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Taking care of someone who has dementia can be overwhelming. Difficult behavior is the norm, not the exception. But sometimes challenging behaviors have a correctable cause.

People who have dementia are often difficult. Sometimes, however, challenging behaviors are linked to a treatable, medical cause or to a change in routine that can be modified. If your loved one's or patient's actions have you wondering whether you'll "lose it" yourself, take time to assess the situation and see whether these conditions could be troubling your dementia patient.

Bad weather

Even people with dementia often understand the dangers of lightning, high winds, blizzards, and tornados. Anxiety and paranoia make the situation worse for them. It is important to be reassuring during a weather crisis.

Constipation

It's only normal to get cranky if your bowels haven't moved in a week. People who have dementia may not be able to communicate that they are experiencing pain and discomfort from constipation, which cause agitation and acting out.

Dehydration

A dementia patient may seem perfectly healthy one day and be dangerously near death from dehydration the next. Fluid loss is a complication of medications and simply not remembering to drink.

When patient fluid intake is not monitored, dehydration is always a risk. People who become dehydrated become delirious. Because of the dementia, it is not always easy to notice when delirium is part of the neurocognitive disease and when it is part of dehydration. If the patient has a rapid pulse, a dry and pale lining in the mouth inelastic skin, dizziness, and hallucinations, consider the need for emergency treatment for dehydration. Usually this cannot be done in a nursing home. It has to be done in the ER.

Delays

Even when people can no longer speak, they may have a very clear idea of when lunch, breakfast, dinner, and snacks are to be served. Delays in meals are a common trigger for challenging behaviors, as are delays in transportation.

Dental problems

Abscesses, cavities, and sores in the mouth can cause pain and agitation, but someone who has dementia may not be able to tell you about them and may not be willing to let you look in their mouth to inspect for them. Lost and ill-fitting dentures are another problem for many older dementia patients. Look for a dentist who has experience in dealing with older people who have cognitive issues.

Excessive stimulation

People who have dementia tend to be "stressed out." Excessive environmental stimulation can add to their stress. To be considered are staff caregivers, other residents, visitors, interpersonal interaction and communication, recreational activities, food, odor from other patients' food, TV programs, background music, noise outdoors, and odors in the room, Excessive environmental stimulation interferes with eating and drinking more and more as dementia progresses.

Falls and fractures

People who have dementia often become clumsy. They may fall and pick themselves up without telling you about the incident, with disastrous consequences. Even slight head injuries can cause bleeding in the brain that must be treated promptly to avoid even more deterioration in the patient's condition. And because they also may be prone to conditions like osteoporosis, they may continue to use fractured limbs that cause them unspoken pain. When someone who has dementia is difficult, consider whether they could have taken a fall.

Hearing problems

Hearing loss is a risk factor for developing dementia, and it is a complicating factor once dementia has occurred. Hard of hearing people who have dementia may lose their ability to process the emotional meanings of sounds. They may have trouble tracking a sound, telling where it is coming from. They may misunderstand sounds so that it appears they are suffering auditory hallucinations. The usual remedy for hearing loss is a hearing aid, but someone who has dementia may not remember what a hearing aid is for. They may think it is a harmful foreign body in the ear. All of these issues contribute to behavioral issues for caregiver, and profound discomfort for the patient.

Different kinds of dementia tend to produce different kinds of hearing loss. Frontotemporal lobe dementia may cause an excessive fondness for music, tinnitus, and an inability to identify nonverbal sounds while retaining an ability to understand speech. Dementia in Parkinson's disease is often associated with auditory hallucinations. Both frontotemporal lobe dementia and Parkinson's can result in auditory anhedonia, an inability to enjoy sound. Alzheimer's, in particular, can cause an inability to respond to speech. Any rapidly progressive form of dementia can be accompanied by increased sensitivity to sound.

Hygiene

People in nursing care can't always bathe, shower, shave, or use deodorants and fragrances as often as they would like. They may become distressed by their own body odor. It's important to make sure that every patient in dementia care gets adequate opportunities to maintain personal hygiene. However, in many situations, it is also important that it not be a family member that helps with this. For some people with dementia, sensitivity to nudity in front of adult children may be the deciding issue in choosing institutional versus home care.

Incontinence

It's only natural to be distressed when you can't make it to the bathroom in time, or when you have to wear diapers. Timely care of toilet needs is essential to motivating desirable behaviors.

Modesty

Many or most people do not feel comfortable with strangers gawking at them when they shower, use the toilet, or get dressed. Too much attention when undressed makes people with dementia feel uncomfortable (or in the case of those treated with dopamine or dopaminergic drugs, sometimes too comfortable). Accommodate the religious and personal preferences of the patient concerning nudity and touching members of the opposite sex. This is an issue for some people of all religions and no religion at all.

Moving to a residential care facility

The trauma of moving to a new residential setting the dementia patient cannot understand can trigger many kinds of undesirable behaviors. You yourself may simply have to take a break and allow professional staff to deal with your loved one. But before you take a break from caring for the person who has dementia, make sure they have familiar items in their room, such as photos, a favorite blanket, or a radio or television set. Don't be dishonest. Don't tell them "We're going for a ride". And don't promise a short-term stay when you know the placement will be permanent.

Be careful when a social worker or an occupational therapist tells you "We think your loved one can be completely rehabilitated and return home." Many things can go wrong during a stay in a care facility.

Nausea

Nausea and dizziness often go together. Dizziness often precedes falls. To prevent falls, take proactive measures when nausea is a problem.

Pets

Some people in nursing care miss their pets. Visiting with pets is conducive to better behavior. However, it is important not to force contact with pets when people don't want it.

Pressure sores

Pressure sores and bedsores develop when someone sits down or lies down without changing position for prolonged periods. They are most common over bony areas: heels, ankles, knees, hips, buttocks, spine, shoulder blades, and elbows. The skin becomes fragile and is easily bruised or broken, even during ordinary washing. Pressure sores can become infected, and the resulting systemic inflammation is one more factor in agitated behavior.

Vision problems

When people who have dementia cannot see the world around them, they are even more isolated and become even more agitated. In diabetics, a common problem is floaters. Tiny blood clots may seem to fall down like a rain of inky black blobs. This can be terrifying if you don't know what is happening. As these blood clots accumulate, they can modify vision so that it's a little like looking out at the world through a sheet of plastic wrap. 

When something goes wrong with just one eye, people start to have problems with depth perception. They may not know how far to reach to grab a handrail, or they may have trouble estimating the distance from a plate of food to the mouth and drop it. Checkerboard patterns, like black and white squares on a bathroom floor, may look more like holes. All of these issues are frightening even to people who don't have dementia. But a visit to the ophthalmologist may be helpful.

Sometimes dementia is complicated by a condition called agnosia, the inability to understand what is seen. In these cases, the ophthalmologist cannot be of help.

Bad behavior is sometimes the only way someone with dementia can communicate what is wrong. Insightful caregivers who take the time to understand the origins of undesirable behaviors get better results over the long run.

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  • Photo courtesy of SteadyHealth

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