Expert: Mary Gordon - 2/23/2011

Question
My mother has alzheimer's. She is in a nursing home. She does not like to be touched. She gets combative when we give her a shower, try to feed her, etc. We can deal with that by talking and getting her quiet. The problem we are having is clipping her nails. I do not want her to dig her nails into anyone. Last night I was trying to clip and she was fighting me. Any ideas on how t clip when a person is aggressive. I tried to clip while she is asleep, but she wakes up. The only time I saw my change to clip was when she was on a pain pill. I would hate to resort to given her a pain medication just to clip her nails. Her doctor refuse to give her any sedatives for her behavior because she holds saliva in her mouth and he is afraid that she will aspirate. Any suggestions on the nail clipping and her behavior period will be appreciated. thank You.

Answer
Hi Barbara, is there a time of the day  when she is calmer?

Quite often, people with dementia do better in the morning with challenging activities, after they are fed. At that point in the day, they should be the least stressed - they are rested, not hungry, the light levels are good, and they haven't been through a long trying day of confusion.

Have you tried combining clipping her nails with giving her a shower or bath (i.e. when the nails are softer?) Might it work to give her a nice hand and arm massage with lotion or oil to sooth her and gently work in doing her nails? What about as part of a manicure (i.e. to be followed with a little nail polish?). Sometimes it helps to soak the hands in some warm soapy water, not only to clean the hands and soften the nails for cutting, but also to make her feel relaxed and maybe pampered.  

You know her best - is there anything that she enjoys that might distract her, like music, a pet, a picture book?  Does she do better if you slowly talk her through an activity, describing what you are doing along the way in a soothing patter? Is there anything in specific that seems to upset her about getting her nails cut - the noise? The sensation of clipping through something brittle. Does it seem to hurt her? Is filing them any easier?

Drooling (sialorrhea) can result from the person's inability to swallow saliva leading to its accumulation in the throat - I wonder if this is what is going on rather than the doctor's suggestion she's holding it in her mouth on purpose. This may be evident only at night when person is lying down and thus lose gravity's assistance in swallowing. In a few patients. drooling may result from an overproduction of saliva. Drooling usually improves with the use of medications, especially the anticholinergic drugs which decrease the production of saliva.

I don't think it is reasonable for the doctor to outright refuse to consider ALL of the drugs that might reduce her combativeness. Being that upset can't be an enjoyable experience for her. You need some support from a doctor to at least TRY some alternatives that might make her more comfortable and also make daily life less of a struggle.

I'm not suggesting sedating her into zombie hood - sedatives are just one of the options, and not often recommended because they often make the person sleepy or floppy.

Many people only need meds for a short while, and then after that seem fine, and sometimes as the illness progresses, they become less agitated. Trying one isn't a permanent commitment. Not every drug will work for everyone. Not everyone gets the same side effects. You might have to try different drugs and play with dosage. I'm not saying medication is the answer, but it might be an option, given that it sounds like you have tried many approaches, and she's still very distressed. If you notice anything with respect to her saliva, you can always stop the specific medication or try something else.

Antidepressant medications for low mood and irritability
Examples include: citalopram (Celexa®) fluoxetine (Prozac®) paroxetine (Paxil®) sertraline (Zoloft®) trazodone (Desyrel®)

Anxiolytics for anxiety, restlessness, verbally disruptive behavior and resistance
Examples include: lorazepam (Ativan®) oxazepam (Serax®)

Antipsychotic medications for hallucinations, delusions, aggression, hostility and uncooperativeness
Examples include:
Newer “atypical” agents such as aripiprazole (Abilify); olanzapine (Zyprexa); quetiapine (Seroquel); risperidone (Risperdal); and ziprasidone (Geodon) Older first-generation drugs such as haloperidol (Haldol)

I don't know if this helps at all. Thinking of you.

Mary