Psychological/Cognitive Causes of Challenging Behaviors in Dementia

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.

_Sources:

_{Alzheimer’s Association. How to respond when dementia causes unpredictable behaviors. Accessed February 24, 2012. www.alz.org/national/documents/brochure_behaviors.pdf}

_{Alzheimer’s Foundation of America. Behavioral Challenges: Potential Causes of Behavior Problems. Accessed February 24, 2012. http://www.alzfdn.org/EducationandCare/causes.html}

_{Family Caregiver Alliance. Caregiver's Guide to Understanding Dementia Behaviors. Accessed February 24, 2012. http://www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=391}

_{HelpGuide.org. Alzheimer’s Behavior Management. Accessed February 24, 2012. http://www.helpguide.org/elder/alzheimers_behavior_problems.htm}