MANAGING CHALLENGING BEHAVIORS

As Alzheimer’s disease progresses, dementia can cause mood swings and changes in the person’s personality and behaviors, including agitation and restlessness, vocal outbursts, wandering, sleep disturbances, “sundowning,” and inappropriate sexual activities.

Agitation and Aggression

Agitation is a state of extreme irritability often characterized by hitting, pacing, yelling, cursing, arguing, threatening, and verbal or physical aggression. Agitation can be triggered by environmental factors, fear, fatigue, and feelings of abandonment. Often it is triggered when the person perceives that control is being taken away from them.

An agitated person requires an assessment for any physical cause of discomfort or pain. The following strategies may also be helpful when dealing with agitation and aggression:

• Give the person space and time to calm down.
• Avoid confrontational body language.
• Avoid criticizing or correcting the person.
• Speak slowly, using a low and soothing pitch.
• Remember that anger or fear responses naturally subside within seconds in the absence of continued triggers.
• Reduce noise, clutter, or number of persons in the room.
• Keep routines and maintain a consistent environment with familiar objects and photographs.
• Reduce intake of caffeine, sugar, and other energy-spiking foods.
• Use gentle touch, soothing music, reading, or taking a walk.
• Avoid restraining the person.
• Support independence.
• Acknowledge anger over loss of control, and verbalize understanding.
• Validate feelings and then attempt distraction or redirection.
• Keep dangerous objects out of reach.
• Use the three Rs: Repeat, reassure, and redirect.
  (FCA, 2021b)

Vocal Outbursts

Disruptive vocal outbursts become increasingly common as Alzheimer’s progresses and the ability to communicate is lost. Verbal outbursts are often triggered by fear, anger, depression, grief, confusion, helplessness, loneliness, sadness, impatience, and frustration. Environmental factors may include poor lighting, seasonal changes, overstimulation or lack of stimulation, loud noises, or excessive heat.

Outbursts may also signal physical illness or discomfort, including pain, hunger, thirst, incontinence, constipation, infection, or fatigue. React by staying calm and reassuring. Validate feelings and try to distract or redirect the person’s attention to something else. Do not try to reason with the person.

Interventions to prevent vocal outbursts related to environmental or physical factors may include:

• Assess for pain, hunger, thirst, constipation, full bladder, fatigue, infections, and skin irritation.
• Avoid being confrontational or arguing about facts.
• Redirect the person’s attention.
• Respond to the emotion not the behavior.
• Create a calm environment.
• Allow adequate rest between stimulating events.
• Provide the person with a security object.
• Acknowledge requests and respond to them.
• Look for reasons behind each behavior.
• Explore various solutions.
• Don’t take the behavior personally.
  (Alzheimer’s Association, 2021a)

Wandering

At least 6 out of 10 people with dementia will wander at least once. If not found within 24 hours, up to half suffer serious injury or death (ASAC, 2021). The following approaches may be helpful in addressing wandering:

• Make time for regular exercise to minimize restlessness.
• Use large-print signs to mark destinations, with a drawing of the activity.
• Place a photo of the person as a younger adult on the room door to help the person find “home.”
• Ensure that doors have locks requiring a key. Recognize that a danger of this approach is fire safety; the lock(s) must be accessible to others and not take more than a few seconds to open.
• Do not try to restrain the person unless there are obvious hazards.
• Remain calm and reassuring instead of controlling.
• Avoid negative commands such as, “Don’t go out there!”
• Avoid arguing with the person.
• Use a barrier to mask the door, such as a curtain, stop sign, or “do not enter” sign.
• Paint a door to look like a piece of furniture.
• Place a large “Do Not Enter” sign on exit doors.
• Paint a black space on the front porch floor that may appear to be an impassable hole.
• Add “child-safe” plastic covers to doorknobs.
• Do not lock a person with dementia in the home or car unattended.
• Install a home security system or monitoring system, such as a GPS tracking device.
• Put away items such as the person’s coat and purse.
• Sew ID labels in the person’s clothes, or have the person wear an ID bracelet.
• Inform neighbors about the wandering behavior and provide them with a telephone number.
• Have a current photo available should the need arise to report the person as missing.

Caregivers can also leave a copy of the person’s photo on file at the police department or register the person with the MedicAlert + Alzheimer’s Association Safe Return program, a nationwide emergency response service for individuals with Alzheimer’s or a related dementia (FCA, 2021b). (See also “Resources” at the end of this course.)

Sleep Issues and Sundowning

Restlessness, agitation, disorientation, and other troubling behavior often worsen at the end of the day and sometimes continue through the night. This behavior is referred to as sundowning.

Possible contributing factors to sleep disturbance include:

• Mental and physical exhaustion
• Biological clock upset, causing a mix-up between day and night
• Reduced lighting, causing misinterpretation of what is seen
• Disorientation due to inability to separate dreams from reality when sleeping

The following are some strategies to help manage sleep issues and sundowning:

• Schedule major activities in the morning or early afternoon hours.
• Encourage a regular routine of waking up, meals, and going to bed.
• Include walks or time outside in the sunlight.
• Identify triggers for sundowning events.
• Reduce stimulation during the evening hours.
• Offer a larger meal at lunch and lighter evening meal.
• Keep the home well-lit in the evening to reduce confusion.
• Avoid physically restraining the person.
• Identify activities that are soothing, e.g., listening to music.
• Discuss with the provider about best times of day for taking medications.
• Limit daytime naps.
• Reduce or avoid alcohol, caffeine, and nicotine.
  (Alzheimer’s Association, 2021a)

Perseveration and Compulsive Behaviors

Repetitious speech or actions are those that occur on a continuous basis and generally serve no functional purpose. They may include:

• Checking locks, doors, or window coverings over and over
• Having rigid walking patterns, including pacing
• Collecting or hoarding items
• Counting or organizing objects repeatedly
• Going to the toilet frequently
• Selective eating habits
• Asking the same questions repeatedly

Consider whether the person might have a need they are not able to express, such as boredom, hunger, insecurity, or need to use the toilet. It may be of benefit to substitute the behavior with another activity, such as folding laundry. Remove or hide objects in the environment that might trigger the behavior.

Repetitious activity often has a basis in the person’s past, such as going to work. Helpful measures to consider may include:

• Distract with a snack or activity.
• Avoid reminding the person that they just asked the same question.
• Ignore the behavior or question, and refocus the person into an activity such helping with a chore.
• Don’t discuss plans until immediately prior to an event.
• Learn to recognize certain behaviors (e.g., pulling at clothing to indicate a need to use the bathroom).

When the person is very rigid and resistant to any interference with the activity, avoid provoking an aggressive reaction.

• Use a calm, matter-of-fact tone of voice.
• Do not become bossy or condescending.
• Distract the person with something appealing to them.
  (UCSF, 2021; FCA, 2021b)

Shadowing is a repetitive behavior in which the person constantly follows their caregivers around since caregivers represent security and protection. Helpful suggestions include:

• Establish and maintain a daily routine to help the person feel more secure.
• Speak reassuring words every day and often, such as, “You’re safe.”
• Avoid moving household furnishings or other items around or rearranging them.
• Use a simple white board to indicate today’s date or to let the person know when the caregiver will return.
• Involve and engage the person in familiar household activities.
• Play favorite musical selections.
• Play a recording of the caregiver’s voice or any reassuring familiar voice.
• Play a videotape of recent events or familiar movies.
• Consider using a day center or hiring a professional caregiver.
  (Alzheimer’s Association, 2021a)

Inappropriate Sexual Behaviors

Because of dementia, many individuals lose the ability to determine the appropriate time, place, or manner to express sexual needs. Inappropriate behaviors may include undressing in public, making lewd remarks or unreasonable sexual demands, and sexual aggression, such as fondling, exposing genitals, or attempting to engage in sex acts with people other than their partners.

Persons who masturbate in public places should be gently led from the public area to their room. If persons have truly problematic sexual behaviors, visitation should take place in the person’s room, and once the family leaves, the person should immediately be involved in some activity.

Every attempt should be made to determine whether the person is suffering from pruritus, an infection, or a chronic stress condition. Undressing in public may also be due to being too warm or frustration about trying to remember how to dress and undress. Clothing that closes in the back makes disrobing difficult in inappropriate settings.

Forewarn family and friends of the person’s behaviors to better prepare them with what to expect and how best to respond.

If the person is disruptive or making someone else uncomfortable, make eye contact and say, “Stop,” with a calm but firm tone of voice, and then distract.

If it is thought that the person is seeking more physical affection or intimacy, consider pet therapy, a stuffed animal, and socially appropriate touching such as hand-holding, dancing, back rubs or massages, manicure/pedicure, or brushing/combing hair (UCSF, 2021).