The 4 p.m. Exit-Seeker
Mrs. Kwan, 85, has moderate Alzheimer's disease and moved in two weeks ago. Every day around 1600 she becomes restless, paces the hallway, and walks into other residents' rooms, picking up their belongings. She tells you, 'I have to get home, my husband won't have any dinner,' though her husband died six years ago. When you take her arm to guide her back to her room, she pulls away and says loudly, 'Don't touch me!' One of the other residents' daughters has just complained at the desk that her mother's room is not private anymore. It is 1620 and dinner is in 40 minutes.
1. What is most likely happening, and what do you actually do in the hallway right now?
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This is the classic late-afternoon pattern - sundowning - combined with exit-seeking, in a resident who cannot be reasoned out of her reality.
- Approach from the front, at her eye level, calm and slow. Use her name. Never come up behind her or grab her arm; that is what triggers the 'Don't touch me.'
- Do not correct her. 'Your husband died six years ago' is true and cruel - it delivers fresh grief and escalates the agitation. Answer the feeling, not the fact: 'You're worried about getting dinner on the table. Let's get something started.'
- Redirect into a purposeful task: walking with you to the dining room to fold napkins or sort silverware, carrying a tray, buttering bread. Purpose beats 'come back to your room.'
- Check unmet needs first: hungry, thirsty, needs the toilet, in pain, too much noise, overtired. Fixing a full bladder often ends the whole episode.
- If she pulls away, stop and step back. Do not block, restrain, corner, or lock her in.
- Report the pattern and what worked, so the care plan can be built around it.
2. The other resident's daughter is at the desk demanding that 'something be done about that woman.' How do you handle her?
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- Listen and acknowledge the concern without agreeing to a version of events: 'I can hear that this has been upsetting for you.'
- Do not discuss Mrs. Kwan at all - no name, no diagnosis, no behaviour description, no apology on her behalf. That is another resident's private health information, and sharing it is a rights violation even when the family member is angry.
- Say what you will do: 'I'm going to tell the nurse right now so the team can look at this.' Then actually do it - the nurse decides what is shared and how the situation is managed.
- Do not promise things outside your role ('we'll move her to another unit,' 'she'll be restricted to her room').
- Offer something concrete you can control: knocking before entering, closing doors, walking with her mother to the dining room.
- Report the complaint along with the wandering behaviour, because both are real safety issues - the roaming must be addressed for every resident's sake, not because the daughter shouted.
3. Two hours later, while you are helping her change into a nightgown, she grabs your wrist hard and tries to hit you. What do you do?
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Stop the care and step back out of arm's reach. Do not hold her down, do not scold, do not finish quickly 'for her own good.'
- Lower your voice and slow down. Give her space and a moment; a rushed, startled, or undressed resident is exactly when this happens.
- Assume an unmet need: pain, a full bladder, being cold, being startled by touch, too much noise, or a task she did not expect.
- Try a different approach later, and bring a second staff member if needed: same care, slower, with her holding the nightgown, with step-by-step cues.
- Do not retaliate or threaten. No restraining, no 'you'll be sorry,' no PRN medication - medication decisions belong to the nurse.
- Report the behaviour, especially if it is new or increasing.
- Document the ABCs: what happened just before (Antecedent), the Behaviour, and what helped (Consequence) - that pattern is what lets the team prevent the next episode.
The judgement: aggression in dementia is communication, not defiance, and the correct response is to change the approach, not to win the struggle.