The neurology behind unintentional 'nastiness'
At the core of a person with dementia's behavioral changes are physical changes in the brain. The deterioration of neurons in specific areas of the brain can strip away a person's ability to control impulses, regulate emotions, and recognize their own deficits. Understanding the root cause is the first step toward empathy and effective management for caregivers.
The role of the frontal lobe
The frontal lobe, often referred to as the brain's emotional control center, is one of the areas most impacted by dementia, particularly frontotemporal dementia. This part of the brain is responsible for:
- Impulse control: Deciding not to blurt out an inappropriate comment.
- Social awareness: Understanding what behaviors are acceptable in different social situations.
- Judgment and planning: Thinking ahead about the consequences of one's words or actions.
When the frontal lobe is damaged, these executive functions fail, leading to disinhibition. A person who was once mild-mannered may become rude, make inappropriate comments, or lash out. This is not a choice; it is a neurological symptom of the disease.
How loss of inhibition changes behavior
Loss of inhibitions can manifest in many ways that caregivers and family members perceive as "nasty":
- Verbal aggression: Using profanity, yelling, or making hurtful comments.
- Physical aggression: Pushing, hitting, or resisting care, often out of fear or confusion.
- Social inappropriateness: Losing tact, telling crude jokes, or showing poor table manners.
- Intrusiveness: Making inappropriate sexual advances or touching others without consent.
The symptom of anosognosia
A critical component that explains why a person with dementia may seem unaware of their unpleasant behavior is a condition called anosognosia. This is a neurological inability to recognize one's own illness or impairment, and it is a common symptom of dementia. Anosognosia is distinctly different from denial, which is a psychological defense mechanism. A person with anosognosia genuinely does not have the brain function to perceive that they are ill or that their behavior has changed.
Anosognosia vs. Denial
| Characteristic | Anosognosia (Neurological) | Denial (Psychological) |
|---|---|---|
| Cause | Physical changes/damage to the brain (e.g., frontal lobe) | Emotional coping mechanism to avoid a distressing truth |
| Awareness | The person is genuinely and physiologically unaware of their deficits. | The person subconsciously refuses to accept a reality they are aware of. |
| Intent | Behavior is not intentional; it is a manifestation of brain damage. | Intentional avoidance of a difficult topic or reality. |
| Response to Confrontation | Confusion, anger, or insistence that nothing is wrong because they truly believe it. | Emotional distress, avoidance, or defensiveness. |
For caregivers, this is a crucial distinction. Arguing with someone with anosognosia about their behavior is fruitless and can increase their agitation. They are not choosing to be difficult; they are physiologically incapable of recognizing the problem.
Triggers for aggressive and hurtful behavior
Beyond the primary brain damage, other factors can trigger or worsen unpleasant behaviors. Recognizing these triggers is key to prevention and management.
- Physical discomfort: The inability to express pain, hunger, thirst, or needing to use the bathroom can lead to frustration and aggression. A person who hits out during personal care, like bathing, may be feeling pain or perceive the touch as a threat.
- Environmental factors: Overstimulation from noise, clutter, or too many people can be overwhelming. Changes in routine or a confusing environment can also cause anxiety and acting out.
- Communication breakdown: As language skills decline, a person with dementia may express their needs through behavior rather than words. A verbal outburst could be a distressed form of communication.
- Fear and confusion: Disorientation, memory gaps, and a distorted reality can make the world a frightening place. A patient may hallucinate or become paranoid, leading them to perceive family members or caregivers as threats.
- Caregiver burnout: People with dementia can often mirror the emotions of those around them. A caregiver's own frustration or distress can unknowingly escalate a tense situation.
Conclusion
It is an overwhelmingly difficult and painful experience for family members and caregivers to witness a once-loving person become aggressive or "nasty." However, it is essential to remember that this behavior is a symptom of a progressive and complex disease, not a deliberate or malicious act by the person they know and love. The root causes lie in the neurological damage from the disease and related conditions like anosognosia, which render a person unaware of their own impairments. By understanding the triggers and addressing the unmet needs that are being communicated through behavior, caregivers can respond with empathy and patience. This approach helps protect the well-being and dignity of the person with dementia while mitigating the emotional toll on their loved ones. The disease, not the person, is responsible for the hurtful actions.
