Sundowning, the Locked Door, and 'Don't Touch Me'
Mr. Kelleher is 84 with middle-stage Alzheimer's disease. At 1730, as the evening shift begins, he paces the hallway repeating that he must get to the shop or his boss will fire him. He has been at the locked unit door twice, pushing the keypad. He is not dressed for outdoors; his temperature and blood pressure were normal at 1600. When you suggest a shower he pulls his arm away and says, 'Don't touch me.' He has not eaten since noon. His daughter mentions that he was a printer for forty years.
1. What is your best response when he says he must get to the shop?
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Do not argue and do not correct him - telling him the shop closed forty years ago invites an argument he cannot win and will escalate. Join the feeling, then redirect to something true and useful: 'You've got a big day at the shop. Let's get these orders sorted first.' Hand him a stack of towels to fold, or papers to 'check,' and stay nearby.
Reasoning: the repeated statement is driven by a need - purpose, routine, the fear of getting in trouble - not by a fact he can be talked out of. Because he was a printer for decades, work tasks are meaningful to him and are likely to hold his attention longer than an unrelated distraction. Physical blocking at the keypad or grabbing his arm tends to produce the aggression you are trying to prevent.
2. Before anyone considers medication, what do you try, and what do you report?
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Try: turn down noise and bright overhead light; offer a snack and something to drink since he has not eaten since noon; offer the toilet; keep the evening routine predictable; give one instruction at a time; offer two acceptable choices rather than a demand; engage him in the work-type task.
Report: that the behavior is occurring in the late afternoon, the exit attempts and how many, the refusal of food since noon, the refusal of care and the pulled arm, and which approaches calmed him and which did not.
Reasoning: evening agitation has physical triggers worth ruling out first - hunger, thirst, a full bladder, pain, fatigue, overstimulation. A pattern written down (time, trigger, what worked) is what lets the nurse and care plan team change the approach rather than just sedate him.
3. While you are helping him to the bathroom he swings his arm at you and repeats, 'Don't touch me.' What now?
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Stop, step back, and give him space. Lower your voice and your posture, say his name, and give one simple direction: 'Mr. Kelleher, I'm right here. The bathroom is two steps to your right.' Wait several seconds. Try again later, or ask a second aide to come, and call the nurse.
Do not force the care, do not grab his arms, and do not use a blanket or sheet to hold him - that is a restraint and is never a CNA decision.
Reasoning: forcing a personal care task on an agitated resident with dementia is how both residents and aides get hurt. Missing one trip to the bathroom is a solvable problem; a wrestling match is not. The refusal itself, and the swing, are reportable - a new behavior can signal pain, constipation, or infection.