CAUSES OF CHALLENGING BEHAVIORS

Difficult behaviors can make caring for someone with Alzheimer's and other kinds of dementia a challenge. One way to approach this is to try to determine the cause of those behaviors so that we can respond more appropriately. All behaviors have meaning, so by figuring out what may be causing the behavior, we can hopefully address the unmet need underneath it.

1.   Physical Causes of Challenging Behaviors in Dementia

- Identifying Unmet Needs to Reduce Behavior Difficulties

2.   Psychological/Cognitive Causes of Challenging Behaviors in Dementia - How Feelings and Thoughts Affect Behavior

3.   Environmental / External Causes of Challenging Behaviors in Dementia

1.   10 Physical Causes of Challenging Behaviors:

As we look at various causes, consider physical causes. Physical (or biological) issues, such as discomfort or hunger, can cause people with dementia to act out or resist care.

Discomfort or Pain

Sometimes behaviors are caused by physical discomfort or pain. For example, if your mother has pain that is unnoticed, she may become restless, anxious or resist being moved or cared for.

Hunger or Thirst

Some people with Alzheimer’s wander around, searching for a snack or a drink. If your loved one needs more snacks or drinks, keep food out on the counter that's safe and easy to eat. You can also fill a covered cup with ice water and a straw and set it out on the counter. This may prevent wandering or restlessness.

Poor Nutrition

As opposed to actively seeking food or drinks, some people don't take in enough food. Perhaps your father lives on his own and is trying to be as independent as possible. He may report that all is well, but unexplained weight loss or a tour of his kitchen may reveal this isn’t the case. Poor nutrition can increase confusion and cause such behaviors as apathy or resistance to care. Older adults with early dementia often struggle with planning and making meals, and may not be getting adequate nutrition. If your father is still able to manage the other areas of living independently, try looking into such services as senior meals or meals-on-wheels to assist with meeting his nutritional needs.

Dehydration

Dehydration is closely linked with poor nutrition. Some people intentionally avoid drinking lots of water because they struggle with incontinence. Others simply forget to drink water throughout the day. Dehydration can cause decreased awareness, disorientation and increased confusion, increasing the risk of wandering and other behaviors. Depending on what medications your loved one is taking, proper hydration can be especially important because some medications can build up in the body and become toxic.

Fatigue

Being overly tired can also result in challenging behaviors. We all have less patience and tolerance when we’re tired, and it’s the same for the person with dementia. Poor sleep can certainly trigger behavior challenges in dementia, especially because people may lack the inhibition to temper their feelings of irritation or crankiness.

A Need for Exercise

Did your mother get some exercise today? If not, she may need to go for a walk or stretch her legs. Building in a time for exercise, even if it’s just walking through the house or the halls, can decrease restlessness.

A Need to Use the Bathroom/Incontinence

Perhaps your loved one is attempting to get up again out of her chair, after you’ve reminded her many times to stay seated so she won’t fall. Rather than getting frustrated with her and viewing her as stubborn, consider that she might not be able to find the words to express her need for the bathroom or to convey that she is uncomfortable, wet and in need of a new incontinence pad and change of clothes.

Urinary Tract Infection

A urinary tract infection (UTI), sometimes called a bladder infection, can dramatically affect behavior. If someone shows a sudden change in behaviors, be sure to investigate this as a possible cause. Other symptoms of a UTI include cloudy urine, pain while urinating (so watch for grimacing while your loved one is using the bathroom), foul smell and fever.

Sensory Impairments

Does the person you’re caring for have a deficit in hearing or vision? This can increase his anxiety since he might be startled by your nearness or touch. Be aware of this deficit and compensate for it by approaching the person from the front, speaking into the ear that has better hearing or gently touching him on the arm to indicate your presence.

Decreased Ability to Communicate Needs or Preferences

Deficits in communication can range from mild difficulties with finding the right words to a complete inability to make needs known. This can cause feelings of helplessness and frustration, which in turn can trigger a behavior problem. Being intentional in adhering, as much as possible, to preferences and routines can help minimize this frustration.

2.   Psychological/Cognitive Causes of Challenging Behaviors in Dementia - How Feelings and Thoughts Affect Behavior

Challenging behaviors are often among the more difficult aspects of coping with Alzheimer's and other dementias. As we consider how to reduce these behaviors, which can be distressing to both the person with dementia and the caregiver, it can be helpful to evaluate the possible psychological and cognitive causes. These include the person's emotions and thoughts.

Psychological and Cognitive Causes:

Boredom

Is your loved one bored? Maybe he needs some more routine in the day or more mental stimulation and interaction with others. Boredom can cause people with dementia to act out negatively or withdraw and become apathetic. If you're the caregiver for someone with dementia, try structuring his day by providing a regular time for games, conversation and physical activity.

Loneliness

Loneliness can also trigger certain behaviors in dementia, such as wandering, sexually inappropriate acts, aggression or agitation.

Sundowning

Sometimes, people with dementia may experience an increase in agitation or restlessness as evening approaches. Research hasn’t conclusively shown why this is, but it’s called sundowning since behaviors often get worse in the evening as the sun sets. Keeping a quiet routine and several lights on in the house may help.

Frustration with a Loss of Control

Some people become frustrated, angry or aggressive because they're aware of the need to depend on others for many things. They may have lost the ability to administer their own medications, make decisions or care for themselves. Often, they're not able to express this clearly by saying, "I'm so frustrated because I feel like everyone is telling me what to do and where I have to go." But those feelings may be present inside. If you sense someone is frustrated, it can be helpful for you to acknowledge this occasionally by saying with a smile, "I'm sorry to be the bossy daughter, mom" or simply, "Are you feeling frustrated?"

Hallucinations/Paranoia/Delusions

Unfortunately, people with Alzheimer’s often experience hallucinations (seeing or hearing something that is not present), paranoia, or delusions. If someone is not in touch with reality, it’s best not to argue or try to persuade him that he’s incorrect. Arguing can increase his frustration and anxiety since he may feel that his fears are not being taken seriously.

Confusion About Reality

While it seems obvious that confusion can be the cause of behavioral concerns, we need to remember that dementia affects that brain. Someone may act or react inappropriately because they don't understand the situation. For example, if a nursing aide is bathing a resident at a long-term care facility, the resident may not understand that he needs that assistance with physical care and may misinterpret it. If you have the television on at home, pay attention to what is on. Even if you think of it as just background noise, your loved one might not know that the TV show isn’t real and could react to it in an anxious or aggressive manner.

Depression

Depression is a significant cause of challenging behaviors. Feelings of sadness and hopelessness can cause apathy (a lack of motivation and feelings of listlessness), and can also cause an increase in confusion. In fact, pseudodementia, a condition where depression blunts emotions and thoughts to the point where it appears the person has progressive dementia, can develop.

Anxiety

Often, anxiety and depression go hand in hand with a dementia diagnosis. These feelings may be difficult to identify at times because the person may have trouble expressing them. Observe for signs of anxiety, such as pacing, worried facial expressions, repetitive questions or statements, hand-wringing, etc., and report them to his physician.

Catastrophic Reaction

A catastrophic reaction is when someone significantly overreacts to something or someone. Perhaps you have ruled out many other causes and yet the behavior, such as physical aggression, continues. It’s possible that it’s a catastrophic reaction to events or stimulation that the person just can’t comprehend; perhaps it's triggering a past negative experience. Your best approach, after ensuring her safety, is to remain calm and reassuring, give her some time and physical space and then return to provide her care after she is calm. You can also try to determine if there's a pattern to her reactions that you could change by approaching her differently.

3.   Environmental / External Causes of Challenging Behaviors in Dementia

Many of the behavioral concerns that arise in Alzheimer's and other dementia have specific causes. In order to effectively address and reduce some of those challenging behaviors, we need to first consider what might be causing the person to behave that way.

One way to approach this is to look at what's happening around, and outside of, the person with dementia. Evaluating the setting can help us determine if there are situations that may be triggering a behavioral reaction by someone whose memory, comprehension or orientation is limited.

Environmental Causes of Challenging Behaviors:

Overwhelmed by Stimulating Surroundings

Are there too many choices, is it too noisy or is more than one person speaking at the same time to your mother with Alzheimer’s? These are examples of situations that can be overwhelming for someone with dementia. She can’t process everything as well as she used to, so if the environment is too busy, this can trigger anxiety, frustration, anger or withdrawal.

Change in Routine

If your usual routine with your loved one is to rise mid-morning and eat a hot breakfast, getting up at 8 a.m. to rush off to an early doctor’s appointment might be difficult. Take this into consideration; when possible, keep consistency in the routine.

Unfamiliar Environment

Changing someone's usual environment can trigger such behaviors as restlessness, aggression and agitation. For example, when your loved one is admitted into the hospital, provide extra reassurances through your presence and through verbal reminders like, "It's going to be okay; I'm here with you." You can also offer comforting touch such as holding his hand (if this is something that usually calms the person).

Lack of Personal Space

Everyone has a personal bubble of space they’re used to keeping as their own. Individuals with Alzheimer’s or another dementia may have an increased sensitivity to a person coming into their space or a decreased awareness of others’ space.

Confrontation with Others

Sometimes, other people unknowingly trigger uncooperative or aggressive behavior in others with dementia. For example, in a facility, one person who is confused may not realize that another person is also confused, and this may unknowingly trigger a reaction of anger or frustration.

Caregiver Approach

This is a critical factor in the behavior of those with Alzheimer’s or other dementias. If the person receiving care feels rushed, patronized or unimportant, this can easily trigger frustration that shows up as resistance, hitting or verbal aggression. Focusing on how caregivers approach someone and interact with them is one of the most effective ways to manage and reduce challenging behaviors in dementia.

(Source:  About.com by Esther Heerema, MSW)