Why inappropriate behavior occurs in dementia
Changes in the brain caused by dementia, particularly damage to the frontal lobes, are the root cause of inappropriate and disinhibited behavior. The frontal lobes control our impulses, judgment, and social conduct. When these areas degenerate, a person loses the ability to recognize and filter socially unacceptable actions. It is critical for caregivers to remember that the disease, not the individual, is causing these behaviors. The person is not acting this way on purpose.
Beyond brain degeneration, specific triggers can set off or worsen these behaviors:
- Unmet physical needs: A person may be hungry, thirsty, tired, in pain, or need to use the toilet but cannot communicate this verbally. A urinary tract infection (UTI), a common issue in older adults, can also cause sudden and severe behavioral changes.
- Environmental stress: Overstimulation from loud noises, a busy environment, clutter, or unfamiliar places can cause confusion and distress. Being surrounded by too many people at once can also be overwhelming.
- Emotional distress: Feelings of fear, anxiety, boredom, loneliness, or a perceived loss of control can manifest as agitation, aggression, or other inappropriate actions. Boredom, in particular, is a common trigger.
- Misinterpretation of cues: Due to cognitive impairment, an individual with dementia may misread social cues or interpret a caregiver's touch during personal care as a sexual advance. Memory loss can cause them to mistake a caregiver for a partner, leading to inappropriate interactions.
- Changes in routine: A sudden change in schedule or an unfamiliar caregiver can be unsettling and trigger anxiety.
Common types of inappropriate behavior with dementia
Inappropriate behaviors can vary widely depending on the type and stage of dementia. They can be verbal, physical, or social. Some common examples include:
- Verbal outbursts: This can include saying tactless or rude things, using foul language, or making sexually suggestive comments that are out of character.
- Physical aggression: Lashing out, hitting, pushing, or resisting help from caregivers, especially during intimate tasks like bathing.
- Sexual disinhibition: This can manifest as inappropriate touching (self or others), public undressing, or making unwanted sexual advances.
- Suspicion and paranoia: Believing others are stealing their possessions, that family members are intruders, or other delusions that are very real to them.
- Wandering and pacing: Restlessness can cause an urge to wander or pace, sometimes stemming from a need to fulfill a purpose, express boredom, or an unmet need.
Comparison of behavioral and empathetic responses
Effective management requires shifting from a corrective approach to one based on empathy and redirection. This is because reasoning and logic are no longer effective communication tools for someone with cognitive decline.
| Response Strategy | Corrective/Logical Approach (Ineffective) | Empathetic/Redirective Approach (Effective) |
|---|---|---|
| During Aggression | Arguing, raising your voice, or demanding they stop the behavior. | Remain calm, back away to create space, speak gently, and use a soothing tone. Validate their feeling of fear or frustration rather than the specific cause. |
| During Public Undressing | Shaming them, scolding them, or telling them what they are doing is wrong and embarrassing. | Immediately and calmly lead them to a private area. Provide privacy and quietly help them re-dress. Check if they are too hot or if their clothes are uncomfortable. |
| During Sexual Comments | Embarrassing them or telling them their comment was inappropriate and hurtful. | Don't overreact. Gently but firmly state that you don't like the behavior. Distract them by changing the subject to something they enjoy or redirecting their attention to another activity. |
| During Paranoia/Suspicion | Arguing with them about what is real or proving that you didn't take something. | Acknowledge their distress. Offer to help them search for the item. Avoid trying to convince them they are wrong, as their delusion is very real to them. |
How to respond and prevent inappropriate behavior
Preventative strategies and responsive techniques are both necessary for effectively managing inappropriate behavior.
Preventative techniques
- Create a consistent routine: Structure and predictability are comforting for individuals with dementia. Keep daily tasks like bathing, eating, and exercise at the same time each day.
- Simplify the environment: Reduce clutter, bright lights, and loud noises to prevent overstimulation. Keep familiar objects and photos visible to create a sense of security.
- Address unmet needs: Regularly check if they might be hungry, thirsty, in pain, or need to use the restroom. Track their behaviors to identify patterns and potential triggers.
- Encourage engagement: Boredom can trigger restless and inappropriate actions. Offer simple, meaningful activities like folding laundry, looking at photo albums, or listening to familiar music.
- Educate others: Inform family and visitors about the disease and how to interact effectively. Limit the number of guests at one time to avoid overwhelming the individual.
In-the-moment responses
- Validate feelings: If they express frustration or sadness, respond to the emotion behind the words rather than the illogical content. Say, “I know you’re upset” rather than trying to correct them.
- Use redirection: Gently guide their attention toward another activity or conversation. This is one of the most powerful tools for de-escalating a situation.
- Use simple, calm communication: Speak in short, simple sentences with a calm and soft tone. Use nonverbal cues like a gentle touch or reassuring body language.
- Assess for underlying issues: If a behavior appears suddenly, consider if an infection (like a UTI), medication side effects, or a new source of pain might be the cause. Consult their doctor to rule out medical issues.
Conclusion
Inappropriate behaviors in dementia are a direct result of brain changes, not a deliberate choice by the individual. For caregivers, understanding this fundamental fact is the first step toward effective management and reduced frustration. By focusing on empathetic communication, identifying and addressing triggers, and using redirection as a primary tool, caregivers can create a safer, calmer environment for both themselves and their loved ones. Support groups and medical professionals can provide additional guidance and strategies for navigating these challenging behaviors. Caring for yourself is also essential, as the emotional toll can be significant. By responding with patience, consistency, and a flexible approach, caregivers can better manage inappropriate behaviors and preserve the dignity of the person with dementia.
