Understanding Challenging Behaviors in Dementia

Alzheimer’s and other dementias often are accompanied by challenging behaviors that we’re not always prepared to handle. Sometimes, dementia seems to bring out the individual's basic personality all the more. Other times, personalities seem to be completely different as dementia progresses.

For example, a loved one may be punctuating every sentence with &**%***#%* — words they've never uttered throughout their whole life. A husband who has been faithful to his wife for their entire marriage may now be attempting to touch someone inappropriately or begin to have a “girlfriend” at a facility where he lives. Yet another person may have always been hospitable and welcoming, and now refuses to open the door to visitors and can be heard screaming for them to leave.

Why Is the Term “Challenging Behaviors” Used?

You can call it what you want, but often the behaviors in dementia do challenge us, as well as the person experiencing them. Other terms used to describe them include:

• Behavioral problems
• Behavioral and psychological symptoms of dementia
• Behavior concerns
• Behavior changes
• Acting out
• Difficult behaviors
• Disruptive behaviors
• Behavioral symptoms
• Inappropriate behaviors

Does Everyone With Alzheimer’s Experience Challenging Behaviors?

There are some people who remain “pleasantly confused” the whole time they have dementia. For some reason, these individuals don’t become anxious or agitated but rather they transition from a gradual forgetfulness to decreased awareness. However, this is usually the exception rather than the rule.

Some Examples

• Hoarding
• Disrobing
• Swearing
• Repetition
• Paranoia/suspicion
• Apathy
• Pacing
• Withdrawal
• Anger
• Inappropriate sexual behavior
• Agitation
• Physical aggression
• Verbal aggression
• Obsessive-compulsive behaviors
• Wandering

Causes

Alzheimer’s is a disease that affects the brain, and the brain is what controls our behaviors. So it follows that not only our thinking and memory are affected, but also our behaviors.

Many times, we can put our detective skills to use and figure out a cause for the behavior, and then that helps us determine how we should respond and try to prevent it. There are three types of factors that cause challenging behaviors:

• Physical causes of challenging behaviors including discomfort or illness
• Psychological/cognitive causes of challenging behaviors such as confusion or paranoia
• Environmental/external causes of challenging behaviors like an overstimulating environment or a different routine

In What Stage Do Challenging Behaviors Occur in Alzheimer’s?

Different kinds of behaviors occur during the stages of Alzheimer’s. Typically, in the early stages of dementia, people will battle the memory loss by initiating behaviors that they feel help them to control the situation or prevent problems. For example, it’s not unusual to see someone develop a level of obsessive-compulsive behavior since routine and repetition are reassuring and can prevent mistakes.

Other people in early dementia will begin hoarding things, either because they forgot they already had the item or because they are comforted by knowing they have multiple items in case of an emergency.

As the disease progresses into the middle stages, individuals may develop more anger, aggression, and agitation. The middle stages tend to be the most difficult in terms of behaviors since the person's ability to reason or use logic has declined. People in the middle stages also might experience some psychological behaviors such as hallucinations or paranoia, which can be very upsetting and distressing for the person and her loved ones.

In the later stages of dementia, people tend to experience more apathy and withdrawal. It can become more difficult to elicit a response from your loved one. In late-stage Alzheimer's, individuals usually require more physical assistance from you in their activities of daily care but display fewer challenging behaviors.

Responding to Challenging Behaviors

Knowing how to respond to challenging behaviors can be a true challenge. When loved ones become angry or aggressive, it's not unusual to feel hurt or frustrated. Reminding yourself that the behavior you're seeing is a result of the disease and not the person's choice can help you cope with these feelings.

Sometimes, family or friends can benefit from a short break if the frustration is too much. It's okay to give yourself a time out to take a deep breath and then return to your loved one after calming yourself.

Some physicians will prescribe medications to help with these behavioral symptoms, but keep in mind that non-drug approaches should be tried first and in a consistent manner.