Last month, we published a sensitive question that one of our readers had put to us.

HelloCare reader Bruce was concerned that at his wife’s nursing home, the constant vocalisation of one resident was disturbing and upsetting other residents. Bruce posed a challenging question that “will no doubt get me some abuse”, he wrote.

His question was, “Who is being abused here: the 19 residents that can’t hear the TV or talk to one another because of the nearly constant noise, or the other one patient if she was to be medicated.”

Here at HelloCare, we are grateful to those who commented on the article, providing much useful information about different approaches to his challenging situation.

We also received a response by email from a retired psychiatrist, which we have published below for the information of our readers. The author wishes to keep his name private.

Dear team,

I am a retired psychiatrist with aged care experience since 1980. I have worked in Australia and also in England.

I certainly hope Bruce has not experienced unwarranted criticism for his dilemma in regard to his wife, but it must be tagged as one of the most intractable problem behaviours in the aged care field.  

I agree with the view that there is no one simple solution or explanation. In my experience medication is of little or no benefit, unless it is able to target a specific cause such as pain. Generally medications such as tranquillisers, antidepressants etc. have been tried and failed, so I can understand the GP being reluctant to prescribe anything. In some cases they could make things worse by increasing confusion, risk of falls etc.     

Serious constant vocalisation that disrupts an entire aged care home requires prompt specialist attention. This means a well resourced geriatric or geriatric psychiatry facility with access to special single room accommodation, and experienced clinical psychologists with behaviour management skills in assessment and treatment. In my experience such resources have become increasingly scarce. With the emphasis in old age mental health units to discharge people quickly, and shift responsibility, it is not surprising that people without dementia in aged care homes are disadvantaged, while the patient and his/her family also suffer.

Managing excessive vocalisation can require many different types of resourcing, yet sometimes even the mental health units to which some people are referred, may not have the necessary qualified and experienced staff, from a range of disciplines needed to tackle the problem.

On one occasion while working for the NHS I was asked to see a man who had suffered a stroke, and was hospitalised in a geriatric unit. His disorder left him with a neurological type of behaviour problem, in which he repeatedly cried out that he was being murdered. Yet within seconds he appeared settled but unable to speak. Such was the problem that occasionally strangers came in from the street to see everything was ok. When interviewed and with his family, the behaviour persisted, much to their great distress. I made some suggestions regarding his management and medication and planned to see him again the following week. Unfortunately that did not please the hospital, which arranged over the weekend to have him admitted to one of my beds under the Mental Health Act. However what concerned me most was that my ward was no better resourced or staffed to manage him, than the one from which he had been discharged. They had however shifted the problem.

A well-resourced specialist multidisciplinary team may be required to tackle exceptionally difficult people at times. Governments do not want to know this, as special care is expensive and lengthy in some cases. It requires experienced, understanding and well- trained staff at all levels, and clinical psychologists with an interest and experience in “hands-on” behavioural observation, assessment and treatment. Also essential is a well- designed physical facility that can modify triggers to noise, by providing a quiet environment for everyone, not just the patient with the problem.

Attention to the physical noise environment in hospitals is sometimes not seen as important today, yet Florence Nightingale wrote firmly of the need for peace and quiet. Instead many hospital and aged care homes have hard floors, television sets running continually and loud chatter amongst staff. Acute general hospitals can be even worse, robbing sleep with trolleys, PA systems and alerts, staff chatter and slamming doors.

I congratulate Bruce for seeking help and hope that those responsible will pay more attention to this kind of exceptionally demanding behaviour seriously, and worthy of better resourcing. Unfortunately, government interest in providing topping-up funds to existing aged care homes is unlikely to have any impact at all, and may only convey the false impression something has been done.   

Yours sincerely,

Name withheld

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