement side hurts when she is moved. Her husband of sixty years died six weeks ago.[4][12]

Two exam questions are now live. What is the "aggression" actually communicating? And why is "something to calm her down" the wrong first sentence? Everything below answers both — and none of it is about denying care when care is genuinely needed.[4][12]

A note on language, and it matters here: a person living in residential care is a resident, not a "bed", a "placement" or a "case". Behaviour is communication, not nuisance. The vocabulary shapes the plan, and a plan written in the language of convenience is a plan written against the person.[1][4]

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2. [2]Finkel SI, Costa e Silva J, Cohen G, Miller S, Sartorius N Behavioral and psychological signs and symptoms of dementia: a consensus statement on current knowledge and implications for research and treatment Int Psychogeriatr, 1996.PMID 9154615
3. [3]Cummings JL, Mega M, Gray K, Rosenberg-Thompson S, Carusi DA, Gornbein J The Neuropsychiatric Inventory: comprehensive assessment of psychopathology in dementia Neurology, 1994.PMID 7991117
4. [4]Kales HC, Gitlin LN, Lyketsos CG Assessment and management of behavioral and psychological symptoms of dementia BMJ, 2015.PMID 25731881
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10. [10]Chenoweth L, King MT, Jeon YH, Brodaty H, Stein-Parbury J, Norman R, et al. Caring for Aged Dementia Care Resident Study (CADRES) of person-centred care, dementia-care mapping, and usual care in dementia: a cluster-randomised trial Lancet Neurol, 2009.PMID 19282246
11. [11]Ballard C, Corbett A, Orrell M, Williams G, Moniz-Cook E, Romeo R, et al. Impact of person-centred care training and person-centred activities on quality of life, agitation, and antipsychotic use in people with dementia living in nursing homes: A cluster-randomised controlled trial PLoS Med, 2018.PMID 29408901
12. [12]Husebo BS, Ballard C, Sandvik R, Nilsen OB, Aarsland D Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial BMJ, 2011.PMID 21765198
13. [13]Ballard C, Lana MM, Theodoulou M, Douglas S, McShane R, Jacoby R, et al. A randomised, blinded, placebo-controlled trial in dementia patients continuing or stopping neuroleptics (the DART-AD trial) PLoS Med, 2008.PMID 18384230
14. [14]Ballard C, Hanney ML, Theodoulou M, Douglas S, McShane R, Kossakowski K, et al. The dementia antipsychotic withdrawal trial (DART-AD): long-term follow-up of a randomised placebo-controlled trial Lancet Neurol, 2009.PMID 19138567
15. [15]Banerjee S, Hellier J, Dewey M, Romeo R, Ballard C, Baldwin R, et al. Sertraline or mirtazapine for depression in dementia (HTA-SADD): a randomised, multicentre, double-blind, placebo-controlled trial Lancet, 2011.PMID 21764118
16. [16]Porsteinsson AP, Drye LT, Pollock BG, Devanand DP, Frangakis C, Ismail Z, et al. Effect of citalopram on agitation in Alzheimer disease: the CitAD randomized clinical trial JAMA, 2014.PMID 24549548