'The Children Will Be Waiting for Their Supper'
Mrs. D., 87, has moderate dementia and moved in five days ago. Every evening around 6 p.m. she becomes restless: she paces the hallway, wrings her hands, and repeats, 'I have to get home - the children will be waiting for their supper.' Her husband died four years ago and her house was sold two years ago. Tonight she refuses to sit down for dinner, tries the locked exit door twice, and says, 'Let me out, I'm late.' She is not combative, but she will not be redirected to her room.
1. What do you do at the exit door, and what do you avoid doing?
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Safety first, then connection - not correction.
- Move between her and the door and stay with her; get another staff member so no one is alone with her at an exit. Confirm the door alarm is working.
- Do not physically restrain or drag her back down the hall. Do not correct her - 'Your husband is dead and your house was sold' produces grief and panic in someone who cannot hold that reality, and it does not stop the exit-seeking.
- Join the feeling instead: 'You're worried the children won't get supper. That's a lot to carry. Come help me - I need someone to butter the bread.' Then walk with her, away from the door, toward a real task.
- Offer a concrete substitute: a snack, a plate to carry, a purse or photo to hold, a chair where she can 'watch for them.'
- Keep your voice low and slow, reduce the crowd around her, and give her one instruction at a time.
2. Name specific changes to her evening care plan that could reduce this pattern.
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Treat 6 p.m. as a predictable event and plan for it rather than react:
- Light: turn lights up and close the blinds before dusk. Shadows and dimming trigger sundowning.
- Noise and traffic: move her to a quieter part of the unit during shift change and the dinner rush.
- Body needs checked before 6: toileting, pain, hunger, thirst, constipation, and room temperature. Offer a snack at 5 p.m. and avoid caffeine late in the day.
- Routine and people: same aide when possible, same sequence each evening, and start dinner earlier if the 6 p.m. timing is the trigger.
- Purpose: a simple, failure-proof task she can do - folding towels, setting napkins - instead of sitting in a loud dining room.
- Rest: avoid long late-afternoon naps.
- Record the pattern - time, trigger, what worked - and take it to the care plan meeting so the whole team runs the same plan.
3. What would make you suspect this is more than her usual dementia pattern and needs same-shift reporting?
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Report urgently if any of these appear:
- The agitation is sudden or different from her baseline - new, worse, or first time, especially with fluctuating attention.
- New physical signs: fever, cough, painful or frequent urination, no bowel movement in three days, poor intake, or new pain. In older adults, infection and constipation present as behavior.
- A recent medication change or a new medication started in the last few days.
- Escalating exit-seeking with injury risk, or any fall, near-fall, or injury.
- She cannot be calmed by any approach that usually works.
Reasoning: delirium is a medical emergency layered on top of dementia and is easy to write off as 'just her dementia.' It is not your call to diagnose it - it is your call to notice the change and get the nurse to her the same shift, with times and specifics.