Managing Exit-Seeking and Aggression Issues in Memory Care Facility?

Katherine Haar

Hello. My mom (83) has dementia. We moved her into a memory care facility last year. Aside from her memory issues, she is very independent (no need for assistance with basic stuff like showering, walking, eating, etc). However, she has strong exit-seeking behaviors, in that she is very upset being locked in the MC ward and always wants to leave to go for a walk. (The MC facility has a separate walled garden but that's not always enough for her, she wants to either walk around the rest of the building or leave the building). When they won't let her, she can get very agitated and sometimes physically slaps back at the staff when they try to move her away from the doors. For now, this seems to be her one big issue. She does not remember that she has dementia and doesn't understand why she's locked in. We've got her on Seroquel and Celexa, which I'm sure is mitigating some of the agitation/depression, but clearly not completely.

I am frustrated because it seems like the only solution that the MC facility has is for us to pay at an hourly rate for an additional "companion" to come and spend time with her. They made us do this for the first month after we had her in the MC ward, and she hated having some woman follow her around and it upset her more. She does not take well to strangers. I think that the staff will sometimes take her on a walk, but they don't seem to have the staffing to do that frequently. Is this common in MC facilities? I have looked at and spoken to other facilities that say that their families don't have to hire companions, and that they would find different ways to redirect her and if it wasn't working they would just take her on a walk. Also, I assume that some physical agitation and aggression (ie the slapping) isn't uncommon in dementia patients, how do most MC facility staff handle that situation?

Thank you for your advice, I feel very lost in understanding what a long-term solution looks like. I'm not sure if it's that this just isn't the right facility for her, or if it's common to provide extra care beyond what the facility provides.

Anonymousjpl123

sorry you’re going through this @Katherine Haar . And welcome to this forum. I don’t think the slap is that uncommon. When my mom first moved to her MC I was shocked by how frequent exit-seeking was of residents. It made me worry if there was something wrong with her facility. Turns out that is quite common, especially in that awful phase which it sounds like your mom is in - when they cannot be left alone, but have enough cognitive reserves in tact to know they want more independence.

I’m not sure if more walks might help, or a different way of redirecting. Have you talked to the staff? Building a good rapport with the staff has been such a big part of making this bearable for me and my mom. The more they get to know you, and her, it may help them understand a bit more of her needs. If it’s a walk, is there a way you could come in the morning? This was a huge issue for me in the beginning. My mom has been in MC about 7 months now and we have finally settled into a routine - of sorts. There are always going to be challenges, but you shouldn’t feel like you can’t ask the staff for help. That’s what they are there for.

In my mom’s MC they do take the residents out for walks and activities, but not typically one on one. Same thing - staffing. So especially in the beginning I tried to come in the evenings and mornings a few times a week to just get her out, even briefly. I hope you find some help.

harshedbuzz

@Katherine Haar Hi and welcome. I am sorry for your reason to be here, but pleased you found this place.

This sounds like a difficult situation— it's pretty unusual for this level of exit-seeking to persist for a year. Care requirements have to be appropriate to care needs and your mom's exit-seeking constrains her to a secure unit sooner perhaps than she would have otherwise given her current level of ADLs. This sucks for a lot of reasons.

Does the MCF offer any engaging social programming? Dad's had a range of options from early morning through 9pm— coffee club, chair exercises, games, crafts, movies, various religious services and musical performances from local volunteers and school groups. Perhaps there's something there that would appeal? Dad would sooner sever a limb than play BINGO, but he enjoyed whatever music they brought in.

Walks outside the building are nice, but it's likely she can't understand why she can't whenever she wants and can't recall that she got to be outside recently. This kindness might actually be triggering. Is the secure outside area available to her? Is it more than a small walled garden? Would this meet her need to get outside?

IME with dad in a SNF, MCF and touring other MCFs, facilities can actively limit access to this amenity. They have to make sure the resident is properly dressed, has sun protection, that it's not uncomfortably warm or cold and they need to do their well checks every 20 minutes rather than the customary hourly ones. Conditions have to be just so and they need to have enough help. I toured a dozen places in late summer/early fall and only saw residents outside at one MCF and they were with a visiting family member.

Or is you mom a bit of an introvert by nature? If so, perhaps she could be engaged by staff by being a "volunteer" assisting them with tasks. A few of the women helped fold their laundry which was done individually on the unit as an optional activity. One man in dad's unit had been a restauranteur— he took over the front of house seating "guests" and bussing tables.

Slapping, shoves and such do happen. How well and how long this is tolerated can vary. Some places might increase her meds in-house if they have an affiliated geripsych while others might send the PWD to a geripsych unit for a short stay to trial meds to eliminate the anxiety the results in this level of agitation. Some places are very strict about this behavior and will ask families to make other arrangements— especially if another resident is the victim. I might look into upping the Seroquel to see if it helps her get unstuck.

In terms of other facilities saying families aren't required to hire companions, that sounds more like a sales pitch. I suspect they're telling you what you want to hear. I wonder if you phrased the question "Can families bring in a private companion?" they'd say something to the effect of "Why, yes, many of our residents have private companions". At dad's MCF, many residents have a private companion aide who visits. Sometimes this is done because family is at a distance or because the aide was their former in-home caregiver and there's a bond worth preserving.

There would also be other reasons why a MCF would require family to bring in additional help. At dad's MCF, residents could age-in-place, but as their care needs became intensive enough that other residents' care was impacted, family was required to bring in more help in the form of private aides and/or hospice. My aunt's SNF required a 24/7 sitter after a hip fracture because she couldn't remember to use her call button and was compelled to wander. This was cost-prohibitive, so her small family covered shifts mostly.

HB

Rick G

Rick G

https://alzconnected.org/discussion/comment/229317#Comment_229317

Thanks for the comments. My DW moved in 2 weeks ago. Her exit seeking behavior was pretty intense at home. She is on Seroquel and Xanax. Also takes trazadone to get to sleep regular hours. This all helped quite a bit. She is much calmer, and the exit seeking is under control. She still says she wants to leave but doesn't act out.