Facility Care For
Combative Dementia?

What are the primary decision factors when an Alzheimer's patient should be moved from home (with current home health care 3-5 days a week) to a facility? Our father is working hard to keep her at home, but he is very often frustrated and totally exhausted by the demands of her sundowning behavior, anger and agitation. He has implemented all the precautions to keep her safe. However, the entire situation has created an adverse environment for both of them. He has the option to extend the home health care into the evenings, but they would not be permitted to provide the physical restraint that is often required of her current aggressive behaviors. Is it worth waiting out this stage of the illness and keeping her at home, or is it wise to seek a facility where she can still enjoy organized activities, 24-hour care, and professionals trained to care for Alzheimer's patients? I know the next phase will not be any less complicated, so wanted to find a way that my parents can still enjoy one another and at the same time, she can receive comfortable, professional care both now and into the final stages of the illness.

I believe you have two different things going on here, and if we don't separate them it will hopelessly cloud your options.

The first, and most important to deal with right away, is the fact that your mother is apparently sometimes angry and agitated to the point where you and your father believe she needs to be restrained so that she doesn't hurt herself or someone else. Just imagine the inner pain she must be feeling to act out in this way, which I'm sure is not the way she behaved when she was healthy. Just as we treat physical pain because it would be unconscionable to allow someone to suffer from a pain we can relieve, we should treat psychic pain as well.

If your mother has not been evaluated by a psychiatrist experienced in treating dementia, you should have that done immediately, on an emergency basis if necessary. If her own doctor doesn't see the need, look elsewhere for a geriatric psychiatrist affiliated with a hospital. This kind of behavior is most often successfully treated on an inpatient basis. If you need to document what your father is trying to deal with, beg, borrow or buy a video camera and discreetly record what's happening.

Until your mother is manageable, no good facility will accept her, and you have already discovered that the home health agency cannot manage her in the evening. She would be dangerous to other residents and staff in a facility, and they cannot permit that. The homecare agency cannot use restraint, nor should they. Neither they nor your father are trained in the kind of behavioral management he is trying to do.

If your mother can be successfully treated, then your hope for care at home could possibly be fulfilled. If you decide that she would be better served in a dementia facility, you can choose the best. The way things stand now, you don't have that choice. The most compassionate thing you can do for both your mother and your father at this time is to seek treatment for your mother's pain, so that you all have better choices for the future.

I hope this points you in the right direction. Don't be surprised if your father resists the idea of psychiatric hospitalization. But, given what you described, it sounds like that would be the most effective thing to do. The trick is to find a good geriatric psychiatrist.

If you don't know anyone to ask for a referral, "Find a Physician" on the Medicare website is an option of last resort. There you'll find a more-or-less up to date list of all the psychiatrists participating in Medicare. You can search by general area or by ZIP code. There is a "Geriatric Psychiatry" option, but you will find that many psychiatrists who are good with elderly people do not list themselves in this section. You'll find a much greater selection under "Psychiatry." It will then be up to you to dig deeper and check whether they do much work with elderly people.