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Alzheimer’s Behavior Management:

LEARN TO MANAGE COMMON BEHAVIOR PROBLEMS

Planning for Alzheimer’s Care

The confusion and disorientation of mid-stage Alzheimer’s bring increasing difficulty with maintaining normal behaviors. The result may be inappropriate behavior in social situations or getting lost in one’s own house. Alzheimer’s patients can become a danger to themselves or others.

Alzheimer’s patients may have a wide variety of behavioral problems including wandering; rummaging through or hiding things; aggressiveness; hallucinations or paranoia; and sleeping and eating problems.

Most behavior problems pose serious difficulties for the person trying to provide care. Management of this behavior will require the caregiver to modify the home environment and change communication styles.

Management of Wandering

Wandering around the house may be irritating to the caregiver, but not necessarily unsafe for the patient. In this case, you may need to adjust your anxiety level about wandering. On the other hand, some wandering can be dangerous and must be prevented: going into areas of the house that are off-limits, especially stairwells, decks, hot tubs, and swimming pools; leaving the house alone via a window or door to go outside; or leaving your yard or property.

You can prevent many instances of wandering by carefully selecting child-safety devices for your home that effectively restrict adults. Some caregivers have “outsmarted” the person who has a desire to escape with novel solutions, such as hiding items like purses, shoes, or glasses that the person would always take with them if they left the house. Or, you may want to acquire comfortable chairs that are difficult for the Alzheimer's patient to get out of! Bean bag chairs and recliners are pleasant to sit in, yet restrict movement out of the chair.

Two characteristic precursors to wandering are restlessness and disorientation. Redirecting behaviors, distracting, orienting, and encouraging physical exercise therefore, serve to reduce the incidence of wandering. Some suggestions are:

  • Immediately redirect pacing or restless behavior into productive activity or purposeful exercise.
  • Make sure the Alzheimer's patient gets plenty of exercise and movement. Even consider singing and dancing! Indoor shopping malls are vast walking opportunities protected from the weather. If you walk outdoors, make sure that you and the patient have clothing that shelters from cold, rain, and sun.
  • Make sure the person is involved in many productive daily activities, such as the simple chores of folding laundry or washing vegetables for dinner.
  • Reassure the person if they appear disoriented.
  • If wandering tends to occur at a particular time of day, distract the person at that time.
  • Reduce noise levels and confusion. These can disorient the person.
  • Disorientation can be a result of medication side-effects, drug interactions, or over-medicating. If disorientation is becoming a problem, consult the doctor.
    If you are moving the patient to a new environment, reduce disorientation by acclimating them ahead of time with several visits.

Planning for when the Alzheimer's patient does wander

In case an Alzheimer’s patient in your care does wander, it’s a good idea to have a plan in place. Make a list of what you should do if the person becomes lost – include telephone numbers to call, places to check, etc. Notify neighbors and local police about your Alzheimer's patient’s tendency to wander, and ask them to call you if they see your elder wandering without supervision.

If a police search becomes necessary, you’ll need a recent photo of the person’s face. You can make the searchers’ jobs easier by also having a video of the person to be able to show them, and by keeping on hand some unwashed clothing from the elder to help search-and-rescue dogs. (To do this properly, place the clothing in a plastic bag with plastic-gloved hands, and replace this clothing monthly.)  Another smart preventative measure is to sign up the patient for the Alzheimer's Association’s Safe Return Program, which is an identification system to help rescue lost Alzheimer's patients who have wandered away.

Where to look for a lost Alzheimer's patient

Rescue is urgent for a wandering person who has Alzheimer's or another dementia. The person may not call out for help or answer your calls. And people in this situation often do not leave many physical cues. The person may get stuck in a place that they cannot get out of, and he or she can die from exposure if left outside too long. Dehydration and hypothermia are dangers. Some ideas about where to find the wanderer:

Finding a missing Alzheimer’s patient

Check dangerous areas near the home, such as bodies of water, open stairwells, dense foliage, tunnels, bus stops, high balconies, and heavily traveled roads.

Look within a one-mile radius of where the patient was before they wandered.

Look within one hundred feet of a road, as most wanderers start out on roads and remain close by. Especially look carefully into bushes and ditches, as the person may have fallen or gotten caught.

Search in the direction of the wanderer’s dominant hand. People usually travel first in their dominant direction.

Investigate familiar places, such as former residences or favorite spots. Often, wandering has a particular destination.

If you suspect that the person used a car or public transportation to go away, you must think of likely places to search that are farther away.

Management of rummaging around or hiding things

Caring for a patient who rummages around or hides things in the home is a challenge, but not an insurmountable one.

Protecting your property

Lock certain rooms or cabinets to protect their contents, and lock up all valuables. Have mail delivered out of reach of the Alzheimer's patient--perhaps to a post office box. If items do disappear, learn the person’s preferred hiding places and look there first to find hidden objects. Restrict access to wastebaskets and trashcans, and check all wastebaskets before disposing of their contents, in case objects have been hidden there.

Protecting Alzheimer’s patients from harming themselves

Remove or prevent access to unsafe substances, such as cleaning products, alcohol, and medications. Patients with dementia sometimes overdose on alcohol. Prevent electrical accidents by blocking unused electrical outlets with childproofing devices. It may also be helpful to designate a special drawer of items that the person can safely “play” with when they are bored.

Management of belligerence, anger or aggressive behavior

Following are some ideas about caring for an aggressive Alzheimer's patient. Consider each idea independently of the others.

  • Don’t confront the person or try to discuss the angry behavior. The person with dementia cannot reflect on their unacceptable behavior and cannot learn to control it.
  • Do not initiate physical contact during the angry outburst. Often, physical contact triggers physical violence in the patient.
  • Provide the person with a “time-out” away from you. Let them have space to be angry by themselves. Withdraw in the direction of a safe exit.
  • Distract the person to a more pleasurable topic or activity.
  • Look for patterns in the aggression. Consider factors such as privacy, independence, boredom, pain, or fatigue. Avoid those activities or topics that anger the person. To help find any patterns, you might keep a log of when the aggressive episodes occur.
    If the person gets angry when tasks are too difficult for them, break down tasks into smaller pieces.
  • Minimize stress and novelty.
  • Maintain calm within yourself. Getting anxious or upset in response may escalate the aggressiveness.
  • Let the person play out the aggression. Just be sure that you are safe and that they are safe themselves.
  • Get help from others during the activities that anger the patient.
  • Don’t take the aggressiveness personally.

Management of hallucinations, illusions or paranoia

Hallucinations can be the result of failing senses. Unidentifiable sounds, shadows, and highly contrasting colors all can become the basis for fantasy. Decrease the number of things in the environment that can be misinterpreted as something else, such as patterned wallpaper or bright, contrasting surfaces or objects. Increase lighting so that there are few shadows while avoiding glare, and remove or cover mirrors if they cause problems. Maintaining sameness in the environment may also help reduce hallucinations. Also, violent movies or television can contribute to paranoia – avoid letting the patient watch disturbing programs.

When hallucinations or illusions do occur, don’t argue about what is real and what is fantasy. Discuss the patient’s feelings relative to what they imagine they see. Respond to the emotional content of what the person is saying, rather than to the factual/fictional content.

Medications can sometimes help to reduce hallucinations, so seek professional advice if you are concerned about this problem.

Management of nighttime wakefulness and other sleep problems

Brain disease often disrupts the sleep-wake cycle. Alzheimer's patients may have wakefulness, disorientation, and confusion beginning at dusk and continuing throughout the night. This is called “sundowning.” There are two aspects to sundowning. First, confusion, over-stimulation, and fatigue during the day may result in increased confusion, restlessness, and insecurity at night. And second, some Alzheimer's patients have fear of the dark, perhaps because of the lack of familiar daytime noises and activity. The patient may seek out security and protection at night to alleviate their discomfort.
Following are some strategies to reduce nighttime restlessness:

Improve sleep hygiene

Physical activities will help the person feel more tired at bedtime. Walk with the person during the day. If the person seems very fatigued during the day, give them a short rest in the afternoon to regain their composure. This can lead to a better night’s sleep. But don’t let them sleep too long – too much daytime napping can increase nighttime wakefulness. Also, limit the patient’s caffeine intake.

Be consistent with the time for sleeping, and keep a routine for getting ready for bed.

Create a calm atmosphere for sleeping

Give the person a bath and some warm milk before bed. Provide a comfortable bed, reduce noise and light, and play soothing music to help them get to sleep.
Close the curtains and leave a night light on all night. Some people with dementia imagine things in the dark and become upset. Stuffed animals or a pet may soothe the patient and allow them to sleep.
Have the person use the toilet right before bedtime. Place a commode next to the bed for nighttime urination. Walking to the bathroom in the middle of the night may wake the person up too much, and then they can’t get back to sleep.
The person may prefer to sleep in a chair or on the couch, rather than in bed. Furniture must be designed so that the patient won’t fall out while sleeping.

Resolve common problems

If the patient paces during the night, make sure that the primary daytime caregiver can sleep. This requires either a very safe room for the patient to pace in, or else another caregiver who takes over at night. You need your rest, too. Do not restrain the patient in bed, but consider a hospital bed with guard rails in the later stages of Alzheimer’s.
If night wakefulness has gotten too hard for you to manage, consult with a doctor if you wish to try administering sleeping pills.

Management of refusing to eat

Try any of or a combination of the following suggestions to care for a patient who won’t eat:

Managing an Alzheimer’s patient who refuses to eat

Encourage some exercise

Exercise can make a person feel hungrier: The hungrier the person feels, the more likely they are to eat.

Monitor medications

Some medications interfere with appetite. Read about the side effects of any medications that the Alzheimer's patient is taking. Discuss with the doctor the lack of interest in eating; you may need to change a medication.

Make sure that the person gets enough liquids with their food, as dry mouth may be a side-effect of some medications.

Make mealtimes pleasing to the patient

If the Alzheimer's patient does not like the person who is feeding them, they may not feel like eating. Try a different caretaker for the feeding process.

Make the patient’s favorite food, and serve food on colored tableware - dishes that contrast highly with food colors. Reduce distractions in the eating area.

Also, avoid foods that are too hot or too cold, as these may be unpleasant to the patient.

Feed the patient like a baby

Try giving the patient little spoonfuls, and sing short, funny rhymes to get them to eat. Get the person to smile so that the mouth opens, and then slip a little food in their mouth. Or put a bit of the food on the person’s lips so that they open their mouth wider.

Provide finger foods and children’s sipper cups: The person may have trouble using utensils and normal cups.

Monitor chewing and swallowing

Chewing and swallowing difficulties can develop as Alzheimer's progresses. If necessary, give instructions on when to chew and when to swallow. Keep the person upright for thirty minutes after eating so that they don’t choke.

Transition into providing only puréed or soft foods

In the later stages of Alzheimer's, the person can no longer swallow food and may choke on food. Swallowing problems can lead to pneumonia because the patient may inhale food or liquid into the lungs.

Begin feeding only liquids to the patient when the time is right - In the later stages of Alzheimer’s, the person can no longer process solid foods.

At the end stage of Alzheimer’s or another terminal illness, the patient’s organ systems begin to shut down and the lack of desire to eat or drink is the usual result. In the final days or hours, starvation or dehydration are not a problem and not a cause of suffering.

Related links for managing Alzheimer’s behavior problems

Managing behavior problems

Dealing with Behavior Problems – Links to detailed materials on agitation/anxiety, aggressiveness/combativeness, delusions/paranoia, apathy/depression, screaming/vocalization, sexual behavior problems and sleep disorders. (Alzheimer’s Association)

Managing Agitation Behavior in Alzheimer's Patients Demented patients show a variety of different behavioral problems, including anger, agitation, depression, suspiciousness, paranoia, wandering, sexual inappropriateness, hallucinations, and delusions. (HealingWell.com) 

The “Challenging Behaviors” Index – An A-Z directory of how to care for and respond to the difficult behaviors of a person with Alzheimer's Disease or other dementia. (Alzheimer's Outreach)  

Caring for someone with dementia: Unusual behaviour – Unusual behaviour gives tips for dealing with unusual behaviors such as repetitive questions, phrases, or motions; following; calling out; lack of inhibition; laughing or crying uncontrollably; pacing; fidgeting; and suspiciousness. Links to articles on more common behaviors like wandering and aggressiveness. (Alzheimer's Society of the UK)  

Hands-On Skills for Caregivers – Gives practical, insightful tips for how to physically approach a difficult patient; how to talk to them respectfully; and how to get them to co-operate with you, both physically and mentally. (Family Caregiver Alliance/National Center on Caregiving)

Management of home safety; safe return program 

Home Safety Behavior-By-Behavior – Ways to make your home safe for the Alzheimer's patient who wanders, who rummages or hides things, who hallucinates; tips for social occasions at home and for adjusting the home environment to compensate for failing senses. (ADEAR: Alzheimer's Disease Education & Referral Center)

Safe Return Program – A national program where you enroll the patient for help with wandering: includes identification products, a network of local chapters, a 24-hour emergency crisis line, and a photo database. (Alzheimer’s Association)

Doug Russell, L.C.S.W., Suzanne Barston, and Monika White, Ph.D., contributed to this article. Last modified on: 12/19/07.

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