Agitation or Aggression?
Recently we had an elderly man on caseload with a diagnosis of advanced dementia. It was obvious he was in the later stages of the process. He couldn't follow commands. His swallow was diminished. He was disoriented times three and demonstrated poor motor planning with any voluntary movement. However, he could still move and verbalize spontaneously.
Unless disturbed, he laid quietly in bed. The problem arose when we tried to get him out of bed. He didn't want to be disturbed. As soon as we started to move him, he told us no and began cursing. This was followed by swinging.
Anyone who works with the elderly knows there are two kinds of swings. Some are ineffectual. These may be taps. There may be a little force. Patients with brain injury frequently flail in bed during the restless state. The intent isn't to strike someone so much as to move. These people might be described as agitated. Restlessness while in bed is certainly agitated.
Then there is the man I described above. He wasn't agitated. He was aiming for us. He didn't want to be moved and was resisting it. On a few occasions, his wife was present when we attempted to get him out of bed. She told us to ignore him. He didn't mean it. Mean it or not, he was trying very hard to hit someone.
Patients have the right to refuse therapy. That statement is made with the assumption the patient understands what he is refusing. In cases of dementia and confusion, we often have to rely on family members to give consent for treatment. This man was clearly refusing despite his wife's statement to the contrary. He knew he didn't want to get out of bed.
After a couple of days of struggling, I discharged him from therapy. Someone was going to get injured if things continued. One of our PRN PTAs knew him from previous interactions. She said this was normal behavior for him and they got him up anyway. He was just agitated. Obviously I don't agree with that. Despite the benefits of being out of bed, there is the real risk of injury to either himself or a caregiver. This went beyond any level of agitation. He was aggressively trying to strike someone.
He has since discharged to a SNF. I don't know if it's the one he came from or a different one. For his sake, I hope a different one that recognizes the difference between agitation and aggression.