Disruptive actions are common among patients with dementia and are the primary reason for up to 50% of nursing home admissions. Disruptive actions include wandering, restlessness, yelling, throwing, hitting, refusing treatment, incessantly questioning, disrupting work of staff members, insomnia, and crying. Behavioral and psychologic symptoms of dementia have not been well characterized, and their treatment is poorly understood.
Deciding what actions constitute a behavioral symptom is highly subjective. Tolerability (what actions caregivers can tolerate) depends partly on the patient’s living arrangements, particularly safety. For example, wandering may be tolerable if a patient lives in a safe environment (with locks and alarms on all doors and gates); however, if the patient lives in a nursing home or hospital, wandering may be intolerable because it disturbs other patients or interferes with the operation of the institution.
Many behaviors (eg, wandering, repeatedly questioning, being uncooperative) are better tolerated during the day. Whether sundowning (exacerbation of disruptive behaviors at sundown or early evening) represents decreased tolerance by caregivers or true diurnal variation is unknown. In nursing homes, 12 to 14% of patients with dementia act disruptively more often during the evening than during the day.
(See also Overview of Delirium and Dementia and Dementia.)
Etiology
Behavioral and psychologic symptoms may result from functional changes related to dementia:
Reduced inhibition of inappropriate behaviors (eg, patients may undress in public places)
Misinterpretation of visual and auditory cues (eg, they may resist treatment, which they perceive as an assault)
Impaired short-term memory (eg, they repeatedly ask for things already received)
Reduced ability or inability to express needs (eg, they wander because they are lonely, frightened, or looking for something or someone)
Patients with dementia often adapt poorly to the regimentation of institutional living. Mealtimes, bedtimes, and toileting times are not individualized. For many older patients with dementia, behavioral and psychologic symptoms develop or worsen after they are moved to a more restrictive, unfamiliar environment.
Physical problems (eg, pain, shortness of breath, urinary retention, constipation, physical abuse) can exacerbate behavioral and psychologic symptoms partly because patients may be unable to adequately communicate what the problem is. Physical problems can lead to delirium, and delirium superimposed on chronic dementia may worsen the behavioral symptom.
Evaluation
Characterization of behaviors (eg, by Cohen-Mansfield Agitation Inventory)
Recording of specific behaviors
Evaluation for coexisting depression and psychosis
The best approach is to characterize and classify the behavior, rather than to label all such behaviors agitation, a term with too many meanings to be useful. The Cohen-Mansfield Agitation Inventory is commonly used; it classifies behaviors as follows:
Physically aggressive: For example, hitting, pushing, kicking, biting, scratching, or grabbing people or things
Physically nonaggressive: For example, handling things inappropriately, hiding things, dressing or undressing inappropriately, pacing, repeating mannerisms or sentences, acting restless, or trying to go elsewhere
Verbally aggressive: For example, cursing, making strange noises, screaming, or having temper outbursts
Verbally nonaggressive: For example, complaining, whining, constantly requesting attention, not liking anything, interrupting with relevant or irrelevant remarks, or being negative or bossy
The following information should be recorded:
Specific behaviors
Precipitating events (eg, feeding, toileting, medication administration, visits)
Time the behavior started and resolved
This information helps identify changes in pattern or intensity of a behavior and makes planning a management strategy easier.
If behavior changes, a physical examination should be done to exclude physical disorders and physical abuse, but environmental changes (eg, a different caregiver) should also be noted because they, rather than a patient-related factor, may be the reason.
Depression, common among patients with dementia, may affect behavior and must be identified. It may first manifest as an abrupt change in cognition, decreased appetite, deterioration in mood, a change in sleep pattern (often hypersomnolence), withdrawal, decreased activity level, crying spells, talk of death and dying, sudden development of irritability or psychosis, or other sudden changes in behavior. Often, depression is suspected first by family members.
Psychotic behavior must also be identified because management differs. Presence of delusions or hallucinations indicates psychosis. Delusions and hallucinations must be distinguished from disorientation, fearfulness, and misunderstanding, which are common among patients with dementia:
Delusions without paranoia may be confused with disorientation, but delusions are usually fixed (eg, a nursing home is repeatedly called a prison), and disorientation varies (eg, a nursing home is called a prison, a restaurant, and a home).
Hallucinations occur without external sensory stimuli; hallucinations should be distinguished from illusions, which involve misinterpreting external sensory stimuli (eg, cellular phones, pagers).
Treatment
Environmental measures and caregiver support
Medications only when necessary
Management of behavioral and psychologic symptoms of dementia is controversial and has been inadequately studied. Supportive measures are preferred; however, medications are commonly used.
Environmental measures
The environment should be safe and flexible enough to accommodate behaviors that are not dangerous. Signs to help patients find their way and doors equipped with locks or alarms can help ensure the safety of patients who wander. Flexible sleeping hours and organization of beds can help patients with sleeping problems.
Measures used to treat dementia generally also help minimize behavioral symptoms:
Providing cues about time and place
Explaining care before giving it
Encouraging physical activity
If an institution cannot provide an appropriate environment for a particular patient, transferring the patient to one that can provide a more appropriate environment may be preferable to using medications.
Caregiver support
Providing caregiver support is crucial.
Learning how dementia leads to behavioral and psychologic symptoms and how to respond to disruptive behavior can help family members and other caregivers provide care for and cope with the patient better.
Learning how to manage stress, which may be considerable, is essential. Stressed caregivers should be referred to support services (eg, social workers, caregiver support groups, home health aides) and should be told how to obtain respite care if such care is available.
Family members who are caregivers should be monitored for depression, which occurs in nearly half of them. Depression in caregivers should be treated promptly.
Use of medications
Medications that improve cognition (eg, cholinesterase inhibitors) may also help manage behavioral and psychologic symptoms in patients with dementia. However, medications directed primarily at behavior (eg, antipsychotics) are used only when other approaches are ineffective and when these medications are essential for safety. The need for continued treatment should be reassessed at least every month. Medications should be selected to target the most intolerable behaviors.
Antidepressants, preferably selective serotonin reuptake inhibitor (SSRIs), should be prescribed only for patients with signs of depression.
Antipsychotics
Antipsychotics are often used even though their efficacy has been shown only in psychotic patients. Other patients are unlikely to benefit and are likely to experience adverse effects, particularly extrapyramidal symptoms. Tardive dyskinesia or tardive dystonia may develop; these conditions often do not resolve when the dose is reduced or the medication is stopped.
Other medications
Antiseizure medications, particularly valproate, may be useful in controlling impulsive behavioral outbursts.
Key Points
What constitutes disruptive behavior is subjective and variable, yet behavioral disturbances are the reason for up to 50% of nursing home admissions.
Behavior often deteriorates when patients are moved from their familiar home environment.
Behavioral disturbances may be triggered by a physical problem that the patient cannot communicate.
Categorize behavioral disturbances using the Cohen-Mansfield Agitation Inventory.
Recognize signs of depression, such as abrupt changes in cognition, decreased appetite, deterioration in mood, a change in sleep pattern (often hypersomnolence), withdrawal, decreased activity level, crying spells, and talk of death and dying, and be alert for sudden development of irritability or psychotic behavior.
Treat using environmental measures, avoiding medications when possible.
More Information
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
BPSD Algorithm: This tool aims to help provide interdisciplinary, evidenced-based care for patients with behavioral and psychologic symptoms caused by dementia. It provides guidance for evaluation and use of medications, as well as a flow chart.
