By Amanda Thornton RN, BSN, MSN, VA-BC, CIC
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“No! Don’t touch me! NO!” said my mom as she slapped my hand away for the tenth time. “What is wrong Mom? Do you have pain? Are you thirsty?” I asked. “Don’t touch me! Get away” she said again as she began pacing and wandering the hallways, looking exhausted. One of the most frustrating things for any caregiver of a person with dementia is the occasional difficulty in trying to figure out what may be bothering that person and causing them anxiety or to react with agitation or aggression. Usually, they are in a state of mind at that point where verbal communication is not going to work. So what then? Jut make your best guess? Actually, there is an approach based on scientific research that may work better when determining what is really going on.
"It is quite true that man lives by bread alone — when there is no bread. But what happens to man’s desires when there is plenty of bread and when his belly is chronically filled? At once other (and “higher”) needs emerge and these, rather than physiological hungers, dominate the organism. And when these in turn are satisfied, again new (and still “higher”) needs emerge and so on. This is what we mean by saying that the basic human needs are organized into a hierarchy of relative prepotency" (Maslow, 1943, p. 375).
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Let’s look at a nursing theory that has been around for a long time and may help us to understand how to best approach and understand a dementia patient who is expressing an unmet need. In 1943, Abraham Maslow proposed a theory about human behavior and psychology titled “A theory of human motivation”. In it he stated that the most basic human need is physical survival, and this will be the very first thing that motivates our behavior. Hunger, thirst, pain, sleep…..these all come first and will be the biggest driver of behaviors. Once that level is fulfilled the next up is safety and security, then love and belonging, self-esteem and self actualization.
When addressing a person who has dementia and is acting out, the clinician or caregiver should approach dealing with the behavior based on the theories behind this pyramid by addressing their needs from the bottom up. Are their physiological needs met, then if they are, do they feel safe? Etc and so on. These two are the first things any professional or caregiver should start with when working with a person diagnosed with dementia.
My grandfather as he progressed through his dementia made it very difficult on my grandmother, who was terribly embarrassed at some of his behaviors, but if we examine them in the light of this pyramid we can see perhaps that they made sense. For example, one morning my grandmother told him to go get dressed for church and he came out of the bedroom very neatly dressed in one of her skirts and a white flowy blouse, with his shiny black men’s loafers on. To put it mildly she was completely horrified at his behavior and yelled at him immediately to go “get dressed right!” Later, when she asked him ‘why he would do such a thing’ he said he just wanted to ‘look good like she did, and why was she so upset’? So in light of the pyramid we can see that behavior fits right into the love and belonging tier. He just wanted to belong!
So, when your loved on is acting out, instead of just throwing wild guesses out there, approach their needs from this behavioral pyramid as follows:
1. Physiological needs:
· Air
· Food
· Water
· Clothing
· Pain
· Toileting
· Sleep
2. Safety and Security:
· Shelter
· Feeling secure and safe
· Employment
· Money and resources
· Health
3. Love and belonging:
· Relationships
· Friendships
· Family
· Love
· Human connection
· Feeling as if you fit in
· Intimacy
4. Esteem:
· Feeling respected
· Status
· Recognition
· Freedom
· Self-esteem
5. Self Actualization: Being all you can possibly be
As any nurse knows when taking care of a non-verbal patient (dementia or not), you always start with the basics: “Do you have pain? Are you thirsty? Are you hungry? Do you need to go to the bathroom? Are you tired and need to sleep? Are you cold? Hot?”. Once these are out of the way you can move on to questions such as “ Do you feel scared for some reason? Are you worried about something in particular?” etc. When communicating with someone who is nonverbal you can also use communication boards that they can point at, which sometimes makes it easier for them if they cannot find the right words. You ask them to point to either the number or the face that best represents how they feel:
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All this being said, there are times when even this approach will not work, and a person will just remain agitated until the “episode” passes, and you may never know what was really bothering them. This is part and parcel of being a caregiver to a person with dementia. We must approach such situations with patience and compassion, and remember that all behaviors, including agitation and aggression, are simply an expression of an unmet need.
References:
1. Maslow, A. H. (1943). A theory of human motivation. Psychological Review, 50(4), 370-96
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