Managing Difficult Behaviors in Dementia
Joseph M. Casciani, PhD
In my “first career” working as a psychologist in nursing homes, I was frequently asked to provide staff education and training classes. One of the most requested topics was tips and strategies on managing difficult behaviors in dementia and those patients with brain injury. Since many of our Living to 100 Club readers may know of or may be a caregiver for someone with the potential for these difficult behaviors, I thought it would be helpful here to provide a summary of principles of behavior management. Although the settings may be different for those in a skilled nursing facility from those residing at home, these basic approaches are very similar.
Causes
Individuals who are experiencing cognitive decline and moderate to advanced dementia will often exhibit problem behaviors. There are many causes or triggers to these problem behaviors, including physical (sensory losses, dehydration, pain), environmental causes (too much or too little stimulation), tasks that are too complicated, communication difficulties (aphasia), and internal triggers (sleep, infections, unmet physical needs), among others. Parenthetically, it is important to fix or treat whatever underlying causes that are possible (i.e., excess deficits). For example, poor vision or hearing may be fixed with proper eyeglasses or hearing aids, and urinary tract infections and other physical problems are often very treatable. This doesn’t reverse the mental impairment, but it can often reduce the distress the person is experiencing.
Nine Principles of Behavior Management
a. The environment should be calm and reassuring. This helps to prevent over-stimulating the individual, and to provide a sense of security, reassurance, and safety. These help to minimize anxiety.
b. Consistency in all routines and caregivers is essential (e.g., schedules for eating, activities of daily living, seating locations, etc.)
c. Keep expectations realistic, especially with dementia cases since it is very easy to over-estimate what a resident can do. This is due to their masking and minimizing symptoms
d. Provide ample opportunities for success, allowing patient to continue doing whatever self-care activities are possible. This helps to avoid greater feelings of loss and failure
e. Keep language and communication simple and limited to short phrases and directions. Patients’ frustration with communication is a frequent source of behavior outbursts.
f. Use distraction whenever dealing with argumentative or combative patients, distracting them to another topic or point of discussion. When a patient is demanding to go home, for example, instead try asking questions about where he was raised, and who lived at home, etc. This helps to reduce the tension and distracts him from the disagreement. Use of logic and reasoning are ineffective when trying to convince or dissuade a patient with cognitive impairment.
g. Use isolation when an individual becomes agitated, it usually helps to escort the person to a less stressful and less stimulating room or area. When settled again, he can be returned to the activity.
One of the Most Important Principles: R-O
h. Provide reality orientation around the clock. This means orienting the patient as to what will be happening, what just happened, what the daily schedule is, days and dates, seasons, holidays, etc. We take these everyday facts for granted but the person with dementia is often unaware of them. The more structure provided, the less anxious the patient becomes. Explaining what is happening around the patient will prevent his “filling in the gaps.” Without the explanation, he draws his own inaccurate conclusions and misinterpretations of the external situation. That is, reduce as much ambiguity as possible, thereby reducing the patient’s anxiety level as much as possible.
i. Caregivers should not take these behavior problems, outbursts, or personal verbal attacks personally. The individuals are responding to a wide range of internal and external stimuli. The caregiver should remember that he or she is usually not the trigger or source of the problem.
Summary
Caring for an individual with a dementing illness is very demanding. It tries one’s patience and leaves the door open for stress reactions for the caregiver. Fortunately, there are many resources available to educate and learn skills that will minimize the frustration and increase our tolerance. Many national organizations helping with Alzheimer’s and related dementias are available: https://www.alz.org/, https://alzfdn.org/, https://www.alzheimers.gov/
Dr. Joe Casciani is the owner and Chief Curator for the Living to 100 Club, a source of solutions to living longer and healthier, with a special focus on mindset and attitudes about aging. He has a 40-year history as a psychologist and manager of mental health practices specializing in behavioral health services with older adults. In addition to his work as a clinical consultant, he is an engaging and inspiring speaker, and helps audiences move beyond their questions and concerns about aging to create a vision of what is possible in the years ahead. He strongly believes there is value in helping people feel inspired about their future.