Changing Moods And
Behaviors In Dementia
If you are
caring for someone with dementia, you may find that they sometimes over-react
to a trivial setback or a minor criticism. They might scream, shout, make
unreasonable accusations, become very agitated or stubborn, or cry or laugh
uncontrollably and inappropriately. This tendency to over-react is part
of the disease and is called a "catastrophic reaction". Sometimes
a catastrophic reaction is the first indication to make relatives aware
of the dementia. It may be a passing phase, disappearing as the disease
progresses, or it may go on for some time.
Coping with such behaviour can be
very difficult and is often a matter of trial and error. Remember that
the behaviour is not deliberate: it is out of the person's control and
they are probably quite frightened by it. They need your reassurance, even
though it may often not appear that way. Trying to make sense of the environment
becomes a difficult task confronting the person with dementia. Simple tasks
such as bathing, dressing and eating are all major hurdles to overcome.
People with dementia are frequently confronted by failure, so maintaining
their dignity is most important.
Three Common Worries Which Caregivers
Express:
- Is the person for whom I am caring
brooding about past tensions and misunderstandings which have occurred
between us?
- Does he hate me now?
- Have I done something unintentionally
to upset him?
These are all normal reactions -
it is important to realise that most of the anger and aggression is directed
against the cargiver because you are the closest person, however, it is
not a calculated personal attack.
Causes of Catastrophic Behaviors:
- stress caused by the excessive
demands of a situation;
- frustration caused by misinterpreted
messages;
- another underlying illness.
Aggressive behaviour may come on
without warning and make you feel very apprehensive. However, if you can
figure out what situations trigger catastrophic behaviour (perhaps by keeping
a diary), you may be able to work out ways of avoiding them. If not, you
may still be able to find methods of dealing with the behaviour quickly
and effectively when it occurs. Remember, each person with dementia is
an individual and will react to circumstances in their own particular manner.
Try To Minimize Stress:
A calm, unstressed environment in
which the person with dementia follows a familiar routine can help to avoid
such reactions.
- approch the person slowly and calmly:
try to avoid conveying your own stress, fear or alarm;
- be aware that the person may not
recognise you: try to give some information which may help, such as your
name and your relationship to them;
- try to make eye contact and address
them by name; touch may be helpful and reassuring, but be aware that some
people may not like it;
- speak clearly and use simple sentences,
allowing time for response;
- try to ask questions that require
only a 'yes' or 'no' response;
- try to talk in a place that is
free from distractions;
- try to focus on familiar skills
which are within their capabilities;
- give limited choices only, to avoid
confusion;
- break a task down into simple steps
which are not overwhelming;
- modify these steps as the person
becomes less able;
- demonstrate visually what you are
trying to say;
- if it has become difficult to understand
what the person is saying, try to focus on a word or phrase that makes
sense, or respond to the feeling they are trying to express;
- it may be necessary to remove yourself
from the situation until the person calms down.
Modifying The Environment:
People with dementia often become
extremely upset if they find themselves in a strange situation or among
a group of unfamiliar people where they feel confused and unable to cope.
The situation may seem to be very simple, but the frustration caused by
being unable to meet other people's expectations may be enough to trigger
an outburst.
- be aware of what situations lead
to difficult behaviour such as aggression and try to avoid them;
- try to do difficult and frustrating
tasks when the person is at their best and not tired;
- use a diary to help you monitor
when good and bad times are likely to occur;
- pictures or labels on objects may
help identify or locate them;
- try to avoid frustration by adapting
the environment to cope with the problem behaviour: e.g. allow the person
to go for a walk if they want to wander;
- close off certain areas of the
house where problems are occurring;
- simplifying the environment: e.g.
place only essential cutlery on the dining table;
- try to use the person's other senses
such as smell and touch;
- try to remember that problem behaviour
may intensify when there is a major change in lifestyle such as moving
house or moving into residential care.
Distraction:
- if there are a few moments before
an outburst when the person becomes increasingly agitated, you may be able
to prevent the over-reaction by calming the person down early;
- first try to respond to the feelings
of anger by soothing, comforting and reassuring the person gently. Then
try to defuse the situation by distracting them and, finally, praise success;
- alternatively, you could try calmly
ignoring the outburst and busying yourself with something else;
- try to distract a person who is
sobbing excessively or laughing uncontrollably because this is not a sign
of true emotion and may be very exhausting.
Things To Avoid:
- try not to argue with the person
when they become upset because they no longer have the ability to be rational
or logical and there is no point in trying to reason: save your energy
and concentrate on trying to remain calm.
- try not to get upset or excited
as well or the situation will simply escalate further;
- try not to order the person around;
- never reprimand or punish, even
if the behaviour appears like an unreasonable tantrum: they are not responsible
for it, cannot learn from it, and may forget the whole incident quite quickly;
- try not to focus on what the person
cannot do: focus on the positive;
- try not to be condescending or
sarcastic;
- try not to ask questions which
rely on memory;
- try not to talk about the person
in their presence;
- try not to take things personally;
- try not to hurry the person;
- never try to restrain a person
because this just increases their anxiety and distress;
- never put your own safety at risk:
if the behaviour escalates out of control, remove yourself from the situation,
call your doctor or the police.
Violence And Aggression:
Sometimes the person with dementia
may become very violent for a short time. They may become verbally abusive,
cause damage to property or become physically violent. (Physical violence
almost always occurs when someone else initiates physical contact.) Try
to stay calm and not show fear or alarm. Try to understand that even if
the aggression is directed at you, it is not a personal attack.
Violence could be caused by:
- defensive behaviour - people with
dementia may feel humiliated and frustrated when they are placed in a situation
where they have to accept assistance, especially with intimate tasks such
as bathing and toileting: when their independence and privacy are disrupted,
they may react angrily; failure of competence - the person is not able
to cope with certain tasks and may feel a failure;
- misunderstanding and bewilderment
about what is going on - as the illness progresses, the person may be bewildered
by events, for example, accusations of stealing may be an attempt to make
sense of their inability to locate something and an unwillingness to accept
that they have forgotten where they put it;
- fear - if the person is unable
to recognise people or places, this may be very frightening. The person
may be convinced they should be somewhere else (e.g. childhood home) or
may believe the person with them is a stranger. Sudden noise or people
approaching from behind may cause a hostile reaction;
- changes in routine such as the
presence of a lot of people, a special event, distracting noise or activity
may cause the person to feel unable to cope;
- attention-seeking;
- boredom, distress, restlessness,
illness or pain may be expressed in terms of anger, aggression or agitation,
especially if the person is unable to communicate such difficulties verbally;
- attempts to control other behaviours
such as wandering.
Coping With Aggressive Behaviors:
Preventive measures
- attempt tasks which cause outbursts
at the time of day when the person is at his best;
- try not to rush the person - reduce
stress by minimising distractions such as loud noise or lots of activity;
- be aware of the person's limitations
and don't expect too much;
- encourage independence by allowing
the person to do as much for himself as possible even if it takes longer
and is not as efficient;
- avoid confrontation wherever possible
- try distraction or suggesting alternatives;
- praise things which are done well
and try not to criticise;
- think about how to offer help tactfully
without taking over;
- a simple suggestion such as having
a cup of tea may defuse the situation - or you may need to withdraw until
things have calmed down;
- it may be helpful to explain the
situation to other people;
- be aware of warning signs such
as anxiety or agitation (flushing or restlessness, or refusal to comply
with requests);
- exercise may be a helpful preventive
measure;
- if you suspect the person is ill
or in pain, particularly if the aggression is uncharacteristic, it would
be wise to consult your GP. The outburst may have been caused by an infection
or discomfort which can be remedied;
- remember that preventive measures
may not always work: don't blame yourself if aggression does occur, but
concentrate on handling it as calmly as possible.
Coping Strategies
- do not attempt to restrain the
person, lead them away, corner them, approach them from behind or initiate
any form of physical contact: it may be better to leave them alone until
they have recovered or you may wish to call in a friend or neighbour for
support;
- try not to take it personally;
- try not to raise your voice;
- do not provoke by teasing or laughing;
- avoid punishment - the person will
probably not remember the event and is therefore not able to learn from
it;
- try not to show fear or alarm;
- try to provide alternatives to
the behaviour;
- speak in a calm, reassuring voice
and attempt to distract;
- try to remain detached and do not
allow yourself to be provoked or drawn into an argument; try taking a deep
breath and counting to ten;
- try to tell yourself that you are
dealing with the illness rather than the person;
- if you do lose your temper, don't
feel guilty - but do try to talk it over with a friend or professional
worker who can offer you support;
- if aggressive incidents are very
frequent, consult your GP and, if necessary, a geriatrician or psychiatrist
- it may be necessary to consider using some form of medication and this
will need to be done with careful monitoring. Some tranquillising medication
can increase confusion.
Looking After Yourself:
Sudden over-reactions may leave
you upset and a little shaky. It is essential that you seek support for
yourself from a supportive family member, a friend, an understanding professional
or a support group, and that you get a break from the constancy of the
task. Identify the areas of support that you need and learn about the services
in your area ( respite care, in-home care, day care etc.) which are available
to help you.
Allow yourself to get help with
other tasks such as cleaning so that you can conserve your energy.
Remember that your own feeling of
distress, frustration, guilt, exhaustion and exasperation are quire normal:
However, if you feel you are losing control, talk to someone, a support
group, a neighbor, a friend, family member or clergy anyone who will listen
and understand.