Dementia and Behavior Problems – Why Do Difficult Behaviors Occur?

We know that an illness like dementia brings with it changes in normal or routine functioning. The deficits that occur in brain function with the onset of various dementias, such as Alzheimer’s disease, vascular dementia, fronto-temporal dementia, or dementia with lewy bodies also increase the possibility of abnormal behaviors. These abnormal behaviors only add to the challenges faced by caregivers, since the verbal or physical outbursts, the inappropriate sexual behaviors, the apathy and withdrawal, the resistance to care, among others, are not intentional or purposeful. Rather, they are the result of behavior controls that weaken and eventually break down with the atrophy of the brain tissue. And with these defective controls, the person with dementia is more vulnerable to minor upsets or frustrations than the average person can tolerate.

In essence, the dementia patient is more sensitive to internal and external stimuli. These stimuli can also be thought of as triggers or causes of the problem behaviors, and can be grouped into four categories:

i. Physical causes include sensory losses (e.g., vision, hearing), acute and chronic illnesses, dehydration, constipation, pain, adverse effects from medications, and anxiety and depression;

ii. Environmental causes include too much or too little stimulation, too little structure, unfamiliar routines, and caregivers who are unfamiliar;

iii. Task-related causes include activities that are too complicated or have too many steps, or rely on previously learned information;

iv. Communication causes include inability to communicate one’s needs, word-finding difficulty, inability to comprehend spoken language.

Many of these causes are outside the control of caregivers but many can be managed or modified. The more caregivers can address potential causes and eliminate or minimize them, the fewer chances there are to tax the person with dementia beyond his capacity. And of course, reducing these potential causes of behavior difficulties can also mean reducing the number and dosages of psychotropic medications needed to control the behaviors. Reducing the need for chemical restraints is always desirable.

See the entire range of educational programs on the CoHealth website, for health care professionals, health care workers, and family caregivers. Two especially useful programs are the courses on differentiating among depression, dementia, and delirium and behavioral approaches for sensory losses in older adults.

Principles of Behavior Management with Dementia – Principle No. 2

This is a second in a series about managing problem behaviors with older adults due to dementing illnesses, whether residing in nursing homes, independent or assisted living facilities, or their own homes. There are many sound, proven approaches for managing these problem behaviors. Psychotropic medications are one choice, but other approaches that are milieu or environmentally-based can complement the psychoactive interventions, and may allow for a reduction or elimination of the drugs altogether.

These caregiving approaches are formulated around the impairments that come with dementia, especially in the areas of cognitive, behavioral, and interpersonal functioning. These approaches recognize that the most effective interventions incorporate an understanding of why the person is behaving the way he is. For example, this blog discusses the need for consistency in all interactions and routines with these individuals, whenever possible. Because the dementia patient is unable to learn and process new information, it becomes necessary to rely on previously learned knowledge and information as much as possible. In long term care settings, this means providing familiar caregivers, familiar rooms for activities and seating arrangements in the dining room, and familiar roommates. Anything that is being provided for this individual should be the same, predictable and consistent as possible. In private homes, meal times, preferred seating locations, and even dressing and hygiene activities should be consistent from one day to the next.

When there are changes in routine, as with new caregivers, or changes in a schedule, roommates, or meal times, those familiar to the person should take extra time to explain the change, as unimportant as it may seem. Without the explanation and extra structuring of the event, we can tax the person’s feelings of security and safety, something that can easily lead to increases in anxiety and agitation. Even when we might think a little change of pace might be enjoyable or refreshing, the person whose neurons in the brain are not firing normally will likely not appreciate the unfamiliar change. And she may become more distressed by it.

As we better understand the various losses that occur with a dementing illness, we can minimize the triggers or causes of these behaviors, and how to de-escalate the problem after it has occurred. For more insights into these issues, see my online courses on differentiating among depression, dementia, and delirium and on managing problem behaviors in dementia patients, and families facing Alzheimer's disease.