People with advanced dementia have difficulties verbalizing their distress and often respond to this in physical ways. As a geriatric psychiatrist, I often get referrals for patients with challenging, resistive responses to care. It is not uncommon for these responses to be directly related to unrecognized bladder infections causing distress, unrecognized spinal compression fractures and sometimes even larger bony fractures such as, in one case in my practice, a hip fracture. Treating this distress with sedating medications including antipsychotics, anxiolytics, and even medications like Gravol decreases the behaviors occasionally but does not treat the underlying discomfort and worsens further the already compromised quality of life in late dementia. We need to carefully assess the underlying causes of responsive behaviors, and in particular, not miss potential sources of pain which might respond to appropriate interventions including appropriate pain management.
As one of many examples I will mention an 89-year-old woman in my practice whom I was asked to see because of severe aggression each time nursing care aides tried to provide care. She would scream, hit them, and resist being turned. Multiple staff members were needed to provide care. After a complete assessment initiated by a junior member of my clinical team, we ascertained that she had spinal compression fractures causing her to have excruciating pain each time she was moved. These, unfortunately, took some time to heal, but meanwhile, she was able to have appropriate treatment of her pain which much improved her cooperation with care and likely her quality of life.
It is truly heartbreaking to see older, frail people who have contributed so much to our community, suffering in pain because we have missed recognizing this.
Geriatric psychiatrist, Saskatchewan Health Authority
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