How To Avoid Catastrophic Reactions In People With Dementia

Catastrophic reactions are an overwhelming response by someone who has a neurocognitive disorder, to what appears, to someone who doesn't have dementia, to be a normal, non-threatening situation.

In early-middle stages of dementia

Someone who has dementia may cry and scream and throw things upon learning the score of a football game. They may call the police on a family member who tells them, "Like hell you are going to (for example, set the piano on fire)." They may climb out a bedroom window to avoid an unwelcome visitor. Or they may attempt to sign away the house to a stranger when an adult caretaker has to be away for a few days for a different family emergency. Or they may try to blow out a candle and call the fire department if the flame reappears. (All of these events have occurred in the experiences of the author of this article.)

In the later-middle stages of dementia

Someone who has dementia may try to bite, pinch, or kick a caregiver they don't remember. They may burst into tears when they can't find a keepsake, even if it is on the table in front of them. They may try to run away when someone they don't like comes to visit them. They may climb out windows, or hide in closets, or try to run away.

Catastrophizing is a characteristic of the early stages of a major neurocognitive disorder, or the middle stages of dementia. The patient is lucid enough to pitch battle over perceived dangers, but not sufficiently "with it" to recognize that a situation is not especially threatening. People who display catastrophic reactions may realize that their mental abilities are slipping away and take unfortunate measures to regain control over their lives.

How do you prevent the more complicated catastrophic reactions that can occur earlier in dementia?

1. Be respectful. Don't be patronizing.
2. Address the person by their name.
3. Minimize the chances for escalation. Don't continue the problem activity unless absolutely necessary.
4. Give the person who is acting out personal space. Don't get too close. This can be interpreted as aggression.
5. Allow the person time to calm down.
6. Divert the person with dementia as they are calming down. Shift the focus of attention to something more pleasant.
7. Reassure the person who is in distress. Remind them of those things over which they have control (without being patronizing).
8. If the person has not had a previous catastrophic reaction, take time to investigate whether there is an unusual health issue, like a fall or a bladder infection. Delirium is a common complication of bladder infections. Or determine whether they have received bad news or something upsetting has occurred.
9. If they have a history of catastrophic reactions, look for triggers that become just too much for them to handle. 
10. Remember, that hallucinations are real to people who have dementia. Be aware that part of the problem may be unseen to you.

For dementia patients who may no longer be able to communicate:

1. Approach the patient from the front, not from behind or from the sides, so they will not be startled.
2. Don't appear rushed, hurried, or worried.
3. Know the patient's preferences regarding touch. Some people like touch, some people are repelled by it.
4. Explain what you are attempting to do before you do it. For example, "Breakfast is ready. Let me put your tray table over your bed."
5. Avoid sudden changes in routine. When they are unavoidable, introduce them slowly. 
6. Avoid fatigue, both in the patient and in yourself. Taking care of yourself may indirectly prevent catastrophizing in the person you are caring for.
7. Look for signs of anxiety, especially in patients who are no longer capable of speech.
8. Communicate with your tone of voice as well as your words. Even when your words are not understood, your tone of voice will be.
9. Avoid odors that have been associated with earlier catastrophic reactions. Some people who have dementia still have strong olfactory member.
10. Don't argue with or attempt to reason with someone who can't argue or attempt to reason with you. An insistent tone can also be interpreted as aggression and provoke a defensive response.