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.

@IlovelurchersYes op cares for him in the past but not now? Why would that be do you think? He’s clearly worsened hasn’t he. He’s not the same person. Dementia changes people and that’s why he’s in a home. If he was the same person as his earlier stages, he would not need the home, would he? The op has not really taken this on board and thinks he’s still the same person and yet she and her mum could not cope. If they could, he would still be at home. So the op should talk to the home but be realistic and maybe observe what’s happening? If she knows better, she can have him home again.

@MeetMeOnTheCorner honestly your post disgusts me the actual lack of empathy. I am a real person reading all these comments.

i am now going to ask mumsnet to take the post down @mumsnet

i wasnt expecting this to be so polarising and was only asking what other people’s experiences of this are by way of trying to assess whether it is normal or not. However I will investigate other forums for any questions on my dad’s care going forward as mumsnet clearly isn’t the place.

My lovely father’n’law was sadly in a home with severe dementia for over two years. I’m sorry you are going through this it is tough. What I did learn was male dementia patients are more at risk of becoming physically violent - we had tried to move my f’n’law to a private nursing home but in general the feedback was they preferred female dementia patients for this reason. The only reason I can think of four people being needed is two are there just incase your father gets violent and the staff need help. I can also imagine four people surrounding you would make you feel more compliant so maybe it’s a preventative tactic. But you didn’t say how / who told you four people were around him for this.

I wanted to add - has a dr checked your dad does not have a physical reason around his anus making cleaning uncomfortable?

@IDontLikeMondays88 is it 4 people every time or have there been occasions where 4 people have got involved?

My DM has vascular dementia and required first toileting assistance and is now doubly incontinent. There have been occasions when she has become combative. I dont think she has ever needed more than 2 carers to do intimate care.

Even though my DM is now on EOL care and has no capacity she can refuse any/all personal care. She has not lost that right.

You/your DM should ask the CH what is happening around intimate care. It is possible that situations are not being well managed, carers becoming 'task focussed' so situations escalating.

Your DF hasnt been in the CH long. It is possible that some carers are doing something which your DF is finding triggering. Ask the CH what each of the 4 people are actually doing.

I am a nurse. Let me tell you sometimes you need 4 people to change someone... one to hold the client's hands (and speak kindly / calmly to them throughout) as dementia patients often hit, bite , pinch and punch. One to hold their legs so carers don't get kicked. The other 2 carers do the turn in bed and wash client and change their pad. This is quite a "normal" practice where I work.

My mother was formerly the most intensely private person imaginable, yet in later stage dementia, doubly incontinent, she had completely lost any tendency to feel embarrassment. E.g. I have been there when in the care home living room, she fished a little nugget of poo out of her pants and said, ‘Oh look!’ as if she didn’t even know what it was.

It was like dealing with a very small child - ‘Come on, let’s go and wash your hands now’, and believe me, I do not say this lightly.

I hated it - for her - that she had come to this. I would not allow any visitors except for close family, because I knew how much her former self would have hated for them to see her in that state. In fact I looked on it as a blessing - for her - that she had lost any sense of embarrassment, since otherwise every day would have been a torment to her.

I think where I struggle with this is that my grandad would pretty much have refused all personal care basically all the time. And if he had done he would have suffered with terrible sores and skin breakdown. The home did their best with a retreat and reattempt approach but sometimes it would be ongoing for so long that they'd have no choice but to clean him up because otherwise he would have been sitting in his own mess for so long that it would have damaged him. I think, in those circumstances, if they had said that they weren't going to change him because he wasn't consenting, that that would have been negligent. But then there are people on this thread saying that under no circumstances should people in those circumstances be restrained.

It was such an awful illness to watch him going through and he was so distressed so much of the time, it was just dreadful.

was only asking what other people’s experiences of this are by way of trying to assess whether it is normal or not.

To which you have received many answers that say "Yes, it can be necessary". But you've argued with all of them. I don't really know why you bothered asking!

I do hope that you get a satisfactory answer from your DF's care home - but you need to make an appointment to discuss it with someone in charge, not ask a random nurse who may not know the whole picture.

I doubt you will get very different answers on other forums. Because, yes, sometimes it is necessary to have 4 carers for a dementia patient when changing and cleaning them. As plenty of people on here have explained.

IMO what some of these posts reveal, is that so many people have absolutely no idea of what dementia can mean in normal, everyday, practice.

I will freely admit that when we were new to dementia, with my FIL, we were equally, blithely, clueless - ‘Just getting a bit more forgetful, how hard can that be?’ - but it wasn’t long before our eyes were opened. And later there were several more years of it with my DM.

So many people honestly have no idea, but they still like to pontificate and tell others where they’re going wrong.

The Alzheimer's Society have an excellent forum,Talking Point.

again that is not what I have said! I said they do not have to ask your permission. I had repeatedly said you should ask them. Which you have not bothered to do before effectively making accusations of abuse against them. Which is not fair.

There is a reason why your DF is now in full time residential care. Dementia is an absolutely awful disease and changes people so much. It’s heartbreaking to see. I very much doubt your DH is embarrassed now, much in the same way that a toddler isn’t embarrassed about being changed. My stepfather needed 3 carers to change him. One on either side to support him as he struggled to weight bearing, and a 3rd to remove trousers, remove pads, clean bottom, replace pad and trousers. If he was very soiled a 4th carer would be needed to assist in showering him. Once he became unable to weight beat at all, he would be hoisted which again required 3 carers. At 6 foot 4, he was heavy enough to cause injury if he lashed out. He once punched a carer in the mouth and she lost 2 teeth!

You don’t need POA, the LA will carry out a needs assessment to determine if residential care is required. They will also determine if the person no longer has capacity and may require a DOLs.

Reaction can depend on other things apart from the staff. people with dementia do have good days and bad days, or it might be the time of day when they need changing...loads of possibilities

I agree with other posters. There is absolutely a need, on occasion, for four members of staff to assist with the personal care of a patient. OP seems to simply be agreeing with the (far fewer) posters who suggest that this isn’t their experience.

In my opinion, there has been an enormous amount of empathy shown to you, @IDontLikeMondays88, and everyone here appreciates the very difficult and emotionally challenging circumstances your family finds itself in. But you seem determined to have your erroneous view reinforced.

Please speak to the home. I find it so strange that you’d be resistant to doing that. It would be my first port of call in your circumstances.

What you need to do, OP, is speak to the nursing home and ask what their procedures are for personal care and why so many people need to be involved in your father's care.

Many people with direct experience of working or having relatives in nursing homes have explained why it might take 4 people and that this can be "normal" for the particular resident and situation. "Normal" for any resident can and does change over time, sometimes within the same day.

It is absolutely possible to provide a degree privacy and dignity to someone who is doubly incontinent. I spent many months doing so for my dad.

I am sure he would very much have preferred not to have his adult daughter dealing with his shit at all. But given that wasn't possible, I still had the option, which I took, of doing so in the least intrusive and embarrassing way possible, given the nature of his needs. His right to as much dignity and privacy as could be afforded was one of my absolute priorities. He was a full human who happened to have a horrible and devastating illness. I thought of him and treated him as such, always, and expected others to do the same.

There are manifold possibilities in between 'leace someone to sit in their shit" and "involve as many people as you feel like in their intimate care". Can you honeatly not understand that consideration needs to be given to that?

Again, I am entirely open to the fact that it may be necessary to involve four people in OP's dad's intimate care - so is she. And OF COURSE staff have a right not to suffer injury and indignity during their work - I would never question that. If it's necessary it's necessary.

But OP is surprised it's necessary, and she knows her own father, and his illness - she was his carer for years.

Not all people who have dementia immediately descend into unpredictable violence. There is a full spectrum of responses.

Again, OP is clearly shocked at the fact that her dad now needs this cafe, based on her years of experience of him. If there has been a sudden, drastic deterioration in his ability to cope, why should she just shrug and accept that, without asking why?

And why do you believe that your opinion of the care he needs, based on never having met or seen him, is more valid than hers, based on her years of experience?

Again, do you believe it is impossible to abuse the elderly, or that this never happens?

And I can only speak from my direct experience of one person, but it absolutely can be the case that someone with dementia still feels embarrassment. One of the hardest and saddest things about caring for my dad, was the horrible embarrassment he felt at times about his condition and the level of intimate care he needed.

Indeed, the only saving grace was that he forgot the incidents very shortly afterwards - sometimes the memory loss aspect of the illness really can be a genuine blessing!

I am sure many other people with dementia cease to feel embarrassment and that's perhaps a mercy - I suppose the point is that they are all different.

Reading this thread is hard, and I should probably stop. I loved my dad so much, and caring for him at the end and trying to balance his different and extreme physical and emotional needs was one of the hardest things I have ever done.

That's why I fully understand why OP is questioning this - I am sure she desperately wants her dad to receive the most compassionate and dignified care possible, in his circumstances. And there is nothing wrong, in my opinion, with her questioning this.

Of course she needs to speak to the home as a first port of call.

To add to my pp, even before his dementia was very advanced, my FiL, who was still physically fit, was apt to fly into furious rages if crossed in the slightest thing (usually out of my control anyway).

It first happened when he wanted to hang an item he’d washed on the washing line - but we don’t have one in our very small garden. I offered to dry it elsewhere or tumble dry it, but no - he flew into such a violent rage, I had to leave the house and take the terrified dog with me. I don’t mind admitting that after having stopped smoking for at least a year, I parked, still shaking, outside the corner shop where I bought a packet of fags,

It was so unlike the FiL I’d known for so long. I know that even dh didn’t really believe me when I told him - he didn’t really believe it until he saw such a rage for himself some time later. Dh is (was then) a big hefty bloke, but even he said he wouldn’t have dared to approach him.

The thing is the OP is not accepting of the fact that, at times at least, it is very possible that her father does require 4 people to assist in showering him or taking him to the toilet.
Why that is can be for a variety of reasons as many have pointed out. Dignity and privacy are incredibly important and all the carers I have worked with over many years of service have always respected that. Having 4 people in the room doesn’t equal lack of privacy necessarily. In fact in many ways it enhances it if that means the individual is successfully prevented from having an accident in the communal areas for example or it prevents someone who has soiled themselves from further embarrassment.

It’s also incredibly important to recognise that dementia is unpredictable and people can have dramatic swings in mood, and in ability. I think people particularly family members find it very uncomfortable to talk or even think about at times. It means confronting the reality that their loved one has changed - sometimes almost unrecognisably from who they once were. It’s scary. It’s devastating. And it’s impossible sometimes not to fear for your own future.

I have experienced similar with a patient, many years ago. he was well known at the community hospital I worked in and boxed in his youth. He lived alone, had been deteriorating cognitively over a couple of years but had been supported at home. he had a fall and had come into a community elderly care hospital to get him back on his feet, knew us when he came in and was happy to be helped, not for toileting but medic assessment, assistance with standing and walking and so on. Then one afternoon, he completely lost it, we never worked out why and became violent. The hospital was, of course full of other patients and this man was rampaging around throwing things and threatening violence if he was not allowed to leave, which of course we could not do. Its the only time in my professional life when i have seen covert medication prescribed and administered, in beer from a nearby pub which is what he said he wanted when offered a drink. Nobody who was involved was unaffected by it. Yes there are bad care homes and bad staff but the majority just want to do the best job they can.

@godmum56, another example, there was a new male resident in my DM’s (specialist dementia) care home. Apparently before retirement he’d held a very senior role in the armed forces. He was prone to furious rages, throwing chairs about, etc.,among the other frail elderly residents, presumably through frustration because he couldn’t understand what was going on, or why he was there.

His wife was often with him, trying to calm him, but it was a very tall order. I felt so sorry for her, since she’d evidently tried to keep him at home for as long as possible.

Eventually, when I visited one day, only a month or two after he’d moved in, he was not there, so I assumed that he’d had to be moved for the safety of other residents.
But no, the poor man hd suffered a fatal heart attack.
I don’t mind admitting that I thought it was the kindest outcome for both him and his family.

I agree for what its worth.

Yes, for too many years that was a lifeline for me. Whatever you’re going through, someone will have been there. There aren’t often any easy answers, but at least there will be others who know exactly what it’s like.

Whereas so many of the general population like to think they know, and like to give you advice, when they usually haven’t got a bloody clue.