Alzheimer's Disease: Difficult Behaviors
What difficult behaviors are commonly associated with Alzheimer's disease?
Alzheimer's disease (AD) is an incurable brain disease. It slowly destroys memory and thinking skills, and it can cause troublesome changes in behavior. Common difficult behaviors are wandering, inappropriate behavior, hallucinations and delusions, and sundowning.
What is wandering?
People with AD often wander--that is, they walk or pace either aimlessly or with a purpose that is not clear to others. Wandering may happen at any time. It is a problem because they might get hurt or lost. They might also intrude on the privacy of others.
Why do people with AD wander?
Some possible reasons for the wandering are:
- Pacing or walking is how they have always coped with stress.
- The behavior is based on habits they used to have. For example, if they used to go back to work after lunch every day, they may now wander outside after lunch.
- They may be searching for something familiar, especially if their environment has recently changed.
- They are trying to find the bathroom or looking for food. They may be cold and looking for warmth, or lonely and looking for a loved one.
- They may be bored or feeling trapped or agitated.
- They may be trying to escape.
- The behavior may be a side effect of medicine.
- They may be shadowing a caregiver because they don’t know what they should be doing.
Nighttime wandering is especially difficult for caregivers, who may be prevented from getting much-needed rest. People with AD may wander at night because they:
- cannot separate dreams from reality
- have days and nights mixed up
- are too inactive during the day
- are having a reaction to medicines
- need to use the bathroom
- don't need as much sleep as when they were younger and go to bed too early.
How can wandering problems be helped?
Trying to stop someone from wandering can result in confrontations that make matters worse. Study the person to try to figure out why they wander. Try to reduce the risks to the wanderer. The following may help:
- Allow the person to wander in a safe environment. For example, let them wander inside the house but not outdoors if a fenced yard with a locked gate is not available. Try removing things from view that may cause them to think about going outside, like hats, sweaters, coats, and gloves.
- Provide a wandering trail where a circular path always returns the person to where they started. Inside the home, this trail can be through a series of rooms. Outside, a path can be made within a fenced yard.
- Try to reduce or prevent daytime napping so that it may be easier for the person to sleep at night.
- Put personal items out where the person can see them so they do not need to search for them.
- Reduce noise (for example, TV). Sound and confusion in the environment may prompt the person to wander to a quieter, calmer area.
- Reduce the number of people interacting with him or her.
- Make sure that walking and other kinds of exercise are daily activities.
- To turn someone in a different direction, approach them from the front and begin to walk with them. Guide them rather than turn them around directly. This avoids confrontation and promotes positive behavior. Talk to them as you walk to provide distraction.
- Speak reassuringly in a normal tone of voice. Try not to scold or them.
- If you think agitation may be a problem, talk to the healthcare provider. Low doses of medicine can often be prescribed to manage agitation. The person may wander less if they don’t feel so agitated.
- Develop a plan of action to follow in case the person wanders away. There may be familiar places to look or a trail the person usually follows. Set a time limit for searching before calling 911 for help. Keep up-to-date photos of the person in case he or she does get lost. Make sure the person carries an ID that cannot be removed (attached to the back of a shirt, for example). Contact the Alzheimer's Association for information on a program called Safe Return. This is a nationwide program that helps when a person with Alzheimer's is missing. The Web site is http://www.alz.org/we_can_help_medicalert_safereturn.asp.
What is meant by “inappropriate behaviors”?
Sometimes people with AD act impulsively in ways that are offensive to others. This might be swearing loudly or talking angrily about an friend, family member, or stranger. Other inappropriate behaviors include undressing in public areas or trying to make sexual contact with others. Even relatively innocent, slightly abnormal behaviors can become annoying to others if the person with AD keeps repeating the behavior or pestering someone.
What causes inappropriate behaviors?
As AD gets worse, more and more brain functions are lost. This includes loss of impulse control, which makes it harder for someone with AD to control his or her behavior. For example, when the person is in pain or discomfort and has lost a sense of time, he or she may not be able to handle delays appropriately. When needs are not met, the person may become angry or insulting or start cursing.
Loss of a sense of what is socially proper happens to almost all people with AD. They may start acing inappropriately around others. They may overreact to stress with aggressive behavior because they have forgotten the proper behavior. They have lost the ability to follow accepted social conventions.
How can I deal with inappropriate behaviors?
Remember, the disease is causing the behavior, not the person. Many of these behaviors come from a need for attention or affection. Giving attention or affection, such as a pat or a hug, can often prevent disruptive behavior.
Some ways to handle difficult situations include:
- Remain calm, even in the most offensive situations. Don't raise your voice. Don't act surprised or angry. The person with AD will mirror your emotions and your behavior. If you stay calm, it helps them to calm down.
- Avoid drawing attention to the person. Try to divert the attention of others away from the person with the inappropriate behavior.
- Distract the person to another activity or another area.
- Show that you understand what they are feeling. Do not scold or shame. It makes the situation worse.
- Be sure the person's physical needs are met. Hunger, pain, thirst, stress, or even an infection may cause behavior changes.
- Avoid situations that the person might believe are dangerous. When faced with a perceived danger, a person with AD will strike out in self-defense.
- Speak in simple, short sentences.
- Limit choices to 2. More than 2 choices can frustrate someone with AD.
- Break large tasks into small ones to avoid frustration.
- Smile and praise accomplishments. Each accomplishment within a task should be praised.
- Take time. People with AD process information slowly. Give them time to do a task or respond to a question.
- Stand close to the person when giving personal care. It gives them a sense of security. And, if they should strike out, the blow may pack less punch than if you were further away.
- Watch for early signs of frustration and change the activity.
- Keep everything simple, easy, flexible, quiet, and calm.
When should I get help?
Sometimes you may not be able to redirect or control the behavior of a person with AD. If you need help quickly in a public place, don’t be afraid to ask a nearby adult. You can ask them to find a public-service employee (police or security guard) or a store manager. Explain that you need a bit of calm help, and that the person with AD has some memory and behavior problems. You need to let them know of the person’s disability, but you don’t need to give lots of details.
Get help moving to a quiet and safe place. Then figure out how you can get the person back to their home or to a caregiver they know. If the person with AD is very agitated and you are unable to manage their safety, you may have to call 911 for skilled EMT assistance.
HALLUCINATIONS AND DELUSIONS
What are hallucinations and delusions?
Hallucinations are perceptions that are not based on reality, such as seeing or hearing things that are not there. Many hallucinations are related to the need to feel safe. For example, someone who does not feel safe may make up an imaginary companion who helps them feel safe.
Delusions are false beliefs. For example, a person with AD may plan activities for a visit with a relative even though the relative is dead. It is thought that people develop delusions to avoid depression and self-blame. The delusions may help them keep feeling good about themselves and a sense of control.
How can I deal with hallucinations and delusions?
Dealing with hallucinations or delusions requires patience and a willingness to listen.
- Don’t contradict the person's beliefs. Encourage them to give more details about the events they are describing. Trying to correct them or argue about what is real may make them more anxious or aggressive.
- Validation techniques are often helpful. This means, for example, agreeing with the person’s feelings, rather than arguing about the content of the delusions or interrupting with the facts. Tell and show the person that you are listening and interested in hearing more. Show that you hear what they are saying, not whether it is correct or incorrect. It is more important to listen and respond to what they are saying than to try to get the person to face reality.
- Always stay calm and friendly. Speak slowly and clearly to make yourself heard. Look directly at the person. This shows your interest in what is being said and may decrease their anxiety.
- Establish a trusting relationship that is not demanding. Find and build on strengths the person has. Feeling safe, trusted, and respected can decrease the need for protective delusions.
When these measures do not help, medicine may be needed to decrease hallucinations and delusions if they cause the person to be anxious or physically out of control. It is important to talk to your healthcare provider about these issues.
What is sundowning?
Late in the afternoon or evening people who have AD may become more suspicious, disoriented, and upset. They may have more hallucinations and delusions. These behavior changes are called sundowning or the sundown syndrome. The cause of sundowning is not known. Maybe it happens because they are tired. Perhaps they have trouble understanding what they are seeing in the dim light of twilight and it is frightening.
How can I deal with sundowning?
- A sort nap before late afternoon may help. This may help lessen tiredness and stress at the end of the day.
- Regular routines are helpful to decrease stress. Always doing the same activity at the end of the day is comforting and reassuring.
- Turn on lights to keep the amount of light constant until bedtime.
- Limit the number of visitors and noise at that time of day to lessen stress and confusion.
- Try to find out which changes in the person’s surroundings cause behavior problems. Try to avoid these changes. It may help to keep a journal about what happens and when and where it happens.
- Provide reassurance and support. When unwanted behaviors do happen, don’t argue or try to change the behavior. Instead, try to divert the person to another activity.
Are there medicines for difficult behaviors?
Research on the effectiveness of medicines to control difficult behaviors does not show that anti-psychotic drugs have great benefits. Studies have shown just some small benefits from medicines with lots of risk from side effects of the medicines. Studies usually show more benefit from behavioral strategies than from medicine. However, if a person has disruptive, difficult-to-manage behaviors, talk to their healthcare provider. In some cases, a trial of medicine may be necessary.
Where can I get more information?
For more information contact:
The Alzheimer's AssociationWeb site: http://www.alz.org 24-hour help line: 1-800-272-3900 (TDD: 1-866-403-3073).
Written by Carolyn Norrgard, RNC, BA, MEd, and Carol Matheis-Kraft, PhD, RNC, for RelayHealth.
Published by RelayHealth.
© 2012 RelayHealth and/or its affiliates. All rights reserved.