In this article we outline a number of common Dementia behaviors and how to address each of them. Being prepared to address certain behaviors and symptoms of dementia is extremely beneficial to the overall health and well-being of both the caregiver and dementia patient. Behaviors that may seem confusing or unexplained are common in dementia patients but often overlooked as symptoms vary throughout individuals. This article will help you understand some common behaviors, and the steps you should take as a caregiver.
- Resistance to Bathing
- Sexual Inappropriateness
- Speech Problems
- Hearing Loss
- Vision Problems
- Anger, Aggression, Agitation
It is increasingly common these days to turn on the radio or television and hear a “Silver Alert” for a missing Senior. Reportedly, six out of ten persons with Dementia will wander. Of all the Dementia behaviors, Wandering can be one of the most frightening and dangerous. Dementia sufferers get confused and can easily get lost when they wander outside of the home, even when they have spent many years in the same home. If your loved one is no longer safe to be out alone, the first thing to do is to “escape proof” the home. Locks, window and door monitors, security cameras and even baby monitors will help.
Wanderers can often have a purpose to their divergence. This unfortunately is often due to their own decline in memory and potential feelings of confusion, abandonment, or disorientation. Like other Alzheimer’s behaviors, look for the why and see if you can determine what makes your loved one want to leave. Your loved one might think they need to get to an appointment, pick the children up, go to work, or complete a different task. They might request to “go home” when they are currently in a house they have resided in for several decades, leaving the caregiver in the dark about what to do.
If there is anything that caregivers don’t get enough of, it’s sleep. Consequently, if the one you are caring for is waking constantly and spending long amounts of time awake in bed, there are a few things you can do before resorting to medication.
- Maintain a regular schedule of awake and sleep times.
- Limit daytime naps.
- Take your loved one outdoors on a regular basis and try to add a walk into that time.
- Eliminate alcohol and anything with caffeine, including soda.
- Make her bedroom restful and noise-free.
- Identify any potential sources of pain or medications that cause wakefulness
Tip for Caregivers:
Ted’s wakefulness developed into a regular habit of leaving his bed and going into his wife’s room. He would then stand over, touch her and ask “Doris, are you awake?” Of course, she wasn’t. Ted would be back with the same question 5 minutes later. Frustrated, one night she jokingly said “Yes, but I am in the middle of vacuuming. Go back to bed and I’ll get you when I am done” Ted turned around and went back to his room. From that point on, every night she would be either washing dishes, sometimes ironing; or even tap dancing. This worked, and they both got relatively good sleep.
Eating either too much or too littlecan be a major problem when one has Alzheimer’s or some other dementia. If a loved one is suddenly losing weight, it could be due to a number of reasons, including:
- Medications (these can affect the appetite and/or change taste)
- Taste and smell functions that often decline as we age
- Someone else is cooking, and it is not to their liking
- Inability to manage utensils
- Are they able to find snacks left for them?
- Dental problems may be affecting their ability to chew
- Are they getting enough exercise?
Tip for Caregivers:
- Develop a sense of humor and some flexibility regarding meals; if Mom suddenly only wants to eat oatmeal for several meals a day, let her. Jazz it up with some fruit, crumble up bacon, add a little protein drink–try something new each day.
- People with Alzheimer’s eat more when they are at the table with others. Take a break and eat your lunch with Mom.
- Eliminate meal time stress: keep the noise level down, shutting off the washer, dryer, and TV.
- Expect “accidents” and messiness–that’s what paper towels and napkins are for.
- Have healthier “snacks” available and visible.
- Serve food that is familiar and easy to eat.
When dealing with Alzheimer’s, one of the most common and difficult dementia behaviors is resistance to bathing. Someone who is already confused and feels total loss of control most likely will not get in a tub or shower willingly.
Investigate some of the reasons. Does the person feel unsafe? Are they able to see and comprehend the actual depth of the water? Have they been shown the safeguards and grab bars? Are they uncomfortable being in a hospital and getting undressed in front of strangers?
It is possible to make Alzheimer’s patients feel comfortable when bathing. Involve them in the process of “getting things ready for a bath.” Picking out shampoos or wrapping a warm towel around their shoulders and sitting for a while is a non-threatening method that can ease the way when it is bath time. Attempt to find out their preferences—bath or shower, early in the morning or just before bed, etc. Women, especially, may respond to “spa time” with soft music, “mood” lighting and nice bath products. Try doing a “dry run” in the tub or shower on the bath seat partially clothed with only a damp face cloth, maybe some moisturizer, but no running water.
Incontinence is one of the most difficult Alzheimer’s behaviors to deal with that most dementia patients will develop by their later stages.
The first step in mitigating the problem starts with the physician by making sure there is no physical cause for the incontinence such as a medication reaction. Urinary Tract Infections (UTI) are often unrecognized in persons with Dementia. They may be in pain but are unable to verbalize what is happening. A sudden dramatic change in mental status is often a sign of a UTI and should be reported to the Doctor immediately.
If the person still manages to use the bathroom some of the time, certain things can improve their success rate:
- Remain calm and reassure them when they do have accidents.
- Provide clothing that is easy to remove (elastic instead of buttons or zippers).
- Make the bathroom easy to find and use (open doors, good lighting).
- Insure that they can they safely get to the toilet, especially at night (bed height, walking distance, or furniture impediments may create difficulties).
- Reduce fluids but only right before bed (manage your patient’s hydration carefully for persons with Alzheimer’s don’t always recognize thirst).
- Establish a consistent bathroom schedule (every two hours, or after each meal).
Eventually it may become healthier for the person with Alzheimer’s and less work for the caregiver if incontinence products are used.
Constant repetition of words or other redundant behaviors can be irritating for both the caregiver and dementia patient. Patients often repeat the same actions or verbiage because they cannot remember details or events, like if they rearranged the bureau or told you that the mailman was coming. The patient is often merely trying to seek or impart some information but, due to the damaged brain cells, are not able to do so. Due to memory damage and cognitive impairment, there is sometimes an important thought within them that gets stuck.
As short term memories disappear, individuals with Alzheimer’s go back in time to memories from childhood. As toddlers, they learned that certain words or phrases should never be used or mentioned in public situations. In patients with Dementia and Alzheimer’s, their social inhibitions and awareness diminishes. This can lead to inappropriate exclamations or unexplained expletives that people can take offense to. It is important to recognize that a dementia patient may not be aware of their unfit behavior, and to apologize on their behalf to anyone who may have taken offense.
A side effect of memory decline or cognitive impairment can often lead to older adults mistaking people for others, acting out of character, or believing they are someone else completely. Sexual inappropriateness can be a side effect of these delusions, and it is necessary to recognize that their behavior is not voluntary but rather due to a lack of inhibition from their dementia. A loved one may unknowingly take part in sexually inappropriate or lewd acts as their dementia progresses to inhibit their social perceptions. It is essential to watch out for signs of this behavior, and help diffuse situations that encourage sexual inappropriateness.
Problems with communication can be stressful for both the dementia patient and caregiver. It can be difficult to respond to someone who may not be able to fully communicate, or remind oneself to refrain from correcting a patient with dementia on their speech or linguistic faults. Due to their type or stage of dementia, the patient may not even be able to comprehend general language or realize that their own speech may be incomprehensible. As Alzheimer’s progresses, patients may form less coherent sentences, more fragmented thoughts, and eventually “word salad.” Caregivers must try to decipher what they can, and gently attempt to get the patient to expand on what they are trying to communicate. Constant requests to correct themselves or communicate differently can frustrate the patient.
While hearing loss is common with age, people with dementia are often examined by audiologists without success because their constant exclamation of “What” is most likely due to a lack of comprehension rather than hearing disability. In the beginning of the disease process, people frequently miss one or two words out of four. As they further decline, they eventually reach a point where they understand one word out of four, which may confuse others in the conversation because the one word that is understood is usually taken out of context or used in a way that is unintelligible.
Tip for Caregivers:
- Short, simple sentences work best. Do not make multiple-part requests.. “Sit down and give me your foot so we can get your socks on” is too complicated for a dementia patient. Make each step a separate request.
- Not all of our communication is verbal. Facial expressions, tone, and body language may influence your loved one’s response even when you think you are doing a good job covering you frustration. Body language and other visual cues are often the most effective method of communication.
Another point to remember is that our vision declines as part of the aging process. Persons with Alzheimer’s or with another dementia are often dealing with the lost “connection” that a normal person’s brain makes when they “see“ an object, and their brain identifies it and this increases as the disease progresses.
Someone with Alzheimer’s disease has less peripheral vision, poor depth perception and less ability to detect movement. The loss of color identification can create identification issues. A white tile kitchen floor may suddenly frighten a loved one as they walks in and see “ice.” This inability to correctly identify objects can often lead to the assumption that the person is hallucinating.
Anger, aggression, and agitation can leave Alzheimer’s caregivers bewildered and frustrated, especially if the behavior is new to their loved one. The agitated behavior can be repetitive, making them appear restless. As an Alzheimer’s or dementia caregiver, you don’t always remember not to respond to verbal or physical outbursts, as it is a common side effect of the disease.
These behaviors are frequently attempts to communicate things such as pain, hunger, or fear. Good caregivers investigate and inquire as to what might be the trigger that sets off the behavior. For example, could the dementia patent be physical with an object such as her purse? Do they not recognize it as theirs? Do they think someone stole from it? Concentrate on why a behavior is happening, not how you feel being on the receiving end. The answer to this particular symptom is to always show your compassion with words and body language.
Tip for Caregivers:
When incidents of Anger, Aggression, or Agitation occur…
- Comfort them; remind them that you are there with them.
- Make sure you don’t react negatively or show your frustration; it is unlikely they know the reason behind their behavior.
- Do something positive for and with your loved one: a cup of tea, or even a hand massage. A moisturizer such as almond oil has a pleasant smell, calms, and accommodates two senses: touch and smell.
While verbal aggression can be tolerated, physical aggression should never be ignored. Make sure you protect yourself and/or others who could be harmed. Remove items that could be used as weapons. Call your physician immediately and, if necessary, call 911 for help. It is sometimes necessary to have an individual hospitalized if aggressive behavior is consistent or dangerous.
As stated before, individuals who suffer from Dementia may reside in their own realm of reality. They might accommodate for gaps in their memory with false stories that only make sense to them. Because of their false beliefs (delusions), it is not unusual for them to become paranoid. They may believe that you are poisoning them, keeping them captive, or may not even be who you say you are. While a natural reaction might be to tell them that they are wrong, that is not the proper reaction. Do not take offense, do not argue, and let them tell you what they are thinking. No matter how incredulous their story may be, acknowledge what they are saying without judgment in a simple, straightforward way.
People in the later stages of dementia are often thought to be hallucinating. Hallucinations are the perception of something that doesn’t exist. Unlike paranoia, where the individual makes up stories to fit their version of reality, hallucinations can involve sight, sound or smell. They may hear voices, or see things that are not there, or they may be convinced of an odor undetected by anyone else. Vision loss as a result of Alzheimer’s disease is usually a prominent hallucinatory symptom, and not a result of delusional thinking. Limited depth perception as well as the misinterpretation of a color can be frightening. Patterns and designs can be disorienting and distorted perception can cause disorientation which might lead someone to bump into an object and insist it was a person. Medications and pain may also be a cause.
Tip for Caregivers:
Being a great caregiver involves adequate investigation techniques, ultimately making their caregiving job easier. Discovering the cause takes time and patience, but the results can be better than an immediate fix, especially if that fix is medication.
- Do not argue or deny what they are seeing, hearing, or smelling.
- Offer them comfort and help calm them.
- Identify yourself, acknowledge their struggles, and then distract them while physically moving them to another location.
- As with all Dementia behaviors, take a few minutes and investigate. What are they really “seeing” or hearing. Do they fear the glass safety barrier because they can’t see it? Do they think they are standing on a cliff instead of the second floor balcony?
- Finally, if the hallucinations appear suddenly and are not relenting, call the physician, as this can also be a sign of a medical problem such as a urinary tract infection.
A Caregiver’s Story
Many years ago, I convinced a geriatric psychiatrist to occasionally accompany me when I made home visits to clients we shared. Edith was a charming 90- year old with mild cognitive impairment who was being treated for depression. At the time, she was managing her disease in her Berkeley apartment with supportive services such as Meals on Wheels, and transportation and visits from church members. Her medication was adjusted after she reported a problem with sleep. She started complaining about a man outside, watching her every night. During our visit, Dr. T and I both walked in the bedroom, opened the blinds, and looked out through the canvas awning only to find the view blocked by a large tree. There was no place someone could actually look in. While we didn’t comment, she was perceptive enough to realize our disbelief and dropped down onto her bed, frustrated. I sat down next to her, and we chatted while Dr. T was in the kitchen. I turned toward the window and stopped short. I immediately had the Doctor come in and sit down and suggested he look out of one of the small uncovered windows above the blinds. Through that view one could clearly see that the fraternity porch had an “appropriated” Ronald McDonald (wearing a negligee, no less) standing on the roof above the lighted doorway. There was no doubt that after getting in bed at night, and without her glasses, she could see him.