Intro
We went to see a patient who had what was described as "mild dementia", and was temporarily living in a care home whilst recovering from a broken hip. Our appointment plan was to take him out in his wheelchair for a coffee, and try a few paces of walking along the way. The journey from the care home to the cafe all went smoothly, but once we sat down for his coffee, the problems started to play out
What Happened?
The patient had filled his coffee cup too full, and the supervising OT asked me to help lift it to his mouth. About half way up, it spilled a few drops on to his lap. He turned to me and shouted at the top of his voice "LOOK WHAT YOU'VE DONE YOU STUPID WOMAN!". Everyone in the cafe went silent and turned to stare, I was absolutely mortified, but the patient was completely unapologetic. He wailed and screamed about getting the coffee out of his trousers for a few seconds, but by the time I had brought him some napkins he was no longer interested.
For the journey back to his care home, it was my turn to push his wheelchair. Unlike the journey out, he screamed at me every time we went over a crack or bump in the pavement "YOU STUPID WOMAN, YOU'RE HURTING ME", "THESE BLOODY PAVEMENTS, WHY WON'T THE COUNCIL FIX THEM". About half way home, the OT took over, saying "You don't need that kind of abuse", so I assumed he just didn't like me, or that he preferred someone he knew better pushing his wheelchair.
Once she took over though, I noticed he continued his shouting and screaming, but now it was no longer focussed on the pavement or anything in particular. He shouted at the busses being too loud, the cars being too close, the kerbs being too steep. It seemed like these unbridled outbursts of anger were being caused by anything that surprised him.
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Feelings
It was a very emotionally charged appointment. I had no experience of working with someone with anything more than very mild dementia, so I from the get go I was already apprehensive. When he screamed at me in the cafe, I was hurt. Of course I felt guilty for getting coffee on his trousers, but I mostly felt like a failure for shattering our rapport. I thought "great, now he hates me", and I felt like him shouting at me for pushing his wheelchair was only reinforcing that theory. Once the OT took over though and the shouting continued, I realised he wasn't just angry at me, it seemed like he was angry at everything!
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Action Plan
I wanted to relate my learning to other contexts, and reflect on how it might influence the content of a treatment appointment. I found a podcast where Steven talks about his personal experiences with emotional regulation after five strokes, and what he found helped him the most.
He described "flooding sensations" where sounds and lights would bring on severe tinnitus and completely overwhelm him, and he had to hide in dark quiet places for hours to be able to recover. Eventually he found he could recognise his triggers, particularly prolonged exposure to fluorescent lights, and found ways to mitigate them like wearing polarised lenses.
Hearing Steven's story and his coping strategies has helped me to realise that emotional lability can be incredibly distressing for those living with it, but there are ways to help control it by recognising triggers and reducing stimulation.
In light of what I have learned about emotional lability, I now feel better able to recognise it, and know not to take it personally. I future, I will try to recognise triggers that patients are finding overwhelming or distressing, and ask them if they would like to do something else instead that helps to reduce their influence.
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Evaluation
His behaviour reminded me of a toddler when they get overtired, winding themselves up in to a frenzy and lashing out, because they are overstimulated and need to sleep. I realised that he wasn't just being belligerent, he wasn't in control of his emotions, and anything that caught him off guard was causing him to get rapidly and incredibly angry. I thought "wait a minute, is this what emotional lability looks like?". I had read about it and understood the theoretical side, but had never actually seen it, or experienced being around someone who might have it as part of their symptom profile.
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Conclusion
I began looking in to the behaviours associated with emotional lability and how they arise, using resources from Queensland Health. This helped me to realise that this patient did feel anger in response to being caught off guard, but he couldn't inhibit its escalation or control its severity. Its also seemed that he didn't have emotional awareness of himself or others, as he appeared not to have insight of the severity of his behaviour in the cafe.
I learned that triggers for emotional outbursts often relate to fatigue, stress, and overstimulation. The patient was probably already fatigued because of his hip fracture, may have been stressed that we were taking him out of a familiar environment, then was having to process too much sensory information from the bumps in the pavement, loud noises, and coffee spilling in his lap. On reflection, taking him to a cafe may have been pushing him too far, and we could have considered trying some walking exercises in the more familiar and calm environment of his care home.
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Analysis
I realised that if emotional lability was part of the picture, I couldn't just proceed with an appointment without taking it in to account and expect it to result in a meaningful and productive clinical contact. I needed to find out more about the day-to-day aspects of living with emotional lability, and how to help patients feel more comfortable during their appointment.
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