Challenging Behaviours of a Person with Dementia

Behaviours that Present Challenges for Healthcare Staff in a Person with Dementia Living in Nursing Homes and Home Care Assisted living 

Behaviours that challenge are a significant reason of stress to healthcare staff and the aging adults that they care for. Around 90% of individuals affected by dementia will encounter personality and mental signs and symptoms of dementia that are significant enough to be classified as a difficulty throughout the series of their condition.

Support workers who strive to understand the meaning behind the person’s behaviour, and who master the care-giving skills and their implementation will be more successful at dealing with behaviours that present a challenge.

Examples of the most prevalent symptoms are

  • Agitation
  • Wandering
  • Depression
  • Psychosis
  • Screaming and violence

Coping with Changed Behaviours in a Person with Dementia | Elderly care for Challenging Behavior

• Behaviour of people living with dementia may present a risk to support workers.
• Support workers need to know risk management strategies as identified in both client’s care plan and the organisation’s policies and procedures.
• The client’s behaviour that is most likely to result in risk to themselves or others, is aggression and violence.
• It is important for the support worker to be aware and anticipate risks and hazards and know how to manage them.

Remember that:

• The process of the illness is to blame, not the person with the illness, nor the carer
• The progression of the condition can also cause psychiatric symptoms like depression, anxiety, paranoia and hallucinations that often lead to stressful and at risk behaviour
• People who suffer from confusion are at risk usually because they are disorientated. This is particularly evident when the older person is away from their familiar environment.

Generally there are numerous behaviours that can be difficult for healthcare staffs or families affected with dementia. The details below points to various of the considerable elements that can begin and guide some behavior patterns to people and residents with dementia.

1. Hostile and Aggressive Behavior of Elderly with Dementia

You will find 2 kinds of this type of behaviour, it can be physical or verbal outbursts. Examples of physical aggressive behaviour are, hitting out, spitting and biting. Verbal outbursts could include harassing language directed at other people, staff and visitors. Without a doubt this sort of conduct is different from healthy behavior of other individuals. There are a number of factors of this kind of behaviour including

  • Changes in a residents self- esteem and dignity of a person.
  • Decreasing or loss of independence.
  • Medication
  • Cultural factors
  • Overall body changes
  • The disease process of dementia

A person with dementia can be managed to avoid hostile and offensive behaviors. These management strategies consist of…

  • Accurate handover to all healthcare staff and debriefing to a family with dementia the most up to date information about the patient.
  • Creating in depth notes in the person-centered care plans regarding the patient with dementia
  • Making an effective diversion plan and or an individualised set of activities for the resident to get involved in.
  • Enabling the person with dementia to have some time in a particular place that the elderly enjoys.

Positive Coping Strategies

• A calm gentle approach
• Smile
• Distraction
• Remove them from the trigger
• Avoid confrontation
• Check for physical causes, e.g. thirst, too hot/cold, feeling of unwellness, infection, constipation, hunger and pain
• Always remember that the behaviour is not deliberate. Anger and aggression are often directed against family members and carers because they are closest. The behaviour is out of the person’s control and they may be quite frightened by it. They need reassurance, even though it may not appear that way.

Dealing With Aggression – Professional Caregiver Training Video


2. Recurring and Repetitive Behaviors

Recurring and repetitive behaviors generally mean doing exactly the same actions or activity over and over again. The behaviour may vary from inquiring the very same topic over and over again or carrying out a procedure repetitively. This form of conduct can be tough and irritating for a Healthcare Staff or relatives of the elderly with dementia. There are various causes for this behavior of a person with dementia.

People living with dementia may:

• Say or ask things over and over again
• Become very clingy
• Always wanting to go outside Shadow you
• Could repeat the same action over and over again. E.g. tongue moving in and out, tapping, rubbing hands together or on legs, or making the same noise over and over again
• Keep checking things over and over again

This may include one of the following:

  • Medication issue
  • Worry , anxiety, fear, nervousness
  • Slight or significant changes in the residents environment
  • The disease process of dementia

Effect of these behaviours to healthcare staff ( caregiver and nurses ) and family

• Can be very upsetting and irritating for carers and family of people living with dementia

There’s a number of methods that this kind of conduct can be handled. These range from diversional methods and being mindful of some routines that might initiate the repetitive behavior cycle. Other ways such as moving people to quieter areas of the facility or different ways of conversing can also be helpful to the person with dementia and to prevent recurring behaviors.

Positive Coping Strategies

• Distraction may work, e.g. a walk, food or favourite activity
• Respond to the emotion instead of specific question, they may just need reassurance
• Do not tell them they have asked this question before
• Use a calm voice when responding to repetitive questions
• For those who can still read you could use signs, e.g. “We will eat at 5.30 pm”
• Do not react to the behaviour or question. If there is no response,
the behaviour may stop. If not you need to try something else. It is better to be proactive rather than reactive.
• Reassure the resident
• For repetitive movements; try checking medications or occupy the person’s hands with and activity

Repetitive Behaviors Caregiver Training Video


3. Wandering

A common cause of tension and anxiety for the carer of a person with dementia is wandering. Balancing the need to keep the person safe with the need to allow them some independence and choice can be challenging. How this is resolved will depend upon several factors including the neighbourhood environment, The personality of the client and the carer, including coping mechanisms.

Wandering happens in a person with dementia when their memory stops working. It often implies that the person with dementia could not recall exactly where they have been and how to return.

Usually the person with dementia decide to go walking at night as they can’t sleep. Examples of the factors that trigger a person with dementia to wander are changes in the brain and overall deteriorating memory. The person with dementia may also begin to wander as their physical health changes or their environment that they live in has altered in some way.

It is crucial to know how wandering can be handled properly to avoid the resident becoming seriously injured. Good management techniques are:

  • Developing true person-centered care plan for the resident
  • Applying a large variety of diversional strategies and activities
  • Assuring the resident is within a safe and secure environment
  • Keep a safe social environment

What triggers of influences the behaviour
Ask the following questions:
• Is the person on medication which may be causing restlessness? Seek medical advice.
• Is the person in an unfamiliar environment? Assistance to find their way around, and plenty of reassurance may lessen the problem.
• Is the person searching for someone or something? Looking for food, or the toilet or companionship.
• Does the person simply need exercise? Walking is a good way to use up energy, keep fit and can help people to sleep better at night.
• Is the person bored or lonely?
• Is the person trying to escape from something frightening?
• Is it their old routine, e.g. a night worker going to work?

Positive Coping Strategies

• Encourage movement and exercise. If you are unable to take the person for a walk, see if a friend or relative can. Physical activities such as gardening or stacking wood can also provide exercise and
something of interest.
• Enable the person to move freely within safe areas and ensure that the person carries some form of identification. Secure property with locks on doors and gates.
• Consider electronic buzzers, chimes, a bell above the door or a pressure sensitive mat at the door to ward if the person is on the way out.
• Leave a night light on and secure the outside doors. Put the key out of sight.
• Tell your neighbours about the problem. Most people are very helpful once they understand the person is memory impaired.

• If you are unable to find “the wanderer” in the immediate neighbourhood within an hour, let the local police know. Often people follow the same route when out walking. Leave someone at home to answer the phone while you search.
• Do not fuss when the person is found. Walk alongside and gradually move in the direction of home. If you are in a car, offer the person a lift.
• Don’t forget to notify all possible ‘searchers’ when the person has been found.
• Give them meaningful tasks to do (e.g. folding pillow cases) and remember to thank them for the help

Caregiver Training for Wandering (Alzheimer’s and Dementia Care Program)


4. Sundowning

Sundowning is the occurence or build up of one or more unusual behaviours related to their circadian rhythms. Sundowning happens during the late afternoon, evening, and night and is connected with mood swings, suspicious, upset or disoriented, getting restless and hallucinations (seeing things).

A person with dementia are most likely at their best in the morning and during the day a persons memory and ability can deteriorate.

Sundowning can become more obvious to some staff when the usual routine within a dementia healthcare facility has changed or the environment has changed. These changes can cause an increase in the residents restlessness and agitation. In addition to the main trigger being the late afternoon the overall health of the resident, medication, tiredness can start sundowning.

People living with dementia may become more confused, restless or insecure late in the afternoon or early evening
• It may get worse after a move or change in routine
• People living with dementia may become more demanding, restless, upset or disorientated
• Attention span and concentration can become more limited
• People may become impulsive
• They may see, hear or believe things that aren’t real, especially at night

What may trigger or influence the Sundowning behaviour
• No one is completely sure what causes sundowning, although it seems to result from changes in the brain
• A daily cycle of delirium. It could be that changes in physiological or psychological function during the course of each day could eventuate in increased confusion leading to agitated behaviours.
• Fatigue or dehydration, for example, could develop during the course of each day. Disturbances of the daily cycle of body temperature change caused by Alzheimer’s disease have been proposed as a cause of sundowning.
• Change of shift in the afternoon, therefore change in environment
• A person feeling the need to search for the usual family gathering at the end of the working day. They become more anxious about ‘going home’ or ‘finding mother’ late in the day which may
indicate a need for security and protection

Some of the ways to care for a person with dementia experiencing sundowning is to create individualised person- centered care plans using:

  • A large variety of diversional strategies and activities.
  • Ensuring the person with dementia is within a safe and secure environment
  • Increasing communication with the resident at this time.

Positive Coping Strategies

• If fatigue is making the sundowning worse, an early afternoon rest might help
• Earlier evening activities that are familiar to them maybe something
from earlier time in the person’s life, e.g. may be as simple as closing the curtains, pre dinner drink or setting the table
• Don’t physically restrain the person but let them pace where they are safe
• Offer a drink

Sundown Syndrome | Caregiver Training Video


5. Hoarding or Stockpiling Goods

People living with dementia may appear driven to search for something they believe is missing and to hoard things or collect them for safekeeping.

A person with dementia may present signs of hoarding to keep the objects secure. A person with dementia who hoard cannot often express why they are hoarding. Normally they perceived great importance of the hoarded objects far exceeds their true importance. Examples of the factors of hoarding are an altered status of the residents brain, this might be a result of the dementia disease process or:

  • Anxiousness
  • Changes in the environment conditions
  • Loss of choice about a decision made in a healthcare facility
  • The overall loss of independence
  • Changes in the persons health status

Positive Coping Strategies
• Involving family/whanau in management of the behaviour may give clues as to triggers, e.g. usual routine.
• Calm, gentle approach.
• Reminiscence.
• Provide a box or draw full of odds and ends for the person to sort.

Dementia related Hoarding Sample Video


6. Searching and Rummaging

People living with dementia may intrude into others private spaces and ‘rummage’ when they are lost or searching for a purposeful activity. These behaviours can present a problem when they involve other people living with dementia and their family members

Rummaging is to search for things that they have misplaced and lost over time. The cause of searching and rummaging is an altered status of the residents brain, this might be a result of the dementia disease process.

What may trigger or influence the behaviour

• May be ‘looking’ for familiar ideas
• Feeling of being in unfamiliar surroundings
• May be searching for a purposeful activity

Positive Coping Strategies
• Ensure the person’s room is well identified, e.g. a picture of something familiar on the door
• Provide a rummaging box or a draw full of familiar items
• Provide objects which may connect a person with their past interests or work
• Provide distraction
• Have an area or room set up to allow clients to rummage

Rummaging Caregiving Tips


7. Catastrophic Reactions

A catastrophic reaction is the behavioural and emotional response to a situation which
overwhelms or creates stress on the person with dementia because the situation is beyond the person’s ability to comprehend.

A person with dementia can have catastrophic reactions to ordinary daily events. The resident may become troubled and distressed and show levels of anxiety. This behavior may include emotions such as crying or intense laughter that do not fit the situation. Some of the things that might influence and start these behaviors are the changes to their persons health or:

  • An altered state of the persons brain
  • An increase in the nervousness of a resident
  • The loss of independence
  • Health issues that can lead to increased levels of frustrations.

Some of these behaviors and patterns can be managed by the:

  • Ensuring the person with dementia is within a safe and secure environment
  • Increasing communication with a person with dementia
  • Assisting them to a quieter area within the facility
  • Increasing staff education by attending Healthcare facility in service education courses.

Positive Coping Strategies

• Reassurance, gentle, calm, slow speech, smiling and touch may be
• Diversion
• Remove person from the situation
• Remove the stimuli
• Document so as situation may be avoided in the future

Dementia & Challenging behavior Documentary Film

Read more:

Dementia Beyond Disease: Enhancing Well-Being