Perplexity

Mrs. Smith resides at the far end of the long hall. A sound-deflecting acoustic wall on wheels is perched outside the door. She has been with us for weeks, minus a four-day visit to the medical floor for dehydration, uti, and... whatever else they came up with to give us a *little* respite. Sure, we certainly could have managed these issues right here, but... But.
She is aggravating the other patients. Since her stay on our unit, violent outbursts of behavior by patients has increased dramatically, as have our use of seclusion and restraints.

She is a screamer.
That is all she does.
She is not a walkie-talkie.
She is not a danger to herself or others.

She is extreeeeeeeeeemely demented. And the nursing home doesn't want her back. That is how she came to reside with us. She came in for evaluation and medication adjustments. And now she's dumped.
Dementia with behavioral disturbance, her chart asserts.
Ativan and haldol help in small ways. Very.small.ways. Neurontin worked for the first few days, then waned. I could go on and on about the antipsychotics and antianxiety meds that have failed.
She does not converse spontaneously. Sometimes, when questioned, she will answer. Sometimes it is appropriate, often it is not. When asked if she is in pain, she will say yes. She will not articulate where. Palpation does not elicit a flinch. So, she must be in pain. Percocet worked. For three days, until she vomited twice, and her medical doctor cut it. Supershrink initiated duragesic. It also worked. Or, is currently working, as of last night. Medical doctor doesn't believe she needs narcotics. It was pointed out that one could - theoretically - inquire if she believes she is a duck on rollerskates wearing a tutu, and she would likely reply 'yes'. But that would be unprofessional. The point is, the patch is working. (and no, it is not to be applied over the oral cavity).
I should explain that this poor soul's screaming is not an occasional holler. I am referring to all-out, full-on, NONSTOP shrieking that will stand hair on end. *This* is how she becomes dehydrated. She will not close her mouth long enough to take in an appropriate amount of food or fluids. She will, at times, sit bolt upright in bed, and then fling herself backwards with enough force to rattle the teeth in her head, but that's about it. With the advent of the fentanyl miracle, her wailing has decreased significantly, and there are no excessive sedation effects noted. She is awake and responsive, and has long periods of silence. She gets sleep, she gets nourishment.
She was up for discharge today. Wouldn't you know it, yesterday she developed an aversion to swallowing. Not difficulty swallowing, mind you. Seems she might have forgotten how.
Medical doc wants her off the patch.
Anyway, to make a long story longer... she'll be getting a speech eval and swallow study. She probably will go medical again. Family is trying to accept the scenario that end-stage dementia could lead to a peg-tube for comfort measures. Hospice had already been consulted for f/u at the LTC facility. And we know, in the back of our minds, that the first weekend the nursing home gets to enjoy the unending screaming, she will be right back here.
For management.