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

STRATEGIES:

• 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

STRATEGIES:

• 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

STRATEGIES:

• 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
• STRATEGIES:
• 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

STRATEGIES:

• 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

STRATEGIES:

• 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

www.LightBridgeHealthcare.com

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