solved

Mr. Y is a 78-year old man who was born in Korea and moved to the US with his wife 50 years ago. Together, the couple opened a floral shop and ran the business for 40 years. Mrs. Y enjoyed watching her husband’s talent and love of nature come out in his flower arrangements.
When Mr. Y was in his late 60’s, he started having difficulty making his favorite flower arrangements. Their son also noticed Mr. Y misplacing tools, losing paper orders, and forgetting important pick-up times. At home, Mrs. Y noticed her husband having problems remembering recent events, and waking up at odd hours in the night thinking it was time to open the shop. Mr. Y was becoming irritable at home and at the shop.
When Mr. Y was 70 years old, the family decided to sell the business. Their healthcare providers confirmed that Mr. Y was presenting with early stage Alzheimer’s disease. The family decided that Mrs. Y would be appointed as her husband’s Power of Attorney for personal care and property. She continued to care for her husband at home.
When Mr. Y turned 75-years old, he was having increased difficulty remembering where things were in the house. He often woke his wife at odd hours of the night thinking it was time to get up and ready. When Mrs. Y reoriented her husband that it was still night-time, he would get confused an easily upset. Mr. Y was also becoming more physically weak, but did not perceive his limitations. He was home, forgetting where he had to go and which house was his.
Their son recognized that his mother was as happy as she used to be. She was constantly worrying about her husband’s increasing care needs, and could not enjoy activities she used to do. She was stressed and was not sleeping properly. With support from their healthcare providers the family decided that a long-term care setting would benefit Mr. Y and Mrs. Y’s well-being.
Admission to long-term care
At the admission conference, the long term care home’s social worker and charge nurse met Mr. Y and his family, and learned more about his history and preferences. His medical diagnosis includes moderate Alzheimer’s disease and osteoarthritis, with a history of urinary tract infections. Mr. Y hears well, uses reading glasses, and wears upper and lower dentures. Mr. Y also requires reminders to use his walker properly. Mrs. Y always prompted her husband for toileting, as well as when to eat and take medications. Mr. Y requires limited assistance from his wife during activities of daily living, such as dressing or transfers. As for his preferences, Mr. Y loves homemade Korean food, pastries, and warm drinks. He had always enjoyed baths in the evenings.
Mr. Y’s first week
During the first week in LTC, the staff noticed Mr. Y pacing the hallways, pushing locked doors, entering other residents’ rooms. When approached by the nursing staff, he had repetitive questions: “Who are you?”, “What do I do?”, “Where do I go?” Mr. Y required frequent reminders that this was his new home. During meals, Mr. Y ate little despite encouragement and staff offering assistance. During personal care such as changing, toileting and showering, Mr. Y kicked, scratched, grabbed and screamed at the staff. Two staff were required during these care activities.
Socially, Mr. Y actively participated in group craft activities and exercise classes when the therapists and staff coached him. During the times with no scheduled activities, Mr. Y paced the hallways and asked staff: “What do I do?”, “Where do I go?”
Mr. Y’s second week
At the end of the second week in the LTC, Mr. Y was no longer pacing the halls. He was often found napping in his room during the days. One afternoon, a staff nurse went into Mr. Y’s room and found him sleeping. She tried to gently wake Mr. Y, but he was not easy to arouse. She tried a second time and asked very loudly, “Mr. Y, it’s lunch time, are you ready to go?” Mr. Y slowly opened his eyes. The staff nurse repeated the question, and Mr. Y replied slowly, “Oh, I ate last week.” The staff nurse then asked “I know you had breakfast this morning, now it’s lunch time. Are you hungry?” Mr. Y paused and closed his eye. The staff nurse gently woke him again by rubbing his arm and repeated her question. Mr. Y slowly replied, “Yes, my wife is cooking, I will eat.” Together, they walked slowly to dining room.
In the dining room, Mr. Y stared out the window and did not answer the staff nurse when they asked him for his lunch preference. When approached a third time, Mr. Y rambled slowly in English and in Korean to the staff nurse. He continued to speak Korean to the staff nurse as they tried to assist him with his lunch, but he was unfocused and inattentive. He was unable to finish his meal because of his behavior. The staff were worried that he was not eating or drinking enough since admission.
When there were group activities, the therapists found it harder to encourage Mr. Y to attend and participate like he had been doing before. It took a lot of encouragement and assistance to have him attend. During the activity, he did not participate or sometimes fell asleep in the middle of the exercise or social program.
A few nights in a row, he was found wandering outside his bedroom without his walker. One time, he told the staff nurse, “Someone is looking for me.” The PSW reassured him that he is safe, and tried to direct him back to his room. But Mr. Y walked past the staff nurse and said, “I have to go to the bus stop.” After a few attempts, the staff nurse was able to direct Mr. Y to his room to sleep, and reoriented him to the use of the call bell. This behavior continued with increasing disorientation. The sleep disturbances resulted in Mr. Y being too drowsy in the mornings, and not able to eat any breakfast.
Although Mrs. Y was kept informed of her husband’s condition since admission to long-term care, it was not until her first visit during Mr. Y’s third week in long-term care when she realized how much her husband had changed. She was alarmed and asked the staff, “What is happening? What will be done for him? How can I help?”
Behavioral and psychological symptoms of dementia is a term used to describe the way a person with dementia expresses their unmet needs and presents symptoms of dementia. It is important to explore what is going on for the person. Looking at Mr. Y’s first week in long-term care:
He is wandering a lot, and staff has to re-orient him many times. What do you think is happening and why might he be reacting this way?
Mr. Y’s Alzheimer’s has progressed to Middle-stage Alzheimer’s which makes him forgetful of events or personal history, confused about where he is or what day it is, and shows an increased tendency to wander and become lost.
In Middle-stage Alzheimer’s Mr. Y starts to demonstrate personality and behavioral changes, including suspiciousness and delusions or compulsive, repetitive behavior. He may get frustrated or angry and act in unexpected ways, such as refusing to bathe.
I would assess their pain, infections, electrolyte imbalances or metabolic disorders, urinary retention, constipation, cerumen, and others.
During Mr. Y’s personal care, what might be happening for him and why might he be reacting this way?
What other things can you do to explore underlying causes of a person’s behavioral and psychological symptoms of dementia?
A range of non-pharmacological approaches to care have been found to be effective at managing behavioral and psychological symptoms of dementia, but not all approaches are effective or appropriate for everyone. It is important to tailor a care plan to meet the person’s needs and preferences. What non-pharmacological approaches have you used to manage behavioral and psychological symptoms of dementia? Would you want to use these for Mr. Y?
Caring for people with dementia requires effective communication skills. Which strategies might work for Mr. Y? What are some communication strategies that have worked for you in the past?
There are several strategies to preserve Mr. Y’s abilities and promote living well with dementia.
What are some activities that long-term care staff can offer that you think Mr. Y will enjoy? Think of what he liked to do at home.
How can we promote Mr. Y’s social life?
It is important to promote a healthy lifestyle. How can we support Mr. Y’s nutrition?
How can we improve his quality of sleep?
Are there any issues surrounding Mr. Y’s safety? What can we do to make the environment safer?

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