Caring for a loved one with dementia poses many challenges for family caregivers and health care service providers. Bizarre behaviors and memory problems make it difficult to leave the impaired person alone, even for a short time. These behaviors can cause embarrassment, frustration, and exhaustion in those providing the care. You will probably need to explore what works best for you and your impaired relative.

This fact sheet provides some practical suggestions and strategies for dealing with common behavior problems in dementia patients.

Communication
• Eliminate distractions. Turn off the TV or radio when talking to the confused person and maintain eye contact to help keep his/her attention.
• Use short, simple sentences and give only one directive at a time. Avoid sentences phrased in the negative. Instead of saying: "Don't go outside" say: "Stay inside."
• Monitor the tone and level of your voice while talking to the person with dementia. Gestures, pantomime, and pictures can help you get the point across. Use nonverbal cues like exaggerating a smile or a nod.
• Avoid speaking down to your loved one. Speak slowly and clearly, but in an adult manner. Don't be afraid to repeat what you say several times.
• Refrain from discussing topics your relative can no longer remember. Encourage him/her to talk about familiar places, interests, and past experiences.

Wandering
• You may want to change the locks on your doors. Consider a lock where a key is required for exit and entry. A sliding bolt installed at floor level may be effective.
• Try a barrier like a curtain or colored streamer to mask the door. A "stop" sign or "do not enter" sign also may help. Another technique is to place a black mat or paint a black space on your front porch; this may appear to be an impassable hole to the dementia patient.
• "Child-safe" plastic door knob covers are available at children's departments. Special electronic devices also are sold by private companies to prevent wandering.
• Put away essential items such as the confused person's coat, purse, or glasses. Some individuals will not go out without certain articles.
• Have your relative wear an identification bracelet. Maintain a current photo should you need to report your loved one missing. Consider leaving a copy on file at the police department.
• Tell neighbors about your relative's wandering behavior and make sure they have your phone number.
• Allow for regular exercise to minimize restlessness.

Incontinence
• Establish a routine for using the toilet. Try reminding the person or assisting him/her to the bathroom every two hours.
• Schedule fluid intake to ensure the confused person does not become dehydrated. However, avoid drinks with a diuretic effect like coffee, tea, cola, or beer. Limit fluid intake in the evening before bedtime.
• A commode, obtained at any medical supply store, can be left in the bedroom at night for easy access.
• Incontinence pads can be purchased at the pharmacy or supermarket. A urologist may be able to prescribe a special product or treatment.
• Use signs (with illustrations) to indicate which door leads to the bathroom.
• Use easy-to-remove clothing such as elastic waistbands, full skirts, and clothes that are easily washable.

Angry/Agitated Behavior
• Obtain a doctor's evaluation to determine if there is a medical cause, or if medications are causing adverse side-effects. Reducing caffeine intake may be helpful as well. • In severe cases, medication can be prescribed by a neurologist to keep a dementia patient calm.
• Reduce outside noise, clutter, or number of persons in the room. Maintain structure by keeping the same routines. Keep objects and furniture in the same places. Help orient the confused person with calendars and clocks. Familiar objects and photographs offer a sense of security and can facilitate pleasant memories.
• Try gentle touch, soothing music, reading, or walks to quell agitation. Speak in a reassuring voice. Do not try to restrain the person during a catastrophic reaction. Keep dangerous objects out of reach.
• If agitation increases at night, a night light may reduce confusion.
• Limit choices to minimize confusion. Instead of asking "What would you like for lunch, soup or a sandwich?" say: "Here's some soup."
• Acknowledge the confused person's anger over the loss of control in his/her life. Tell them you understand their frustration.
• Distract the person with a snack or an activity. Allow him/her to forget the troubling incident. Confronting a confused person may increase anxiety.

Perseveration (repetitive speech/actions)
• Reassure or try to distract the person. Avoid reminding the person that he/she just asked the same question. Ignoring the behavior or question may work in some cases.
• Do not discuss plans with a confused person until immediately prior to an event.
• You may want to try placing a sign on the kitchen table stating "Dinner is at 6:30" or "Lois comes home at 5:00" to remove anxiety and uncertainty about anticipated events.
• Learn to recognize certain behaviors. An agitated state or pulling at clothing, for example, could indicate a need to use the bathroom.
• Check with the demented person's doctor. Make sure the person is not in pain or suffering any side effects from prescription medications.

Paranoia
• Check out paranoid behaviors with the person's doctor. Adjustments may be needed in prescription medications.
• If the confused person suspects money is "missing," allow him/her to keep small amounts of money in a pocket or handbag for easy inspection.
• Assist the person in looking for a missing object. Avoid arguing. Try to learn where the confused person's favorite hiding places are for storing objects which are frequently assumed to be "lost."
• Take time to explain to other family members and home helpers that suspicious accusations are a part of the dementing illness.
• Respond to the feeling behind the accusation. If the accusation involves hurting or killing someone who has passed away, you might try saying "You really miss your mother; tell me about her."
• Try non-verbal reassurances like a gentle touch or hug.

Traveling
• Do not negotiate an outing with a confused person. Instead of asking, "Are you ready to go out?" Limit what he/she must remember by announcing "Here's your coat" and "We're getting into the car now."
• Reassure the person. New and different surroundings can be anxiety-producing and disorienting for someone with dementia.
• Plan your route as carefully as you can, know about parking, elevators, stairs, etc. Leave plenty of time so you will not need to rush.
• If taking a vacation or weekend away with the dementia patient, consider bringing along another adult to help out.
• Bring something to help keep the confused person occupied if you must wait somewhere. Try a package of snacks, cards, or a picture book.

Additional Problem Areas
• If bathing is a problem, realize that you can skip a day, if need be. Be aware that loss of ability to determine temperature may make the water seem too hot or too cold. Safeguard hot water so that the person does not get burned. Supervise showers or baths, particularly if the person's balance is unsteady. Remove the bathroom door lock for safety. Concern over modesty also may increase agitation, so be reassuring. Try varying the time of day to better suit the person's prior bathing habits.
• Loss of control over appetite can occur and the person may not remember just having eaten. Keep food out of sight during non-meal times. Serve food pre-cut, if using utensils becomes difficult. Respond to the emotion by reassuring the person that you will make sure he/she is well fed. Distract the person with a different activity.
• Dressing is difficult for most dementia patients. Choose loose-fitting, comfortable clothes which have easy zippers or snaps with minimal buttons. Reduce the person's choices by removing seldom-worn clothes from the closet. To facilitate dressing, lay out one article of clothing at a time, in the order it is to be worn. Remove soiled clothes from the room. Don't argue if the person insists on wearing the same thing again.
• If the confused person suffers sleep disturbances or night-time agitation, make sure the house is safe: block off stairs with gates, lock kitchen door or put away dangerous items. Try soothing music or a massage to induce relaxation. If agitation increases after dark, keep the house well lit and close curtains to shut out darkness. • If the person remains awake or restless at night, consider hiring someone for the night shift or find a way to share night-time supervision with others so you can get your own rest. Use sleeping medications only as a last resort.
• When hallucinations are a problem, keep the house well lit to decrease shadow effects which can be confusing. Reassure the person during or after a loud noise such as a storm, siren, or airplane. Give a simple, truthful explanation of the noise, but avoid arguing or trying to convince the person. A distraction may be useful. Check with the person's doctor.
• Other problems may include sexually-inappropriate behaviors, driving a car, stubbornness or violent outbursts.
• For further information on managing problem behaviors, contact Family Caregiver Alliance, your local Caregiver Resource Center in California or a dementia-related community resource.

Recommended Readings
Understanding Difficult Behaviors: Some Practical Suggestions for Coping with Alzheimer's Disease and Related Illnesses, Robinson, A., Spencer, B., and White, L., 1991, Geriatric Education Center of Michigan, East Lansing, MI (313) 487-2335.

Dressing Tips and Clothing Resources for Making Life Easier, Shelly Peterman Schwartz, 1995. Available from the author at 933 Chapel Hill Rd., Madison, WI 53711-2405 (608) 274-4380.

Keeping Busy…A Handbook of Activities for Persons with Dementia, James R. Dowling, 1995, John Hopkins University Press, Hampden Station, Baltimore, MD 21211 (800) 537-5487.

Comforting the Confused: Strategies for Managing Dementia, Stephanie Hoffman and Constance Platt, 1981, Springer Publishing Company, 536 Broadway, 11th Floor, New York, NY 19912-3955 (212) 431-4370.

Respite Care Aide Training Manual, 1989, Family Caregiver Alliance, 690 Market Street, Suite 600 San Francisco, CA 94104

Credits
Rheaume, Y., Wandering, Dementia Study Unit, Veterans Administration Hospital, Bedford, MA.

Gwyther, L., Traveling with the A.D. Patient: To go or not to go?, The Caregiver Newsletter, Duke University, May 1987.

Cherry, D., Visiting the Doctor, Didi Hirsch Community Medical Center, Culver City, CA.

Robinson, A., Spencer, B., and White, L., 1991, Understanding Difficult Behaviors: Some Practical Suggestions for Coping with Alzheimer's Disease and Related Illnesses. Geriatric Education Center of Michigan.

Turner, G., Decreasing the Stimulation in the Environment of Persons Diagnosed with Alzheimer's Disease, American Journal of Alzheimer's Care and Related Disorders & Research, July-August 1991.

Resources

Alzheimer's Association
919 Michigan Ave., Ste. 1100
Chicago, Il 60611-1676
(312) 355-8700
(800) 272-3900

Architectural and Transportation Barriers Compliance Board
(disabled travel assistance)
1331 F St., N.W., Ste. 1000
Washington DC 20004
(202) 272-5434
(800) 872-2253

Lifeline Systems, Inc. Personal Emergency Response System
640 Memorial Dr.
Cambridge, MA 02139-9474
(800) 642-0045

Medic Alert Foundation International
P.O. Box 1009
Turlock, CA 95818
(800) 344-3226

National Association for Continence
P.O. Box 8310
Spartanburg, SC 29305-8310
(864) 579-7900
(800) BLADDER

National Stroke Association
96 Inverness Dr., East, Suite I
Englewood, CO 80112-5112
(303) 649-9299
(303) 649-0122 (TDD)
(800) STROKES

Prepared by Family Caregiver Alliance in cooperation with California's Caregiver Resource Centers, a statewide system of resource centers serving families and caregivers of brain-impaired adults. Revised December 1997. Funded by the California Department of Mental Health.
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