Behavioral Issues Associated with Dementia

Before implementing any medication therapy (BOTH OTC and Rx),
consult with the patient’s medical doctor!

SPECIFIC BEHAVIORAL DISTURBANCES

Loneliness

Loneliness is best treated with involvement of the person with the most positive relationship with the agitated patient, for that person to interact with the patient in a warm and loving manner. Other interventions found useful are one-to-one interaction with a new caregiver, videotapes of family members, contact with animals, massage therapy, and simulated presence therapy, in which the family caregiver tapes his or her side of a telephone conversation that is played for the patient as a repeated phone conversation.

Boredom

Boredom is managed by providing stimulation with structured and unstructured activities and accommodating agitated behaviors. Sensory stimulation includes music tailored for the patient, aromatherapy, and touch therapy. Books and pamphlets can be provided for patients to handle, and aprons with buttons, threads, and other articles sewn on can be provided so that patients can fiddle with these rather than with their own clothing or with harmful materials. For some individuals, it is important to provide a meaningful activity, such as folding towels or kneading dough.

Psychosis

Late-life dementias are associated with delusions and hallucinations. Paranoia may be most prominent in the middle stages of the illness. The most common delusions associated with dementing disorders are of people stealing, breaking in, or having intentions to persecute the patient or of food being poisoned. Visual hallucinations are the most common, followed by auditory hallucinations or combined auditory and visual hallucinations. The content of typical visual hallucinations includes persons from the past (such as deceased parents), intruders, animals, complex scenes, or inanimate objects. Delusions or hallucinations in Alzheimer’s disease may be a marker of a more severe or rapidly progressive dementing process. Impaired visual acuity may be associated with visual hallucinations in patients with Alzheimer’s disease.

Depression

Major or minor depression is seen in up to one half of patients with the disease and can be differentiated from apathy by the presence of psychic distress and a low mood state. Unlike that of most behavioral symptoms, the frequency of depression does not necessarily increase with overall disease severity. Depression frequently goes unrecognized in patients with dementia because of the presence of behavioral disturbances and aggression as part of dementia.

Anxiety

Anxiety is more prominent in the earlier phases of the illness and often results from anticipation of potentially stressful circumstances or an adjustment reaction to the increasing dependency associated with progressive functional decline.

Sundowning

The increased prevalence of psychiatric and behavioral symptoms in the early evening has been linked to changes in sleep patterns (partial arousal from rapid eye movement sleep, sleep apnea, and phase shifting) as well as to sensory deprivation, loneliness, and diminished social and physical time cues.  It is best managed by non-drug interventions. No drug has been specifically found to be useful for this problem.

Apathy

Apathy occurs as frequently as aggression or psychosis in dementia patients and is as important a source of caregiver distress. Apathy may best be characterized as a disturbance of motivation; associated features include loss of interest, fatigue, motor retardation, and emotionless facial expression. Increased severity of apathy symptoms is associated with severity of cognitive impairment, the presence of psychotic symptoms, and with increased severity of symptoms of depression.

Screaming

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Sleep Problems

Sleep disturbances are common with dementia. The normal changes in sleep that occur with aging (reduced REM and slow-wave sleep, with increased nighttime wakefulness and daytime napping) are exaggerated in dementia. The disruptions in nighttime sleep increase in magnitude with increasing severity of dementia. Decreased daytime activity may result from deficient physical stimulation or frailty and in turn cause sleep problems. Depression, sleep apnea, restless legs syndrome, or other sleep disorders can explain increased nighttime activity in some. Sleep disturbance in persons with cognitive impairment may be an indicator of depression, because depressed elderly persons actually have more objective evidence of sleep disturbances than do demented individuals.

Wandering/Pacing

Wandering/pacing is more often a nuisance to other residents and caregivers than to the patient. Psychotropic medications do not help and often worsen the problem. Conventional neuroleptics such as haloperidol often cause akathisia, which mimics wandering/pacing and requires discontinuation of the medication rather than increase in the dose. Patients try to leave their environment and, when prevented by caregivers, may become aggressive. Use of programs such as “safe return” by the Alzheimer’s Association may prevent complications by early detection of dementia patients who wander out of their homes and cannot find their way back. In long-term care facilities, using identification bracelets and position alarms on the person, putting alarms and complex locks on doors, and avoiding restraints are some general measures that may be helpful. Outdoor walks and the use of outdoor wandering areas are also found to be beneficial. It is important to exclude pain, discomfort, and any other physical source as potential causes of wandering/pacing. High-calorie finger foods to replace lost calories, fanny packs filled with food for snacks, and distracting places for the pacer to sit, relax, and rest are also important interventions.

Physical Aggression

Physical aggression is found to be associated with depression, psychoses, male sex, younger age, and use of psychotropic drugs, as well with dementia itself. In mild-to-moderate cases, behavioral interventions are the first line of treatment. In severe persistent cases, atypical antipsychotics or mood stabilizers may be considered for a limited period.

Self-Injurious Behavior

The specific prevalence rate of self-injurious behavior in elderly patients with dementia is unknown. It may manifest as severe self-induced excoriations of the skin secondary to delusions of parasitosis or as excessive skin picking because patients feel “sand” and feel the sand moving through the body.

Hoarding

Hoarding—collecting a large number of unneeded objects—is commonly found in dementia. It can interfere with the hygienic management and health of patients, and patients may become extremely agitated and even violent when family members threaten to discard their possessions. Patients with hoarding have been found to have a higher prevalence of repetitive behaviors. Many nurses and physicians view hoarding as negative and assume that the patient is a bit “strange” or psychotic. This behavior is best managed with non-pharmacologic interventions. Patients with “gathering/shopping behaviors”—those who take belongings from others—should be provided with safe areas from which they can “shop” and with canvas bags where their treasures can be stored and from which they can then be restored to their rightful owners.

Resistiveness

Resistiveness to physical care among patients with dementia is an extremely tiring and burdensome problem frequently leading to caregiver burnout. Executive impairment may be a predictor of resistiveness to nursing care among dementia patients. Resistiveness is best managed by caregiver education and training in non-pharmacologic interventions.

Sexual Disinhibition

Sexual symptoms such as exhibitionism and inappropriate touching (to self or others) need to be evaluated carefully to determine the nature of the gesture, to whom it was made, what preceded it, and its effect on staff and other residents. Such behaviors have not been treated successfully with medications. A multidisciplinary team should develop a consistent plan to manage such behavior.

Delirium

Patients with dementia or other brain damage have a lower threshold for developing delirium and do so with greater frequency.Physicians should suspect delirium in any elderly patient with an acute change in mental status, personality, or behavior. Delirium should be promptly identified and treated.