Managing Difficult Behaviors in Dementia
Ensuring needs are met using reassuring language, changing environments, and engaging in soothing activities are among helpful strategies for addressing undesirable behaviors.
Agitation is the most common reason Americans place loved ones with dementia in nursing homes. There are more than 5 million Americans with dementia,1 and 80% of them may develop behavioral symptoms such as aggression, hallucinations, or delusions at some point.2
As the geriatric population grows, health care practitioners will increasingly encounter distressed caregivers of dementia patients asking for help in handling difficult behaviors. Though most agitation is probably a result of deteriorative changes, health care professionals can influence behaviors.
Why Behaviors Occur
A patient may provide clues about an underlying problem. In one actual situation, a patient complained bitterly that his foot hurt. In the emergency department, an assessment revealed a severe bladder infection. Following treatment, the patient said his foot no longer hurt. He had provided the biggest clue—that he had pain—and it was up to caregivers and health care professionals to find the source.
Caregivers should review the events of the previous day to evaluate whether a patient is fatigued from lack of sleep or whether there are changes to a patient's routine or environment, including the presence of simple holiday decorations, for example. Change is the enemy of people with dementia.
Agitation and Aggression
After checking for physical discomforts, examine what happened immediately before the negative behavior. What triggered it? Spending the time to figure this out may help prevent future incidents. Use a soft, soothing tone and reassurance in addressing the patient, such as "You seem upset. I'm sorry you're upset, but I'm right here. Let's get a cookie."
Try a change of environment, something surprising or distracting: dancing, singing a song, going for a walk, or simply going to another room. Involve the patient in an art activity or ask for his or her help with a task. Go for a ride in the car. Play familiar hymns, Christmas carols, or old time music. Keep in mind that reasoning doesn't work.
• Involve the person in activities throughout the day, such as folding towels, drying dishes, or taking out the garbage. This will improve sleep, increase feelings of control, and reduce anxiety.
• Encourage physical activity by taking a walk, dancing, or exercising together.
• Safety-proof the home with deadbolts or locks that require a key. (Never lock a dementia patient in the home alone.) Put child-safe covers on doorknobs to the outside.
• Disguise the door with a curtain or full-length picture of a bookcase. Other possibilities that deter a patient's approach to a door are STOP! or DO NOT ENTER signs.
• A large black mat in front of or just outside a door may appear to the patient as a huge hole that can't be crossed.
• Inform neighbors about wandering tendencies and make sure they have contact phone numbers.
• Have the patient wear an ID bracelet available through MedicAlert or the Alzheimer's Association. Consider a GPS bracelet designed for this purpose.
• Have a recent photo to show if a patient does wander.
Suspicion or Paranoia
Let the person speak without correcting him or her. Be reassuring, reminding him or her who you are and that you are there to help, using phrases such as, "Let me help you look for the money," and then redirect attention to a photo album in the room. If money is a recurring issue, put coins and small bills in a purse or wallet for you to "find" in the future. If a person believes people are breaking into the house, reassure him or her with statements such as, "That must feel scary. I'm right here. I'll make sure nothing bad happens." Then refocus attention.
People with sundown syndrome may experience mood swings, agitation, yelling, lashing out at caregivers, pacing, tremors, and suspicion. They may have difficulty sleeping, wander more, and "want to go home" as shadows appear. They may be aware of their own confusion, which can lead to additional frustration.
Alzheimer's disease appears to disrupt the brain's regulation of cycles of sleep and wakefulness. Other possible causes include mental and physical fatigue; low lighting and increased shadows; discomfort due to pain, urinary tract infection, fecal impaction, etc; medications; hunger; a noisy sleeping environment; a lack of organized evening activities; excessive daytime sleeping; or people coming and going.
Interventions that may help calm a patient include using reassuring language, such as "You'll be all right. You're in a safe place;" not arguing with or correcting him or her; looking for unmet needs such as cold, hungry, wet, or in pain; relocating him or her to a calmer place, such as the bedroom, with fewer people and noises; occupying him or her with a favorite activity at the time sundowning most often occurs, such as enlisting help to make dinner, engaging in an art project, or taking a bath—something the person likes to do; and reminiscing about bedtime activities with their children when they were young parents.
Consider alternative techniques, including aromatherapy, pets, calming white noise (eg, ocean waves, crickets, or a brook), soothing food or warm milk, singing a favorite song or hymn, reading a familiar poem or children's book, gently brushing hair, or giving a hand massage; several of these techniques can be used at the same time.
Seek medical advice if these measures don't work. There may be medical conditions contributing to the nighttime confusion and agitation. A physician can also review a patient's medications, eliminating those causing reactions or that are unnecessary.
Treat pain first. If the patient experiences pain with movement, medicate at least 30 to 60 minutes before the bath. Have at the ready all the supplies you will use. Explain what you are going to do and allay fears. Maintain modesty and ensure the room and water temperature are comfortable.
Make bathing a pleasurable spalike experience. With time, a patient may look forward to bathing. Play favorite music, offer a snack or beverage, use aromatherapy, or spray a favorite perfume or aftershave. Give a shoulder massage. Find pleasing ways to involve all of a patient's senses.
Let the patient do as much as possible for him- or herself. Providing choices restores a sense of control at a time when the person has lost control of so much. Offer choices such as, "Would you like to wash your face or would you like me to help?"
Maintaining regular routines, including a regular bath routine, is the key to maintaining serenity. Rushing or startling a person with dementia may provoke agitation.
Some people with dementia may continue wanting sexual contact, while others lose interest. As dementia patients lose their inhibitions, some may display inappropriate sexual behaviors, such undressing or fondling themselves in front of others or making inappropriate sexual advances.
Keep in mind that inappropriate behaviors are part of the illness and not personal. A person with dementia may not know how to properly channel sexual urges or when to appropriately express the desire for physical affection.
Don't act alarmed or shame the person. Walk him or her to a private area. This is a good time to employ distraction techniques, offering a special treat, introducing a favorite object, or arranging time with a pet.
During the day, provide physical contact through other means such as holding hands, brushing a person's hair, or giving a back rub.
Focus on your communication style. Sit down, if possible, to be at the person's eye level; standing over someone can feel threatening. If there is a chance the patient has forgotten who you are, introduce yourself. Use a pleasant voice with a smiling facial expression. Speak slowly, calmly, and clearly—not more loudly. Don't argue or try to reason with the person; logic doesn't work.
Speak in short sentences, pausing after each to allow a person to process what you have said. Give one simple instruction at a time. When a patient with dementia is told, "Put on your shoes and socks, brush your teeth, comb your hair, and come to the kitchen to eat your breakfast," none of those things may happen. Use hand gestures when possible, such as patting the chair in which you want the person to sit. Wait patiently for a reply before repeating yourself.
Delirium triggers include a new or changed environment, such as hospitalization; electrolyte imbalance; fecal impaction; urinary retention; drug interactions or side effects; pain; stress; injury; or a serious medical problem such as a stroke, organ failure, or blood clot.
As with agitation, delirium can often be prevented or reversed with a calm, familiar environment and routines, activity during the day and quiet surroundings at night, glasses and hearing aids that are working and in place, and relaxation, such as music, massage, or reading to the patient.
Other Possible Solutions
Exposing elderly adults with dementia to bright light boosts their mood. Circadian rhythms are very sensitive to light. Research has shown that nursing home residents exposed to bright light for nine hours per day experienced fewer dementia and depression symptoms. It also improved disturbed thinking, mood, behavior, functional abilities, and sleep.
Adding melatonin reduced the time it took to fall asleep and increased the length of sleep in the study. However, when given alone, it made residents more withdrawn during the day. When used with bright light therapy, melatonin reduced aggressive behavior and didn't produce resident withdrawal. This research indicates that melatonin should be used only in conjunction with bright light therapy.
Use a large purse, a men's toiletry bag, or any other bag with an assortment of familiar objects that might be interesting to touch, manipulate, or examine. It can be easily filled with common objects in the home. Be sure to avoid items small enough to swallow, sharp objects, or anything that can be disassembled. Be creative. A bag might include items such as keys, address book, wallet, unbreakable mirror, coin purse, small stuffed animal, nonsharp kitchen gadget, sample credit cards, photos, TV remote without batteries, comb, poker chips, old cell phone, sealed flashlight, or a bottle opener.
Patient: "Get away from me! Don't touch me!"
Patient: Repeating same sentence.
Patient: "I want to get out of here!"
Patient: "Where's my suitcase (or pocketbook)? Someone took my suitcase!"
Patient: "I want to go to Sacramento."
Though none of these techniques will work all the time, patience, persistence, and trial and error can reduce agitation in dementia patients, significantly improving quality of life for both patient and caregiver.
— Linda Conti, RN, CHPN, is the director of marketing for Pathways Home Health & Hospice in the San Francisco Bay Area. A certified hospice and palliative care nurse for 22 years, her area of expertise lies in the provision of hospice and home health services in long term and residential care settings.
2. Barnes TR, Banerjee S, Collins N, Treloar A, McIntyre SM, Paton C. Antipsychotics in dementia: prevalence and quality of antipsychotic drug prescribing in UK mental health services. Br J Psychiatry. 2012;201(3):221-226.
3. Sleep issues and sundowning. Alzheimer's Association website. http://www.alz.org/care/alzheimers-dementia-sleep-issues-sundowning.asp