Sometimes someone who has dementia can lose inhibitions in a way that family members and friends experience as embarrassing. And when that person with dementia has a moment of clarity, they can be mortified and depressed by their own behavior. Here are some ways that you can protect a person with dementia for whom you care against disinhibited behaviors that can lead to profound social upset and depression.
Some examples of disinhibition in dementia
What kinds of behavior are "disinhibited" in dementia? Some examples of the problem are relatively innocuous. A person with dementia may greet a visitor with "I hate your hair" and refer back to hating hair throughout the visit. Or they might take off their clothes in a day room or when the priest comes with Holy Communion. Or they may make an unwelcome sexual advance, or use racial epithets to describe staff who care for them. Sometimes people with dementia lose their inhibitions against pinching, biting, and taking a swing at caregivers and family members alike. There can be outbursts of shouting, screaming, singing, interacting inappropriately with strangers, stalking, repeated phone calls, and hoarding, hiding, and losing things.
Causes of disinhibition in dementia
Disinhibited behaviors are particularly common in frontotemporal dementia. They seem to be linked to the loss of white matter (nerve fibers and the protective proteins surrounding them) throughout the brain. When white matter is lost in certain regions of the brain, the result is apathy. When it is lost in other regions of the brain, the result is disinhibition. It is possible for a mixture of apathy and disinhibition to appear in a frontotemporal dementia patient.
While the biological causes of disinhibition may be different in different forms of dementia, optimal caregiver responses follow a consistent pattern. Here are some approaches that usually help.
How to deal with disinhibition
Whenever caregivers have to deal with dementia, there are two primary considerations. One is answering the question "Does this really matter?" A dementia patient whose disinhibition is excessively effusive greeting of family members is not as burdensome as a dementia patients who tries to offer money (or, in my personal experience, frozen smoked turkeys) to staff for sexual behaviors. Sometimes it is possible to accept a disinhibited behavior. Sometimes it is not.
Another basic consideration is considering the source of the behavior. People who have dementia are not evil. They are weakened by their disease. They say and do things that are out of character for them because their brains have deteriorated. Some disinhibited behaviors have to be curbed, but they do not have to be punished.
These considerations may also be helpful:
- It's always best not to escalate minor offenses. Distract the offensive behavior to make it stop. Don't try to punish it. Don't argue with someone who has dementia.
- In many cultures (the US South, for example), talking with strangers is a normal, socially acceptable activity. As long as the dementia patient doesn't act inappropriately, there usually is no reason to curb simple conversations, with one exception: If the dementia patient mistakes a stranger for a family member, then tact and kindness are required. You may not need to disabuse the patient of their mistake, unless inappropriate actions follow mistaken identity.
- Disrobing at inappropriate times and in appropriate places is a common problem in multiple forms of dementia. However, sometimes the issue is loss executive function rather than disinhibition. People whose decision-making skills are compromised may take off their clothes because they are hot. Turn down the heat or turn up the air conditioning, and they may keep their clothes on. When someone starts to take their clothes off at an inappropriate time or in an inappropriate place, take them to a private location to determine if temperature, scratchy clothing, an itch or rash, or tight-fitting clothing is the issue. Consider buying pants without zippers. Sometimes people take off their clothes because they think it is time for a bath or shower. Make sure that the schedule is understood. Keep in mind that people in different cultures have different views of nudity in public. Some cultures absolutely forbid public nudity. Others accept it.
- People with dementia may touch themselves because they have lost inhibitions about sex. Or it may be that they need to go to the toilet or because they have fungal or yeast infections.
- Expressing outrage at a sexual advance by someone who has dementia is understandable, but it is almost never helpful. Hospitals that have zero-tolerance policies for certain patient misbehaviors may react harshly to this kind of behavior from someone who has dementia who is in a medical ward. If you are the caregiver, be patient with staff. Apologize. Ask for help from the social worker.
- Pay attention to situations that occur ove and over again to ascertain whether there are triggers for disinhibited behavior. Learn what buttons not to push or not to let others push.
- When someone takes personal offense at the behavior of someone who has dementia, it may be helpful to speak them privately, without the patient present, to explain its reasons.