Behavioral Challenges

Behavioral Challenges

Causes & Strategies

Potential Causes of Behavior Problems

Symptoms of dementia can cause a flood of emotions and physical reactions, which can manifest in behavioral problems. Understanding the cause and effect can help family and professional caregivers cope better with situations that may arise.

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Reaction to Loss
We all rely on input from our environment to guide us in activities and relationships. An individual with dementia has lost both the benefit of such input and the ability to inform us of their internal world. This absence causes fear, insecurity and frustration, which may present in the form of aggression and agitated behavior.
Some Suggestions:

  • Provide reassurance.
  • Speak in a calm voice.
  • Promote a sense of security and comfort
Inability to Meet Basic Needs
As a result of cognitive impairment and psychiatric symptoms, a person’s basic needs might not be met. The resulting hunger, dehydration, elimination problems and fatigue can produce behavioral changes. Individuals with dementia may stay hungry because of, for example, their inability to feed themselves, depression or loss of muscle coordination.
They may show their discomfort through agitated and aggressive behavior. Likewise, they may forget how to pour water into a cup or never ask for a drink due to their inability to communicate. Dehydration can lead to urinary tract infection, constipation and fever’ ”putting individuals at a high risk for delirium and consequently more behavioral problems.

Similarly, an individual may forget where or what the bathroom is, and eventually may not recognize the internal cues for urination or a bowel movement. Elimination problems may manifest in the form of agitation, aggression, wandering, pacing, and incontinence. Compounding this, they may develop urinary tract infections or constipation which, left
untreated, could result in delirium. Lastly, someone with dementia may get tired easily because of wandering, pacing and disruption of the sleep-wake cycle. Fatigue often leads to irritability and aggression.

Suggestions:

  • Offer verbal and physical assistance during meals.
  • Serve foods that the individual likes.
  • Provide adequate snacks and supplements.
  • Prevent distraction during meals by rearranging the environment
  • Serve pre-cut or finger food if using utensils becomes difficult.
  • Consult with a healthcare professional about swallowing problems.
  • Schedule fluid intake to ensure six to eight glasses of liquid per day.
  • Avoid coffee, tea beverages with caffeine that act as diuretics.
  • Establish a routine for using the toilet, such as assisting them to the bathroom every two
    hours.
  • A commode, obtained at any medical supply store, can be left in the bedroom at night for
    easy access.
  • Put up signs (with illustrations) to indicate the bathroom door.
  • Use easy-to-remove clothing, such as those with elastic waistbands.
  • Try soothing music or a massage to induce sleep.
  • Reduce environmental stimuli.
  • Encourage short periods of napping to prevent exhaustion.
Co-Existing Medical Problems
Pain and discomfort from a medical problem (i.e., dental pain, urinary tract infection) or medication side effects can go unnoticed because of the individual’s inability to report it due to poor memory and/or loss of verbal skills. In addition, caregivers may have difficulty gauging the individual’ss pain because they do not respond to questions. As a result, these individuals may not receive necessary medication or treatment. Those who are in pain and discomfort tend to exhibit verbal and physical aggression, restlessness, depression or mania, and those with mental retardation are likely to exhibit more behavioral problems when they develop dementia than other individuals without psychiatric illnesses. Those with hallucinations or delusions and who are depressed or manic tend to exhibit more aggressive and agitated behavior.

Suggestions:

  • Consult with your physician about available medications, such as anti-depressants, antipsychotics
    and other mood stabilizers, to control symptoms.
  • Provide reassurance.
  • Distract and redirect with other activities.
Environmental Factors
Excessive noise, poor or glaring lighting and cold temperature in the home or a longterm care facility, and overcrowding in a group setting can increase agitation, screaming and aggressive behavior. Any change in the environment or routines, such as bathing and eating, can cause frustration and agitation. As well, boredom that results from lack of activities, and conflicts among residents in a group setting can manifest in behavioral
changes.

Suggestions:

  • Reduce excess stimuli, such as the TV or radio.
  • Elevate the room temperature.
  • Ensure adequate lighting.
  • Carefully and gradually introduce changes in routine or the environment.
  • Provide activities that are simple and creative.
  • In a group setting, staff should anticipate the characteristics of each resident and adjust
    the environment accordingly.
Sensory Impairment
Individuals with hearing or visual impairments tend to be more paranoid, hallucinate more, and feel more frightened and frustrated. For example, those with poor eyesight may not eat their food or they may be at risk for falls.

Suggestions:

  • Assess vision and hearing.
  • Ensure that individuals who wear glasses or hearing aids have them in place.
  • Evaluate problems such as cataracts, glaucoma or other eye diseases, and correct them
    with surgery, if feasible, or by creative environmental changes
Factors Related to the Caregiver
A caregiver’s attitude and knowledge of dementia affect the care of individuals with the disease. The more one knows about dementia, the less likely they will be to resent certain behavioral problems. Individuals usually respond to a caregiver’s mood and behavior accordingly.

Suggestions:

  • Become educated about the disease.
  • Learn effective communication techniques and how to cope with specific behavioral
    challenges.
  • Use a calm tone of voice combined with physical touch to convey reassurance.
  • Be patient and kind.
  • Take care of your own physical and mental health.
Strategies to Head Off or Deal with Behavioral Problems

Strategies To Head Off Or Deal With Behavioral Problems

 

  • Pay attention to what the individual with dementia is saying both verbally and nonverbally. Caregivers also should be aware of their communication techniques, including providing one-step instructions and speaking in a reassuring tone.
  • Think ahead and plan for situations that could result in problem behaviors.
  • Understand that trying to argue with someone who has dementia only results in
    frustration for both them and the caregiver.
  • Distract and divert attention whenever possible.
  • Hold to the same routine.
  • Keep things simple to avoid frustration.
  • Promote a sense of security and comfort.
  • Use positive reinforcements, such as smiles, a gentle touch, personal attention and praise.
  • Allow the individual to have some sense of control. Being able to “save face” is important to someone who is very confused.
  • Maintain a calm manner even when the individual becomes aggressive or agitated. This can defuse a tense situation and help reduce a person’s fears.
  • Assess the situation to protect yourself. Should an individual’s aggression become violent, be mindful of your own safety first.
  • Caregivers should practice ways to reduce stress when they become angry or frustrated, since anger and frustration could aggravate a behavior problem.
  • Remember that behavior problems result from the disease. Do not take things that the person says and does personally; it is the disease speaking.
  • Be creative and use common sense.
  • Try to keep a sense of humor even in the most difficult situations.

Communication

It’s not what you say, but how you say it. This expression holds doubly true when communicating with individuals with dementia. Alzheimer’s disease or related illnesses impair a person’s ability to understand words and to speak. However, they can still benefit from non-verbal communication’s body language, voice tone and facial expressions. As the individual’s ability to process verbal information declines, the importance of how caregivers communicate with them, verbally and non-verbally, increases.
 
Here are Some Tips to Enhance Interactions

  • Remember that the individual with dementia might be feeling confused, anxious, irritable and depressed, and suffering from low self-esteem.
  • Speak in a tone that is calm and reassuring; talk slowly and distinctly; and use simple words.
  • Approach the individual from the front. It may startle and upset him if you touch him unexpectedly or draw near from behind.
  • Before asking the individual to do something, address him by name to get his attention. While you are speaking, maintain eye contact to help him focus.
  • Ask only one question at a time and allow time for an answer. If he does not seem to understand, repeat the question using the same wording. If this does not work, after a few minutes, rephrase it.
  • Allow the individual adequate time to respond in conversation or when performing an activity. Rushing will increase confusion.
  • If the individual repeatedly asks a question, keep in mind that he cannot remember the response you have just given him. Instead of answering the question after a second or third repetition, reassure the individual in some way-everything is fine, you will be with him, you will help him.
  • Eliminate distractions, such as the TV or radio, when talking to the person with dementia.
  • Avoid statements that sound negative. For example, instead of “Don’t go outside,” say, “Stay inside.” Use humor whenever possible, though not at the individual’s expense.
  • Break down all tasks into simple steps. Tell the individual one step at a time what to do. Giving too many directions at once or too quickly will increase confusion. If the individual gets upset and becomes uncooperative, stop and try again later.
  • Use non-verbal gestures, when appropriate, to help convey what you want done. For example, point to objects or demonstrate an action, such as brushing your teeth.
Storytelling
Creative storytelling is a therapeutic tool for individuals with Alzheimer’s disease and their families. It is increasingly being used in adult day programs and other group settings. Pleased with the results, experts say families can adapt this technique for use in their home environments as well. Storytelling sparks memories, encourages verbalization and promotes self-esteem among those with dementia, according to healthcare professionals. “Inevitably, storytelling is about memories, but it opens the rules to include imagination and to create something new that accepts who they are and where they are in the moment. That’s a great thing for families,” noted Anne Basting, founder of the Milwaukee-based National TimeSlips Project. Renya Larson, a TimeSlips facilitator and the associate director of the National Center for Creative Aging, Brooklyn, NY, calls TimeSlips a “potent” tool designed for individuals in the middle to late stages of Alzheimer’s disease who can no longer communicate through conventional methods. Participants can comfortably incorporate gestures, sounds and facial expressions into the story.
For individuals still in the earlier stages, Larson suggested, “Creativity may be threatening. They want to hold on to the true stories they still have.” However, it may be possible to adjust the program by including more reminiscence and current events.

How-to of creative storytelling:

  • Create the right scene.Eliminate background noise, like TV and radio, and set up in a dedicated space. Prepare a sketchpad, brightly colored markers and an image. Do storytelling during the “magic hour” for higher cognitive functioning’€”9:30 am to 11:30 am or right after lunch. Maintain eye contact
  • Choose pictures carefully.The more unrealistic the picture, the better. Large, colorful pictures that are odd or include animals mimicking what people do spark creativity. While you might be inclined to use family photos, they raise the possibility of right and wrong answers, and a sense of failure. Instead, try a picture that triggers something from the past, but that is not too close so that it prompts the person to focus on remembering.
  • Learn questioning techniques.The wording of the questions is even more critical than the images. Questions that elicit yes and no, or direct answers will not work. Inquiries like “Who is this?” or “What is this?” are outlawed. These create a pressure cooker for an individual with dementia, and set them up for a wrong answer. Only open-ended questions are encouraged, such as: “What should we call the person?” “Where are they going?” “What could this be?” “What is going on here?”
  • Be persistent. If the method does not click one day, try again another day. It might take a lot of cajoling to get the person to respond. Engaging other family members in storytelling can stimulate more responses from the person with dementia, bringing the process closer to a group experience.
  • Keep a stiff upper lip. The whole idea is to open up the thought process. Responses may be negative, incorrect or resurrect family baggage. Individuals often voice their contrariness or use sexual or bathroom language. Still, echo whatever is said and make that the story. Otherwise, if you frown upon their answers, they will be afraid to participate. It is important to validate comments-however shocking, and move on.
  • Integrate music. Sometimes music will prompt responses even among individuals who are no longer verbal. Bring in music by asking open-ended questions, such as, “What might she be singing?” or “What music does the character like?”
  • Go with the flow. You do not have to write the story down if you feel it will distract from enjoying the moment. Consider using a tape recorder or involving a youngster as the scribe.
  • Redefine “story.” Creative storytelling does not have to have a beginning, middle and end, nor does it have to make sense. For example, a character can have three names and words can be nonsensical. Most of all, remember this is creative storytelling. Noted Basting: “It can be scary for people to let go of literal language. But if you can follow to where the person is, you can find a whole new way to connect to your loved one.”

 

Note:

Experts caution that creative storytelling can be more challenging one-on-one than in a group setting. Families will need to jump over some hurdles, but, with that done, this technique can be successfully adapted to the home and can be very rewarding all-around.

Anger & Aggression

Dementia affects the parts of the brain that control mood and behavior. An individual can become anxious and fearful, which often manifest as anger and aggression.
 
Suggestions

  • Seek a doctor’s advice to determine if there is a medical cause, or if medications are causing adverse side effects.
  • Limit outside noise, clutter or the number of persons in a room.
  • Keep to the same routines.
  • Reduce caffeine intake.
  • Restrict choices to minimize confusion. Do not ask, “What would you like for lunch-soup or a sandwich?” Instead, say, “Here’s some soup.”
  • Keep objects and furniture in the same places.
  • Help orient the confused person with calendars and clocks.
  • Dot the environment with familiar objects and photographs to provide a sense of security and promote pleasant memories.
  • Try gentle touch, soothing music, reading or walks.
  • Speak in a reassuring voice.
  • Distract the person with a snack or an activity.
  • Learn to recognize certain behaviors. An agitated state or pulling at clothing, for example, could indicate a need to use the bathroom.
  • Do not try to restrain the person during a catastrophic reaction.
  • Keep dangerous objects out of reach.
  • If agitation increases at night, a nightlight may reduce confusion.
  • In severe cases, doctors can prescribe medication to calm an individual.
  • Acknowledge the person’s anger over the loss of control in their life.

Paranoia

Individuals with dementia may become paranoid as a result of false beliefs, or delusions, which are a symptom of the disease. Examples of paranoia are accusations that someone is poisoning their food or stealing their money, or statements such as, “My spouse is an imposter.”
 
Suggestions

  • Discuss paranoid behaviors with the individual’s doctor. Medications may need to be adjusted.
  • Explain to other family members and caregivers that suspicious accusations are a part of the illness.
  • Respond to the feeling behind the accusation. If the accusation involves hurting someone who has passed away, you might suggest, “You really miss your mother; tell me about her.”
  • Try non-verbal reassurances like a gentle touch or hug.
  • If the individual suspects money is “missing,” allow them to keep small amounts of money in a pocket or pocketbook for easy inspection.
  • Assist the person in looking for a missing object. Try to learn where their favorite hiding places are for storing objects that are frequently “lost.”
  • Avoid arguing.

Sundowning

Sundowning is a dementia-related symptom that refers to increased agitation, confusion and hyperactivity that begins in the late afternoon and builds throughout the evening. Most sundowning emerges in mid-stage dementia and slowly worsens as the disease progresses. What causes it? Dementia may damage the body’s internal clock, causing a disruption of sleep-wake cycles. Secondly, individuals with dementia become fatigued by their inability to process information; the more hours spent on this process, the more exhausted and irritable they may become.
 
Suggestions

  • Plan activities or outings in the morning.
  • Do only simple, calming activities in the afternoon.
  • Keep individuals awake during the day.
  • Increase indoor lighting before dusk.
  • Ensure that the individual is not suffering from hunger, thirst, pain or fear.
  • Correct potential causes with basic interventions such as hydration and snacks.
  • Remove excess stimuli and clutter.
  • Watch for sundowning in early-stage dementia or rapidly worsening symptoms, both of which may suggest delirium.
  • Consult your doctor to see if medications may help.
  • Be twice as patient and kind during these hours.

Wandering

This behavior includes attempting to leave, roaming, visiting and rummaging. To assure safety, individuals should be assessed to determine possible causes of these episodes, and treated with behavioral, medical or pharmacological interventions.
 
Suggestions

  • Do not leave a person with dementia home alone.
  • Monitor and record the individual’s wandering patterns, frequency, duration, time of day, etc. For example, if wandering occurs first thing in the morning, they might be hungry; in the late afternoon or early evening, they might be experiencing “sundowning”; and during the night, they might need to use the bathroom.
  • Consult with a physician to see if medications can help. Individuals who wander as a result of delusions or hallucinations may require psychotropic medications.
  • Provide recreational activities, music therapy, physical exercise or movies, for example to reduce boredom, under-stimulation or lack of socialization that prompts wandering.
  • Ensure that the individual is well fed, well hydrated and using the bathroom since individuals may wander to fulfill these basic needs. Consider setting a schedule.
  • Reduce environmental stimuli like loud music, screaming or overcrowding that might spark this behavior.
  • Outfit the individual with an identification bracelet, and put some form of identification in every jacket, pocketbook or other article. MedicAlert markets a bracelet with a teal emblem specifically designed to symbolize Alzheimer’s disease and related dementias.
  • Obtain a wristband transmitter, such as those used by Project Lifesaver, to more easily track wanderers.
  • Have a current photo readily available and find out about leaving one on file at the police department.
  • Secure doors in a way that are difficult to open.
  • Add electronic chimes or doorbells so a caregiver is alerted if the individual attempts to exit.
  • Identify bathrooms and other rooms with colorful signs to re-orient individuals.
  • Post a large sign that says “stop” or “do not enter” on exits.
  • Mask exit doors with a curtain.
  • Place a black mat or paint a black space by an exit, which may appear to be an impassable hole to those with dementia. Likewise, a large line, strip of tape or VelcroTM may act as a barrier.
  • Provide familiar objects, such as family photographs, slippers and a quilt, to an individual living in a long-term care facility to make it feel like home.
  • Put away essential items, such as the person’s coat, shoes, pocketbook or glasses, since some individuals will not go out without certain articles.
  • Tell neighbors about the person’s wandering behavior and make sure they have your phone number.
  • Look for changes in patterns. For example, those who begin to wander after a prolonged period in a facility may suffer from a new medical, psychiatric or cognitive complication. For instance, delirium may produce the abrupt onset of wandering.
 
 

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