Principles of Behavior Management with Dementia – Principle No. 3

This is the third in a series about managing problem behaviors with older adults due to dementing illnesses, in nursing homes, assisted living facilities, or those residing in their own homes. These principles are based on proven methods to modify or change behaviors, or prevent them from worsening.  The approaches are based on the cognitive, behavioral, and emotional impairments that accompany dementia.

The third principle is to keep expectations realistic.  Do not be deceived by how much we think the person with dementia follows what we are saying. One of the hallmarks of this condition is the tendency to deny, or disguise the extent of cognitive changes occurring from the disease. The individual does not complain or emphasize the various problems he is experiencing, such as with memory, concentration, or attention to details. On the contrary, we can expect this person to minimize or mask these problems. Consequently, if we do not lower our expectations, it is very easy to overestimate what the person is understanding or comprehending in our communications. So we might think the person is perfectly okay with the explanation that we are giving, but in fact, it will probably be too complicated to process. For example, we might quickly explain why there is a change in the meal schedule or eating location. We assume the person follows our explanation, by nodding and agreeing, but eventually, the person’s distress builds because of the change from the familiar, from the routine. Even though she acts as though she is understanding and following what we are saying, the result is a lot of frustration on both the caregiver’s part and the patient’s part because of that inability to fully understand and follow that communication.  If we tax the person too much beyond her capabilities, we might trigger a catastrophic reaction, which is an intense outburst and strong emotional reaction to the task demands.  These reactions can quickly cascade into behavioral outbursts and severe behavior problems.

The lesson here is to not assume the dementia person is understanding us just because she is superficially agreeing. In fact, in the next minute, it may appear as though no explanation was given at all, and we have to start the conversation all over again, from the beginning.

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