Are We Listening to Our Patients?

This story is not unlike many that you hear about today. As a seasoned gerontological nurse practitioner joining the ranks of gray-haired older moms with aging parents, aging patients with their aging children, I have learned that one must keep an open mind, open heart, open time, and listen, listen, listen to what our patients are saying, and look at what they are doing. There is a reason for all behaviors. We soon learn that it is the job of the clinician to delve into the mystery at hand, and explore all possibilities.

This story begins at 2:00 AM when my phone rang at home. It had been a very, very long day and night at our retirement community. The security resident service person was calling to tell me that one of our residents was refusing to sleep in her own bed. The resident would not even go back into the apartment. She was in her nightgown sitting in the front lobby with her eyes closed and refused to move. She said, “There is a mouse in my bedroom, and I cannot possibly go to sleep there.”

What you need to know is that this resident was quite a woman. She had gorgeous auburn hair that had never been dyed and with natural curls. She was the life of the party, the “hostess with the mostest,” and expressed herself with a dramatic flair that would always get your attention. Her earrings always matched her dress, and her red, red lipstick always matched her perfect red nails.

She was both demanding and forgiving at the same time. She was gregarious as well as gracious, easily devastated, and catastrophically crushed by the slightest negative misperception or misinterpreted gesture of another. She was, in fact, 96 years old with multi-infarct dementia, well into stage II, with Alzheimer’s-like features, exhibiting periods of paranoia, hallucinations, and delusions. She often saw people in her closet, and sometimes a man sleeping in her single bed. At times she would cut up her money, throw it in the garbage, and then report that someone had stolen it. Unfortunately, she was now beginning to have violent angry outbursts in public. It was becoming clear that there would soon become a need for a different environment to support her needs and cognitive decline, despite her moments of lucidity.

She would, at times, be talking to her husband as if he were still alive, then turn around and be shocked by his absence in the chair and come running out to the lobby screaming and crying, “He’s gone, he’s gone, has anyone seen my husband, he was right there sitting in the chair just a minute ago.” After a comforting hug, a kind listening ear, a walk among the flowers, she would then ask, “Did my husband die? Please tell me the truth.” I would answer, “Yes, a long time ago,” and she would reply, ”I thought so, thank you for telling me the truth. I must have forgotten. Sometimes I don’t know what is real.”

It should be noted that one could have just let her sleep in the lobby; however, that would have been harmful to this particular resident since she had a history of stroke, hypertension, cerebrovascular disease, poor circulation, chronic lower extremity edema with a propensity for cellulites, glaucoma, hearing loss, and severe osteoarthritis as comorbidities. Sitting all night in a chair would have caused problems related to these comorbidities, as well as great distress to the other residents who would be coming down early for breakfast. Obviously, it also would not have addressed the problem.

So at 2:00 in the morning, knowing her background, neither the security resident service person nor I actually thought that there was a mouse in the house. Racing through my doubting mind were thoughts of differential dementia diagnosis, such as Lewy body, where hallucinations such as mice running across the room are so common; however, knowing that this was a first for this resident, and knowing that she was responsive to low doses of antipsychotics, I struggled to believe her. Nevertheless, I got up and drove 25 miles back to the retirement community with my trusty dog, James. James would serve both as a distraction and a comfort to our distressed resident since we knew she loved dogs.

She was happy to see we were armed with James to the rescue! After much lapping, hugging, and sniffing, she finally consented to go back into her apartment. Then with more lapping, hugging, sniffing, silly stories, a little laughter, and a few more stories she decided to go back to bed after James had checked under the blankets and every corner of the apartment. We also told her that we were going to have security personnel conduct hourly mouse checks for her safety. A further plan would be to call her primary care physician for an order for lab work to rule out any causes for delirium such as anemia, upper respiratory tract infection, urinary tract infection, etc. By now it was 4:00 AM, and all was quiet.

Oh, by the way, during our mouse safety checks, we did indeed find not just one but two mice, which were quickly ousted from the house! Always keep an open mind, an open heart, open time, and opened eyes, and listen, listen, listen to our patients—and smile. Your residents with cognitive impairment see what they see. It is up to us to figure out if it is their actual eye or their mind’s eye that is perceiving the event.