What are the 3 P's of dementia? Essential guidance for caregivers

Up to 90% of people with dementia will experience behavioral and psychological symptoms at some point, often frustrating and confusing for caregivers. Before assuming behavioral issues are solely due to cognitive decline, it's critical to understand the concept of the 3 P's of dementia. These represent three of the most common, yet often overlooked, physical causes of behavioral changes in people with cognitive impairment.

Quick Summary

The 3 P's of dementia—Poop, Pee, and Pain—refer to the frequent, underlying physical causes for behavioral symptoms like agitation or withdrawal. Caregivers should check for constipation, urinary issues, or untreated pain when a person with dementia behaves uncharacteristically.

Key Points

• The Three P's: Poop (constipation), Pee (urinary issues), and Pain are critical underlying causes of behavioral changes in people with dementia.

• Behavior is Communication: Challenging behaviors like agitation or withdrawal are often the only way a person with cognitive decline can express physical discomfort or an unmet need.

• Check Physical Needs First: Before assuming a behavioral issue is solely due to dementia, systematically investigate for constipation, urinary problems, or unexpressed pain.

• Observe for Non-Verbal Cues: Because verbal communication is difficult, caregivers must rely on observing body language, facial expressions, and changes in routines to identify signs of distress.

• Seek Medical Advice: Persistent issues with the 3 P's require a doctor's assessment to rule out conditions like UTIs or treat underlying pain, which can often quickly resolve the behavioral problem.

• Employ a Holistic Strategy: Beyond addressing the 3 P's, creating a calm, consistent environment and using non-pharmacological interventions like music or distraction are crucial for managing dementia behaviors.

Understanding the communication behind behavior

As dementia progresses, individuals lose the ability to express their needs verbally. This communication breakdown means that their behavior becomes the primary way of signaling discomfort or unmet needs. Agitation, wandering, and aggression, often assumed to be direct symptoms of the disease, can actually be a person's attempt to communicate distress caused by a simple, treatable physical problem. By learning to look past the outward behavior and investigate the root cause, caregivers can improve the individual's comfort and well-being.

The three P's defined

As coined by hospice and palliative care teams, the 3 P's provide a critical framework for caregivers to assess a person with dementia when there is a sudden change in behavior.

P is for Poop (Constipation)

Constipation is a common and often painful issue in older adults, particularly those with dementia. It can cause significant discomfort, which the person may not be able to articulate verbally. The resulting agitation, restlessness, or refusal to eat can be mistaken for behavioral symptoms of dementia.

Signs of constipation

• Restlessness and fidgeting
• Increased agitation or aggression
• Change in appetite or refusal to eat
• Facial expressions of sorrow or discomfort
• Repetitive behaviors like moaning
• Fewer than two bowel movements per week

Management strategies

• Monitor bowel movements: Keep a log to track frequency and consistency.
• Increase fiber and fluids: Offer fiber-rich foods and encourage adequate hydration, as dehydration is a common problem.
• Encourage gentle exercise: Simple physical activity, like a daily walk, can stimulate bowel function.
• Consult a doctor: If the issue persists, a physician can rule out other medical causes and suggest a treatment plan.

P is for Pee (Urinary Issues)

Issues with urination, such as urinary retention or infection, are another common source of discomfort that can lead to behavioral changes. A urinary tract infection (UTI) can cause delirium, which is a sudden state of severe confusion and agitation. The inability to effectively communicate the urge to urinate or discomfort can lead to pacing, restlessness, and anxiety.

Signs of urinary issues

• Increased restlessness or wandering
• Taking off/putting on clothes inappropriately
• Crying out or moaning
• Signs of pain during urination
• Sudden onset of confusion or delirium
• Fever (in the case of a UTI)

Management strategies

• Establish a routine: Remind and assist with toileting every two hours to avoid accidents and retention.
• Track fluid intake: Ensure they are not becoming dehydrated, but limit fluids in the evening if nighttime incontinence is an issue.
• Watch for UTI signs: Be vigilant for signs of a UTI, as these can cause a sudden, marked change in mental status. Always consult a doctor if you suspect an infection.
• Create a safe path: Make sure the path to the bathroom is clear, well-lit, and easy to navigate.

P is for Pain (Untreated Physical Pain)

Pain is the third crucial 'P'. People with advanced dementia are at risk for pain from conditions like arthritis or pressure ulcers, yet they may lose the ability to locate or describe their pain. Because pain can't be communicated, it often manifests as a difficult behavior, leading to frustration for both the person and the caregiver.

Signs of pain

• Aggression or resistance to care (especially during bathing or dressing)
• Irritability or sudden mood changes
• Repetitive vocalizations or noises
• Increased pacing or restlessness
• Grimacing, guarding a body part, or changes in posture

Management strategies

• Observe non-verbal cues: Pay attention to facial expressions, body language, and changes in routine. Pain may be most apparent during movement or specific activities.
• Check for injuries: Perform a regular, gentle check for any new bruises, cuts, or sores, as the person may not remember how they occurred.
• Consult a doctor: Talk to a healthcare provider to assess for underlying painful conditions. The physician can prescribe appropriate medication.
• Use non-pharmacological methods: Try soothing music, gentle massage, or therapeutic touch to alleviate discomfort.

Medical vs. Behavioral: Distinguishing the cause

Symptom	Triggered by Medical Issues (3 P's)	Triggered by Cognitive Decline (Dementia)
Onset	Often sudden, with a marked change in baseline behavior.	Typically gradual, progressing over time with increasing severity.
Pattern	May correspond to a physical cycle (e.g., eating, evening hours) or a new medical issue.	Less related to specific physical cycles; behavior is more unpredictable and generalized.
Communication	Stems from an urgent, unmet physical need that cannot be expressed verbally.	Results from memory loss, confusion, or fear related to failing cognitive function.
Intervention	Responds well to addressing the underlying physical cause (e.g., medication for pain, laxatives for constipation).	Requires redirection, distraction, and a consistent, calming routine rather than treating a physical cause.
Intensity	Can be intense and appear suddenly aggressive due to severe, untreated discomfort.	May vary in intensity but often linked to emotional triggers like frustration and loss of control.

A holistic approach for caregivers

By systematically checking for the 3 P's, caregivers can prevent unnecessary stress for both themselves and the person with dementia. A caregiver's role is not just to manage behavior but to act as a detective, looking for the physical clues that the person cannot convey verbally. In addition to addressing the 3 P's, creating a supportive environment and managing caregiver stress are crucial.

For more information on managing behavioral changes and getting caregiver support, resources from the Alzheimer's Association can be invaluable. Visit the Alzheimer's Association website for a wealth of information and support groups: https://www.alz.org/.

Conclusion: The power of observation and empathy

Understanding what are the 3 P's of dementia? fundamentally shifts the caregiver's perspective from viewing difficult behaviors as a challenge to seeing them as a form of communication. When a person with dementia acts out, it is not intentional or malicious; it is often the only way they have left to signal distress. By methodically checking for constipation, urinary issues, and untreated pain, caregivers can provide comfort and relief. This approach not only improves the individual's quality of life but also fosters a more compassionate and understanding caregiving environment, leading to better outcomes for everyone involved. The key is careful observation and a deep sense of empathy for what the person may be silently enduring.

Frequently Asked Questions

How do I know if agitation is from pain or a dementia symptom?

Agitation due to pain may be more sudden and intense, sometimes correlating with movement or specific activities like dressing. Agitation from dementia alone often follows a more gradual pattern and is linked to emotional triggers like confusion or frustration. Check for physical signs of pain and consult a doctor if you suspect an underlying medical issue.

What if my loved one can't tell me they're in pain?

Many people with advanced dementia lose the ability to articulate pain verbally. You must rely on non-verbal cues. Look for grimacing, moaning, guarding a body part, or a change in appetite or posture. A sudden increase in restless or aggressive behavior can also indicate pain.

How can I check for constipation when communication is limited?

Monitor bowel movements by keeping a simple daily log of frequency and stool consistency. A persistent change in eating habits, repetitive moaning, or increased restlessness can also be indicators. Increasing fiber and fluid intake is a safe first step, but a doctor should be consulted for prolonged issues.

Can a urinary tract infection cause confusion in dementia patients?

Yes, a urinary tract infection (UTI) is a very common cause of sudden-onset delirium, which involves severe confusion and agitation, in people with dementia. Other signs might include taking off clothes inappropriately, increased restlessness, and fever. Immediate medical attention is necessary if a UTI is suspected.

What is 'sundowning' and how does it relate to the 3 P's?

Sundowning is increased confusion and agitation that occurs in the late afternoon or evening. While related to the internal body clock, it can be exacerbated by physical discomfort. Checking the 3 P's before sundown—ensuring the bladder is empty, there is no untreated pain, and bowel movements are regular—can sometimes help minimize the symptoms.

How can a consistent routine help manage these issues?

A predictable daily routine can reduce anxiety and confusion, which are often triggers for agitation. Consistent timing for meals, activities, and bathroom breaks can also help regulate bowel and bladder function, proactively preventing issues with the "Poop" and "Pee" P's.

Is it okay to argue with a person with dementia about their pain or discomfort?

No, it is not effective to argue or try to reason with a person with dementia, as their ability to process logic is impaired. Instead, validate their feelings and respond with verbal and physical expressions of comfort, support, and reassurance. Focus on addressing the potential physical cause rather than the outward behavior.