Why would four staff be needed for personal care in dementia?

[IDontLikeMondays88]

Dad has late stage dementia. We are being told he is so agitated when receiving personal care ie toileting that he is needing 4 members of staff attending to him to do this.

can anyone explain why 4 staff members would be necessary? I just don’t get it unless they are restraining him which I assume they shouldn’t be doing.

from my point of view I just am thinking well no wonder he is agitated with there are 4 of them at him.

Think about going into any dangerous situation. You take 3 people minimum. 2 so no one is left by themself and the third is a runner.

So if it take two people to do the job. Which is usually does in care.

They obviously don’t think that’s working.

With 2 if something happens you are leaving one person alone.

With 3 if something happens you are leaving two people alone but if he attacks one of them that leaves one person running and leaves one person only trying to get him off.

With 4, you can lose a runner and you still have 2 people able to try to save the last.

Someone with a broken arm has capacity to choose to sit in their own shit.
Someone with advanced dementia may not.
And for people suggesting medication as an alternative, surely holding someone's hand in a comforting way, but also as to prevent them lashing out, to more quickly complete care, is less restrictive than giving medication that will sedate them for hours.

I presume you have very limited experience dealing with aggressive dementia patients

holding there hand by all means but you can’t hold onto if they want to pull it away you have to let go that’s a form of restraint effectively restrictive practice

theres a massive procedure and rightly so to medicate anyone and it’s generally the last resort

My late Mum had broken her hip and was in hospital and whilst there a elderly women was put into the next bed. This women was probably 8 stone wringing wet. The staff put the screen around and four of them went in. I could still see what was happening. She needed changing and kicked out with her arms and legs and started thrashing around on the bed. It was like she was possessed.

One of the staff tried to hold her legs, the other one was talking to her gently but in the end they said that they would come back later.

This women then turned towards Mum and started screaming. She then tried to get out of bed to get to Mum. Luckily I was there and I started shouting for the nurses to come and I literally put myself between Mum and this women. I grabbed her and quite honestly it was horrible. The women seemed to have super human strength.

Our hospitals are dangerous places and when I asked whether this women could be moved to a dementia ward I was told that was full!

I have worked in a secure dementia ward, though not delivering care. Sometimes restraint is is in the patients best interests, and sometimes physical restraint is less restrictive than medical restraint.

In the end I spoke to the Ward Sister and said I was concerned that without me being there Mum would have been attacked by this women. She dismissed this and although I was ready with a stronger answer I asked her would she feel the same if this was her Mum.

She didnt say much but within 30 mins a porter arrived to move this patient.

@PropertyD i am not sure what the point of your story is to be honest. That is not the situation here.

Although well done @PropertyD for advocating for your Mum.

my Dad also deserves to be advocated for even though he has dementia.

Well unfortunately in many cases it just has to be .. You can not have people sitting in their own urine/faeces .. If they physically will not let you help them you are left with little option .

The point I am trying to make is that dementia patients often have super human strength. I know its the illness but I was scared I would hurt this women. She didnt do it on purpose of course but what if I had knocked her over?

a) Changing someone who has incontinence pads does not need to happen in a bathroom/toilet. It could be done in their bedroom.

b) The bathrooms in my relative's care home were large - each had a bath with a hoist, and a wetroom-type shower area (ie the same floor area, not separate), and a toilet. Five people would easily fit in.

If he is resisting and flailing his arms and legs and possibly even biting, spitting then they need to try and calm him down. They want clean him as quickly as possible as it's distressing so two to actually do the clean and change, then the other two to verbally or gently physically distract him/keep him still enough not to cause injury to himself or others.

I think it's not that uncommon in late stage dementia for some people to get very agitated about this. As they don't understand why people are touching their private parts. Or even why they're there at all.

But it wouldn't be dignified or sanitary to just not clean them. Or send only one or two who could be overwhelmed and at risk of harm to him or themselves. So they need strength in numbers.

Even if someone is frail their body can put up a lot of resistance to something they don't want to do.

Being soiled is often the cause of distress and agitation.

I am also wondering, isn’t placing someone in a care home a form of restrain? Do they always have the capacity to consent to that?

You can’t just “put someone in a care home”. You have to have a power of attorney and the person needs to have a lack of capacity (as assessed by a doctor).

so in answer to your question no.

either the person is there of own free will or they have no capacity. My Dad is totally away with it for want of a better expression. He doesn’t know what day it is, he doesn’t recognise close relatives or the town he has lived in for 78 years, or the house he built and has lived in for 45 years. He needs help with everything. He is not safe at home (but not because he has attacted people at home) which is why he is in a care home.

I really do take offence to the suggestion he’s been “put in a care home” and thus I have restrained his freedom.

What a ridiculous comment truly ridiculous.. .. it’s a bodily function that we all do until our last dying breath.

Sorry if I've missed it OP, but what did the care home manager say when you asked them?

My Mum was 5ft in her stockinged feet with a tiny body frame. It took 3 people to provide any intimate personal care for the last 18 mths or so of her life with dementia. Two people to hold her and a 3rd to change clothing, wash / wipe / dry. She would fight and lash out in a really aggressive way - she caught me once with a lucky swipe and I was too slow ducking. It hurt. She would have been totally mortified to know she was capable of such violence pre-dementia. But she had dementia and didn't know what she was doing. But being hit still hurt whether she meant it of not.

The care home staff for my Mum were lovely - the 2 staff holding her arms would be chatting to her, trying to distract / re-assure.

I can well imagine a taller, broader, stronger man needing 4 people.

Yes, it is a normal bodily function. If someone has an accident, or is incontinent and wears a pad full of faeces/urine, they will feel uncomfortable. If their dementia, or other medical condition, leaves them unable to wash themselves or ask for help, that level of discomfort will increase rapidly. Some people will be upset, and some people will become agitated, not understanding why. They can feel something is wrong but they are not able to express what it is.

Some people were talking about consent earlier, “the resident is not consenting to be changed therefore should be left alone”, but that resident was probably not able to consent to being admitted in the care home, to begin with.
Leaving someone soiled can contribute to their agitation if we add on the pain caused by a sore bottom.
What is the most dignifying option? I honestly don’t know.

I don’t know the answer but you are definitely in your right to go and ask why and question why 4 people are needed. Does seem a bit excessive.

being the voice for your Dad is going to be incredibly important.

When elderly people reach behind themselves, grab a big lump of wet poo and start thrusting it in people's faces, throwing it, smearing it on walls, furniture, bedding, then 4 is the minimum number of people required, especially if they can cover other residents.

Late stage dementia is worst case scenario time, and faeces everywhere is truly awful requiring a lot of time to clean up and a lot of upset. Sadly, like a baby, the sheer quantity of poo can be enormous too, maybe 3 times a full nappy, especially if it follows a long period of constipation or limited diet.

The faeces gets everywhere, under nails, on clothes, in hair, in mouths, eyes, everywhere... It's hours of cleaning up for the workers and a huge length of added agitation for the patient. Add urine which can also be sprayed long distances, and I think you've got my point.

Bullshit! You clearly know absolutely nothing about elderly dementia care.

It absolutely matters if someone is being violent and refusing care. The carers cannot leave someone in a shitty pad to get sore. Do you have any idea how quickly elderly people skin can start to break down? Leading to open sores and infections.
Dementia is an awful disease that causes huge amounts of distress both to the individual and to their wider family, friends and carers. Unfortunately sometimes that distress cannot be prevented.
I have worked in care my entire working life of over 15 years. I have known of many people who sadly were extremely difficult to manage due to their level of distress. All of them needed 3 to 4 carers to enable safe effective and as low stress personal care as possible.

it is horrible yes. But it’s horrible for everyone involved and absolutely not something that care homes do without good reason.

@Kelticgold consent to being in the care has been given by my dad’s attorney as my dad doesn’t have capacity. I don’t think you understand the concept of legal capacity / a power of attorney so that is an irrelevant point you are making. And actually my Dad had a rare lucid moment when he went into the home and wanted to “give it a go” so you could take that as consent anyway.

however I do agree that if he is soiled that may increase agitation.

Yes @todayImstruggling but the point is this hasn’t been discussed or explained to us really.

I spoke to one nurse today and she says she can get him changed on her own or at other times it is 2 of them which does make me wonder if it’s a bit to do with the approach of the specific staff that are on. Who knows. I don’t think I’m wrong to question it though.

Do you mean changing his clothes? Because that is a very different situation from cleaning him.

Also, it probably depends on the time of day and his mood.

I do hope you get some answers here. Have you spoken to a manager?

No I think this is to do with toileting. I think if he doesn’t want to shower/change clothes they just leave him to it.