16: Difficult Behaviors Associated with Dementia

This program will discuss:

  • Different types of difficult behaviors associated with dementia
  • Causes for these behaviors
  • Strategies for managing difficult behaviors
  • There are no easy answer when its comes to the care of another
  • Our hope is to offer you useful information and guidelines for caring for someone with dementia
  • These guidelines will need to be adjusted to suit your own individual needs

Verbally Non aggressive

  • Complaining
  • Negativism
  • Repetitive questions
  • Constant requests for help

Verbally Aggressive

  • Cursing
  • Making distressed noises
  • Verbal sexual advances
  • Screaming

Physically Non aggressive

  • Disrobing
  • Eating inappropriate things
  • Handling or moving items
  • Wandering
  • Hoarding
  • Hiding

Physically Aggressive

  • Physical sexual advances
  • Hurting self or others
  • Throwing items
  • Grabbing, pushing and hitting
  • Spitting, kicking and biting
  • “Is there a need or reason that explains the behavior even if not apparent to the observer?”
  • All behavior has meaning, and it is the caregiver’s responsibility to figure out that meaning
  • Pain, distress, fatigue, thirst, hunger, toileting needs, constipation, fever, medication issue, and infection or other medical issue
  • Address needs before difficult behaviors occur or before difficult behaviors escalate
  • The person is not intentionally being difficult — It is the disease, not the person, causing the behavior
  • Behavioral and Psychological Symptoms of Dementia (BPSD)
  • Generalized range of psychological reactions and psychiatric symptoms and behaviors that often occur in people with dementia
  • There will be different types of corresponding symptoms and behaviors
  • Increase stress within the family unit
  • Affect the quality of life and mortality of the person with dementia
  • Distressing to caregivers
  • Cause anxiety, disrupt sleep, increase stress and health issues
  • Can lead to care recipient abuse
  • Difficult behaviors are often caused by frustration, fear, or distress
  • Caregivers must learn to read non-verbal messages to determine what may have caused it
  • A combination of pharmacological and non-pharmacological approaches can be most effective for managing difficult behaviors
  • Non-pharmacological approaches should always be attempted

What could be causing Robert’s behavior?

  • A. There is too much noise in the room.
  • B. Robert thinks that he needs to go to work.
  • C. Robert is in pain.
  • D. All of the above.

Choice A: There is too much noise in the room, is a possibility.

  • People with dementia need mental and social stimulation, though the difference between the right amount of stimulation and over-stimulation can be very small
  • Dementia lowers the person’s ability to tolerate stress (stress threshold)
  • People may react by wandering and pacing, yelling, or lashing out

Choice B: Robert thinks that he needs to go to work, is another possibility.

  • People have a need for occupation in meaningful activities
  • Although the person may no longer be able to perform the task or job, the impulse to do it can remain
  • The strong urge to be somewhere or do something can lead to agenda behavior

Choice C:Robert is in pain, is another possibility.

  • People with dementia have difficulty expressing their needs with words and so may wander,become agitated, or act out
  • Consult a healthcare professional if a person’s behavior or level of functioning suddenly deteriorates
  • Because all of these choices are possible reasons for robert’s behavior, the best answer is choice D:All of the above
  • Wandering, pacing, rummaging, protective, and catastrophic or explosive reactions
  • Expressions of agitation resulting from fear or frustration
  • Due to environmental stressors, relationships, physical discomfort, medications, unmet needs, and misinterpretation of the environment
  • Failure to recognize surroundings
  • Need or want something
  • Looking for someone or something
  • Expression of pain, discomfort, or toileting need
  • Display of uneasiness, restlessness, or confusion
  • Wandering can turn into pacing
  • Wandering can be a form of exercise


  • Adapt the environment
  • Hazards of wandering include getting lost, falling down, and getting injured
  • Enroll the person in the Safe Return® Program Click here to learn about the Safe Return® Program
  • Locating device systems
  • GPS (Global Positioning System) locator
  • RFID (Radio Frequency Identification) locator
  • Cellular locator
  • Wanderer alert systems
  • Walking back and forth in distress, fear or anxiety


  • Spend time with the person
  • Walk alongside, smile, and show interest
  • Use a distraction
  • Consider medications if needed
  • Searching through drawers or closets
  • Handling, rearranging, or taking items
  • Hoarding things
  • Caused by fear of losing things
  • Suspicious of unfamiliar environments and people


  • Offer to help find the item
  • Ask about the item and then transition to another subject
  • Distract with another item or pleasant activity
  • Misperception of the environment can lead to fear of harm, which can lead to protective behaviors
  • People with dementia can have primitive protective behaviors
  • Falling back to primitive behaviors is called reverse development
  • Provide reassurance using a calm tone of voice and body language
  • Redirect the individual to an idea or an image that is familiar and pleasant
  • Remove any environment triggers
  • Exaggerated response to an ordinary event
  • Screaming, hitting and throwing things
  • When stress threshold (limit) has been breached, a small incident can cause an unreasonable, uncontrolled reaction
  • People with dementia typically have low stress thresholds and may have already built up a high level of underlying stress


  • Watch for non-verbal messages and anxious behavior that suggest that the person’s stress threshold is approaching
  • Simplify, shorten, or slow down activities to adjust to the current level of stress
  • Particular activity, object, or person
  • Remove any environmental stressors
  • Take the individual away from that situation to a quiet, calming environment
  • Distract with a relaxing activity
  • Rest period
  • Music therapy with preferred music
  • Snack
  • Reduce clutter and noise

Click here to learn more about Progressively Lowered Stress Threshold (PLST)

  • Dementia
  • Normal changes of aging
  • Medical conditions
  • Stress from the environment
  • Expectations in task performance
  • Exaggeration of pre-existing difficult behaviors
  • Pre-morbid personality
  • Damage to the front part of the brain affects a person’s motivation, judgment, social behaviors, and impulse control
  • Increasing frustration and loss of control can result in inappropriate outbursts and aggression
  • Tolerance for stress declines


  • Look for signs that people are approaching their stress threshold
  • Restlessness, pacing, tense facial expressions, irritability, calling out, and scratching or hand wringing
  • Help relieve the stress through exercise, taking a break, or relaxing activities

Click here to learn more about Progressively Lowered Stress Threshold (PLST)

  • Aging causes a general loss of abilities
  • Medical factors that affect behavior include acute and chronic illness
  • Medical issues can limit a person’s level of functioning
  • Unfamiliar or new surroundings
  • Causes of sensory overload or deprivation
  • Bright or clashing colors
  • Cold or hot temperatures
  • Loud noises
  • Mirrors
  • Physical environments should be designed for comfort
  • Soothing colors and contrasts
  • Minimal background noise and loud noises
  • Familiar and comforting objects
  • Comfortable temperature
  • Human environmental factors
  • Approach, attitude and mood of the care team
  • Keep familiar routines with familiar people
  • Gender and ethnicity may need to be taken into consideration
  • Activities and tasks should be familiar and simplified to match the person’s level of abilities
  • Difficult behaviors are often manifestations of agitation and fear
  • Common difficult behaviors include wandering, pacing, rummaging, protective reactions, and catastrophic reactions
  • Common causes:
  • Environmental stressors
  • Human environment
  • Unmet need for occupation
  • Inaccurate perceptions of people and the environment
  • Aging factors
  • Medical issues
  • Lowered stress threshold
  • Strategies for preventing and managing difficult behaviors:
  • Observe the person for signs of stress or frustration
  • Relieve the stress with simple, pleasant activities, relaxation, or rest
  • Adapt environments to provide comfort and avoid triggers
  • Modify activities to match the person’s level of abilities
  • Manage medical issues
  • Needs or wants should be anticipated and addressed
  • Provide reassurance
  • Address any unmet needs or wants
  • Redirect to a topic that is familiar and pleasant
  • Distract with a simple, pleasant activity
  • Remove the trigger
  • Removing them from the situation
  • Playing calming music

Written by:
Catherine M. Harris, PhD, RNCS.
Mindy J. Kim-Miller, MD, PhD

Edited by:
Sasha Asdourian


15: Activity-Focused Dementia Care: Preventing Excess Disability and Difficult Behaviors

Select the best answers from the list of choices following each question.

Click here to open Certificate of Completion
  • Alagiakrishnan DL, Brahim A, Wong A, Wood A, Senthilselvan A, Chimich WT, & Kagan L, (2005). Sexually inappropriate behavior in demented elderly people.Postgraduate Medical Journal 81: 463-466.
  • Allen RS, Burgio LD, Fisher SE, Hardin JM, & Shuster JL, (2005). Behavioral characteristics of agitated nursing home residents with dementia at the end of life. The Gerontologist 45: 661-666.
  • Beck C, Frank L, Chumbler NR, O’Sullivan P, Vogelpohl TS, Rasin J, Walls R, & Baldwin B, (1998). Correlates of disruptive behavior in severely cognitively impaired nursing home residents. The Gerontologist 38(2): 189-198.
  • Boettcher IF, Kemeny B, DeShon RP, & Stevens AB, (2004). A system to develop staff behaviours for person-centred care. Alzheimer’s Care Quarterly 5(3): 188-196.
  • Brandt, J, Campodonico, JR, Rich, JB, Baker, L., Steele, C., Ruff, T., Baker, A., & Lyketsos, C. (1998). Adjustment to residential placement in Alzheimer disease patients: Does premorbid personality matter? International Journal of Geriatric Psychiatry 13 509-515.
  • Bourgeois, MS & Burgio, LD, (1997). Modifying repetitive verbalizations of community-dwelling patients with AD. The Gerontologist 37(1). 30-40.
  • Burgener S, Murrell L, & Shimer R, (1993). Expressions of individuality in cognitively impaired elders: the need for individual assessment and approaches to care.Journal of Gerontological Nursing 19: 13-22).
  • Burgio L, (1996). Interventions for the behavioral complications of Alzheimer’s disease: Behavioral approaches. International Psychogeriatrics 8: 45-53.
  • Coen RF, Swanwick GR, O’Boyle CA, & Coakley D, (1997). Behavioral disturbance and other predictors of caregiver burden in Alzheimer’s disease. International Journal of Geriatric Psychiatry 12: 331-336. Behavior problems appear to have far greater impact than do cognitive or functional impairment.
  • Cohen-Mansfield J, (2000). Theoretical frameworks for behavioral problems in dementia. Alzheimer’s Care Quarterly 1(4): 8.
  • Cohen-Mansfield J, (2005). Nonpharmacological interventions for persons with dementia. Alzheimer’s Care Quarterly 6(2):129-145.
  • Draper B, Brodaty H, Low L, Richards V, Paton H, Lie D, (2002). Self-destructive behaviors in nursing home residents. Journal of the American Geriatrics Society 50:354-358.
  • Feil, N (1982). Validation: The Feil method. Edward Feil Productions. Cleveland Ohio.
  • Hall GR, Buckwalter KC, (1987). Progressively lowered stress threshold: A conceptual model for care of adults with Alzheimer’s disease. Archives of Psychiatric Nursing 1(6): 399-406.
  • Hall,GR, GerdnerLA, Zwygart-Stauffacher M, & Buckwalter KC, (1995). Principles of nonpharmacological management: Caring for people with Alzheimer’s disease using a conceptional model. Psychiatric Annals 25(7): 432-440.
  • Hart DJ, Craig D, Compton SA, Critchlow S, Kerrigan BM, McIlroy SP & Passmore AP, (2003). A retrospective study of the behavioral and psychological symptoms of mid and late phase Alzheimer’s disease. International Journal of Geriatric Psychiatry 18: 1037-1042.
  • Heeren O, Borin L, Raskin A, Gruber-Baldini AL, Menon AS, Kaup B, Loreck D, Ruskin PE, Zimmerman S, (2003). Association of depression with agitation in elderly nursing home residents. Journal of Geriatric Psychiatry and Neurology 16(1): 4-7.
  • Hellen CR, (2004). Enabling success: Hands-on care strategies and behavioral refocusing interventions. Alzheimer’s Care Quarterly 5(2: 178-182.
  • Hooker K, Bowman SR, Coehlo DP, Lim SR, Kaye J, Guariglia R, Fuzhong L, (2002). Behavioral change in persons with dementia: Relationships with mental and physical health of caregivers. Journals of Gerontology Series B: Psychological Sciences & Social Sciences 57B(5): 453-511.
  • Keene J, Hope T, Fairburn CG, Jacoby RJ, Gedling K, & Ware CJG, (1999). Natural history of aggressive behaviour in dementia. International Journal of Geriatric Psychiatry 14: 541-548.
  • Kong EH, (2005). Agitation in dementia: Concept clarification. Journal of Advanced Nursing 52(5):526-536.
  • Kunik ME, Lees E, Snow AL, Cody M, Rapp CG, Molinari VA, & Beck, CK, (2003). Disruptive behavior in dementia. Alzheimer’s Care Quarterly 4(2): 125-136.
  • Landes AM, Sperry SD, Strauss ME, & Geldmacher DS, (2001). Apathy in Alzheimer’s disease. Journal of the American Geriatrics Society 49:1700-1707.
  • Logsdon RG, McCurry SM, Teri L, (2005). A community based approach for teaching family caegivers to use behavioral strategies to reduce affective disturbances in persons with dementia. Alzheimer’s Care Quarterly 6(2) 146-153.
  • Martinio-Salzman, D., (1991). Travel behavior of nursing home residents perceived as wanderers and nonwanderers. Gerontologist. 31(5): 666.
  • Matteson MA, Linton AD, (Barnes SJ, Cleary BL, & Lichtenstein MJ, (1996). The relationship between Piaget & cognitive levels in persons with Alzheimer’s disease and related disorders. Aging Clinical and Experimental Research 8(1): 61-69.
  • McCabe BW, Baun MM, Speich D, & Agrawal S, (2002). Resident dog in the Alzheimer’s special care unit. Western Journal of Nursing Research 24(6): 684-696.
  • Mirakhur A, Craig D, Hart DJ, McIlroy SP, Passmore AP, (2004). Behavioral and psychological syndromes inAlzheimer’s disease. International Journal of Geriatric Psychiatry 19:1035-1039.
  • Morriss, RK, Rovner, BW, German, PS, (1994). Changes in behavior before and after nursing home admission. International Journal of Geriatric Psychiatry. 9(12):965-973.
  • Nagaratnam N, & Gayagay G, (2002). Hypersexuality in nursing care facilities. Archives of Gerontology and Geriatrics 35(3): 195-204.
  • Nagaratnam N, Patel L, Whelan C, (2003). Screaming, shrieking and muttering: the noise-makers amongst dementia patients. Archives of Gerontology and Geriatrics 36(3):247-259.
  • Payne KA & Caro JJ, (1997). Behavioral disturbances in dementia as a factor institutionalization. Biological Psychiatry 42: 210S.
  • Ramadan FH, Naughton BJ, Prior R, (2003). Correlates of behavioral disturbances and pattern of psyhchotropic medication use in five skilled nursing facilities. Journal of Geriatric Psychiatry and Neurology 16(1): 8-14.
  • Richards K, Lambert C, Beck C, (2000). Deriving interventions for challenging behaviors from the need-driven dementia-compromised behavior model. Alzheimer’s Care Quarterly 1(4): 62.
  • Roberts S, Durnbaugh T, (2002). Enhancing nutrition and eating skills in long-term care. Alzheimer’s Care Quarterly 3(4): 316-329.
  • Robinson KM, Adkisson P, Weinrich S, (2001). Problem behavior, caregiver reactions, and impact among caregivers of persons with Alzheimer’s disease. Journal of Advanced Nursing 36(4): 573-582.
  • Rolland Y, Gillette-Guyonnet S, Nourhashemi F, Andrieu S, Cantet C, Payoux P, OUsset PJ, & Vellas B, (2003). Wandering and Alzheimer’s disease: Descriptive study.Revue de Medecine Interne Supplement 3 Vol. 24(s3): 333s-338s
  • Scarmeas N, Brandt J, Albert M, Hadjigeorgiou G, Papadimitriou A, Dubois B, Sarazin M, Devanand D, Honig L, MarderK, Bell K, Wegesin D, Blacker D, Stern Y, (2006). Delusions and hallucinations are associated with worse outcome in Alzheimer disease. Archives of Neurology 63(4): 627.
  • Shinoda-Tagawa T, Leonard R, Pontikas J, McDonough JE, Allen D, & Dreyer PI, (2004). Resident to resident violent incidents in nursing homes. JAMA 291(5):591-598.
  • Skjerve A, Holsten F, Aarsland D, Bjorvatn B, Nygaard HA, Johansen I, (2004). Improvement in behavioral symptoms and advance of activity acrophase after shortterm bright light treatment in severe dementia. Psychiatry and Clinical Neurosciences 58: 343-347.
  • Talerico KA & Evans l, (2000). Making sense of aggressive/protective behaviors in persons with dementia. Alzheimer’s Care Quarterly 1(4):77-89.
  • Teri L, Logsdon RG, Uomoto J, McCurry SM, (1997). Behavioral treatment of depression in dementia patients: A controlled clinical trial. The Journals of Gerontology Series: Psychological Sciences and Social Sciences 52B: P159-P166.
  • Teri L, (1994). Behavioral treatment of depression in patients with dementia. Alzheimer’s Disease & Associated disorders 8:66-74.
  • Teri L, Logsdon RG, (1991). Identifying pleasant activities for Alzheimer’s disease patients: The pleasant events schedule. The Gerontologist 32(1): 124-127.
  • Teri L, Schmidt A, (1993). Understanding Alzheimer’s: A guide for families, friends, and health care providers. Seattle: University of Washington.
  • Vance DE, Burgio LD, Roth DL, Stevens AB, Fairchild JK, Yurick A, (2003). Predictors of agitation in nursing home residents. The Journals of Gerontology Series F:Psychological Sciences and Social Sciences 58: P129-P137./li>
  • Williams L, (2004). When residents attack residents. Nursing Homes: Long-Term Care Management 53(8).Zeisel J, Silverstein NM, Hyde J, Levkoff S, Lawton MP, & Holmes W, (2003). Environmental coorelates to behavioral health outcomes in Alzheimer’s special care units. The Gerontologist 43: 697-711.