"My Children Are Waiting at the School"
Mrs. B, 84, has moderate dementia and normally walks with a cane to the dining room for meals. At 3:30 p.m. she begins pacing the hallway in her blouse and slacks, picking at the fabric, and saying, "I'm late - my children are waiting at the school." She has tried the locked exit door twice and becomes louder when staff approach. She ate little lunch and has not been toileted since 1 p.m. She was treated for a urinary tract infection two weeks ago. You are one of two aides on a 30-resident unit and must also finish three sets of vitals before 4 p.m.
1. What is your first approach, and why are correcting her and physically steering her both wrong?
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Approach calmly from the front, at her eye level, using her name and a quiet voice. Join her feeling rather than her facts: "You're worried about being late. That's a lot to carry - come walk with me and we'll sort it out." Then walk beside her, matching her pace, and gradually steer toward a quiet, safe area.
Correcting her ("Your children are grown, there is no school") attacks a reality she cannot access and usually escalates the agitation, because from her side you are the one who is confused.
Physically steering or blocking her raises the stakes and can provoke a push or a fall, and it edges toward restraint, which requires an order and is never a convenience tool.
Reasoning: the behavior is communication, and the exit door is a safety problem to be solved with supervision and redirection, not with force. Staying calm also protects you - matching her distress makes the situation worse for both of you.
2. What could be driving this behavior, and how would you check without derailing your shift?
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Run through the usual causes quickly: toileting (nothing since 1 p.m.), hunger or thirst (little lunch), pain, fatigue, overstimulation at a busy time of day, and infection - she had a UTI two weeks ago and a recurrence can present as sudden confusion. Evening restlessness also fits a sundowning pattern. Constipation and a new medication are two more possibilities.
How to check: offer the toilet first, then a snack and a drink, and watch her face and gait for pain. Do it as part of the walk you are already taking, so it costs you minutes rather than a separate trip.
Reasoning: any sudden or worsening change in behavior in a resident with dementia should be treated as possible delirium or infection until the nurse says otherwise, not automatically as "just her dementia." Untreated pain and a full bladder are the two causes most often missed.
3. With two aides, thirty residents, and vitals due at 4 p.m., how do you keep her safe - and what must you report?
Read the worked answer
Keep her within sight, keep her walking with you toward the quiet end of the hall, and tell the other aide where you are so someone knows. Offer the toilet, a snack, and a calm activity such as folding towels. If she cannot be safely supervised while you do vitals, ask the nurse to help prioritize - vitals can be fifteen minutes late; a resident out an exit door cannot.
Report to the nurse: the new pacing and exit-seeking, the repeated attempts at the locked door, what she is saying, the missed toileting, poor lunch intake, and the recent UTI - and ask for an assessment, since a sudden change may mean infection, pain, or a medication problem.
Reasoning: you do not solve this alone and you do not tie her down. Do not request or apply a restraint as a substitute for supervision; restraint use requires a physician order, a documented reason, the least restrictive option, and ongoing monitoring. Document the behavior, the triggers you found, and what worked.