Alzheimer's Disease: Managing Common Behaviors

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KEY POINTS

• Alzheimer's disease can cause changes in behavior such as wandering, acting out, hallucinations and delusions, and sundowning.
• When you need to deal with troublesome behaviors, remember that the disease not the person is causing the behavior.
• It often works best to try to deal with the behavior than to give the person medicine. There are several things that can help. However, if the person is very upset or aggressive, talk to their healthcare provider. Medicine may help some symptoms.

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What behaviors are common with Alzheimer's disease?

Alzheimer's disease (AD) affects brain cells. It slowly destroys memory and thinking skills. Over time it can cause loss of the ability to speak, remember, control emotions, and make decisions.

AD can cause changes in behavior such as wandering, acting out, hallucinations and delusions, and sundowning.

Wandering

People with AD often wander, meaning they walk or pace either aimlessly or with a purpose that is not clear to others. Wandering may happen at any time. It is a problem because they might get hurt or lost. They might also disturb the privacy of others. This behavior can be very stressful for caregivers.

Some possible reasons for wandering are:

• Pacing or walking is how they have always coped with stress.
• The behavior is based on habits they used to have. For example, if they used to go back to work after lunch every day, they may now wander outside after lunch.
• They may be searching for something familiar, especially if they are in a new place.
• They are trying to find the bathroom or looking for food. They may be cold and looking for warmth, or lonely and looking for a loved one.
• They may be bored or feeling trapped or upset.
• They may be trying to escape.
• The behavior may be a side effect of medicine.
• They may be following a caregiver because they don’t know what they should be doing.

Nighttime wandering is especially hard for caregivers, who may be prevented from getting much-needed rest. People with AD may wander at night because they:

• Cannot separate dreams from reality
• Have days and nights mixed up
• Are sleeping too much during the day or don't need as much sleep as when they were younger, so they wake up during the night
• Are having a reaction to medicines
• Need to use the bathroom

Trying to stop someone from wandering may make matters worse. Try to figure out why the person wanders and reduce the risks. The following may help:

• Let the person wander in a safe place. For example, let them wander inside the house but not outdoors unless the area is fenced. Try removing things from view that may cause them to think about going outside, like hats, sweaters, coats, and gloves.
• Provide a path that always returns the person to where they started. Inside the home, this trail can be through a series of rooms. Outside, a path can be made within a fenced yard.
• Try to limit daytime napping to help the person sleep at night.
• Put personal items out where the person can see them so they do not need to search for them.
• Reduce noise (for example, TV). Sound and confusion may cause the person to wander to a quieter, calmer area.
• Reduce the number of people around him or her.
• Make sure the person gets some kind of exercise every day.
• To turn someone in a different direction, approach them from the front and begin to walk with them. Guide them rather than turn them around directly. This avoids arguments. Talk to them as you walk to distract them.
• Speak calmly. Try not to scold or yell at them.
• If the person seems agitated, talk to the healthcare provider. Medicine may help.
• Develop a plan of action to follow in case the person wanders away. There may be familiar places to look or a trail the person usually follows. Set a time limit for how long you search before you call 911 for help. Keep up-to-date photos of the person in case he or she does get lost. Make sure the person carries an ID that cannot be removed (attached to the back of a shirt, for example).

  Contact the Alzheimer's Association for information on a program called Safe Return. This is a nationwide program that helps when a person with Alzheimer's is missing. The Web site is http://www.alz.org/care/dementia-medic-alert-safe-return.asp.

Acting out

Sometimes people with AD act in ways that bother others. This might be swearing loudly, talking angrily, undressing in public places, trying to make sexual contact with others, or pestering someone. This happens because, as AD gets worse, more and more brain functions are lost. This includes loss of impulse control, which makes it harder for someone with AD to control his or her actions. For example, when the person is in pain or their needs are not met, they may get angry or insulting or start cursing.

Acting out is common to almost all people with AD. Often, they get more aggressive over time.

When you need to deal with acting out, remember that the disease not the person is causing the behavior. Many of these behaviors come from a need for attention or affection. Giving a pat or a hug may help prevent acting out.

Other tips include:

• Stay calm and don't raise your voice. Don't act surprised or angry. The person with AD will mirror your emotions and your behavior. If you stay calm, it helps them to calm down.
• It’s better to say, "Let's do this now, over here," rather than trying to tell them why they shouldn't do something. Speak in a slow, calm tone of voice. Avoid sudden movements with your hands or body.
• Show that you understand what they are feeling. Don’t scold or shame. That makes things worse.
• Be sure the person's physical needs are met. Hunger, pain, thirst, stress, or an infection may cause behavior changes.
• Avoid things that the person might see as a threat. This could be strangers in the home, feeling pressured to do something, or a sudden event. If a person with AD thinks there is danger, they will strike out in self-defense. Figure out how close you should stand while giving care. Respecting the personal space of a person with AD may decrease acting out.
• Speak clearly and simply and slowly. You may need to repeat or rephrase your message to help the person understand.
• Give them time to do a task or respond to a question. Multiple choices can be hard for people with AD to handle. Giving a limited number of simple choices, may be best. For example, “Do you want to rest now or would you like to listen to a story?" Also break large tasks into small ones.
• If the person with AD is very agitated and you are unable to manage their safety, call 911 for help.

Hallucinations and delusions

Hallucinations means seeing or hearing things that are not there. Many hallucinations are related to the need to feel safe. For example, someone who does not feel safe may make up an imaginary friend.

Delusions are false beliefs. For example, a person with AD may plan activities for a visit with a relative even though the relative is dead. The delusions may help the person feel good about themselves and have a sense of control.

Hallucinations and delusions may be caused by changes in the brain. They may also be caused by very high fever, lack of sleep, or side effects of some medicines.

Dealing with hallucinations or delusions requires patience and a willingness to listen.

• Don’t argue with the person's beliefs. Show that you hear what they are saying, without trying to convince them that they are wrong. It’s more important to listen and respond to what they are saying than to try to get the person to face reality. Trying to correct them or argue about what is real may make them more anxious or aggressive.
• Always stay calm and friendly. Speak slowly and clearly. Look directly at the person. This shows that you are interested in what the person is saying and may help decrease the anxiety.
• Establish a trusting relationship that is not demanding. Find and build on strengths the person has. Feeling safe, trusted, and respected may decrease delusions.

When these measures do not help, talk to the healthcare provider. Medicine may help in some cases.

Sundowning

Late in the day or evening people who have AD may get more suspicious, confused, and upset. They may have more hallucinations and delusions. These worsening behaviors are called sundowning.

The cause of sundowning is not known. Here are some ways to deal with sundowning:

• A short nap before late afternoon may help. This may help lessen tiredness and stress at the end of the day.
• Routines help decrease stress. Always doing the same activity at the end of the day is comforting and reassuring.
• Turn on lights to keep the amount of light constant until bedtime.
• Limit the number of visitors and noise at of the end of the day.
• Keep a journal about what happens and when and where it happens. This helps you find out if changes in the person’s surroundings cause behavior problems. Try to avoid these changes.

Does medicine help?

Many medicines used to try to control troublesome behaviors have side effects. It often works best to try to deal with the behavior than to give the person medicine. However, if the person is very upset or aggressive, talk to their healthcare provider. Medicine may help some symptoms.

Where can I get more information?

You can get more information from:

• The Alzheimer's Association
  http://www.alz.org
  800-272-3900 (TDD: 1-866-403-3073)