OHSU

Behavioral Problems with Alzheimer's Disease

Alzheimer's Disease develops slowly and causes changes in the brain long before they are are obvious. Typical problems in the early stage of the disease are:

  • Loss of recent memory
  • Trouble finding words
  • Difficulty with organization and finances
  • Become lost on the way to familiar places

Over time, a person with AD may:

  • Become restless or agitated
  • Lose concern for personal appearance
  • Show poor judgment
  • Continuously repeat the same story or questions

Eventually, people in the late stages of Alzheimer's:

  • Do not recognize family members
  • Cannot communicate effectively
  • Are not able to eat on their own

It is important to realize that anger, agitation and wandering are not deliberate behaviors.

Remember that individuals with dementia cannot control their troubling behaviors. Caregivers, friends and family can change the ways they act around people with Alzheimer's.

Useful tips for caregivers.

Activities of Daily Living

The ability to perform routine daily tasks, called activities of daily living (ADLs) provides a measurement of how well a person is functioning. Your doctor will ask about ADLs in order to help make a diagnosis and recommend a care plan. Other people who have been caregivers offer tips about how to make life easier at home.

Sleep problems

Individuals with memory problems and dementia often have trouble sleeping. Disruptive sleep habits may interfere with caregivers' rest, and lack of sleep may contribute to increased behavior problems.

Tips to Make Sleep Easier

  • Establish a routine with a regular bedtime: try giving a snack or warm milk, a warm bath or reading before bed.
  • Start a daily exercise routine: walking, sweeping, stationary bicycling, joining an exercise group, etc.
  • Encourage spending less time in bed. Try later bedtimes or earlier wake-up times.
  • Try short naps in the early afternoon, if a nap seems necessary.
  • For chronic pain, a mild pain relief medication at bedtime may be helpful. (Check first with their healthcare provider.)
  • Check to ensure a good room temperature for sleeping, not too cold or too warm.
  • Encourage emptying the bladder before bedtime.
  • Consider sleeping medications, but not as the first approach.

Other considerations

  • Sleep problems may be a symptom of depression; discuss this with their healthcare provider.
  • Medications may cause problems with sleep; review medications with healthcare provider on a regular basis.
  • If a person experiences confusion upon waking in the night, leave night lights on in bedroom and bathroom.
  • Remove daytime clothing from sleeping area.

Things to avoid

  • Caffeine, including coffee, tea, colas and chocolate. Don't limit water or juice.
  • Alcohol.
  • Going to bed too early. Total sleep time can become less as we get older, and this could make your loved one with AD sleep less. experience that as age increases, total sleep time decreases.
  • Long naps during the day.
  • Upsetting situations before bedtime. Avoid arguments and action-packed TV programs before bed.

Caregiver issues

  • Make the house safe if nighttime awakenings do occur.
  • Secure home so that person cannot leave during the night, remove dangerous objects.
  • Caregivers need enough sleep: Nap during the day, arrange nighttime rest for yourself, use separate bedrooms.

Wandering

Coping with wandering behavior

Approximately 25 percent of people with memory problems or dementia will wander (get lost, try to leave home).

Some people never get lost or try to leave home. Others do this often. If your loved one wanders, watch closely to see what could be causing this behavior.

  • Does the person wander at a particular time of day or in a certain location?
  • What happened before the wandering behavior?
  • Does the person wander when particularly confused or tired?

Wandering to fulfill specific needs

  • Lack of physical activity during the day.
  • Hunger, need to use the restroom or discomfort.
  • Not knowing where he or she is.
  • Needs help finding his or her room.

Confusion

A person with memory problems or dementia may be:

  • Searching for people or places from the past.
  • Trying to do old behaviors such as going to work or picking up the children from school.

To help:

  • Reassure the person about where he or she is and who is there.
  • Distract with another activity.
  • Do not argue about misconceptions.

Strategies:

  • Remove things that are reminders of going outside, such as coats, hats or purses.
  • Place a "STOP" sign on doors leading outside.
  • Label the doors of other rooms, such as bedroom and bathroom.
  • Get an ID bracelet.
  • Provide a safe place to wander, such as a securely fenced yard.
  • Improve lighting inside the home.
  • Place locks very high or very low on doors, out of the normal line of vision.
  • Install a bell or a buzzer that lets you know when a door has been opened.
  • Keep a current picture of the person on hand. Approach a wanderer in a calm and non-threatening manner.
  • Go for a ride in the car, or take a walk with the person.
  • Encourage daily exercise and simple chores.

Anxiety and Agitation

How to cope with agitation and aggression

Agitation means that a person is restless and worried. He or she doesn't seem to be able to settle down. Agitated people may:

  • Pace a lot, not be able to sleep.
  • Act aggressively toward others.
  • Verbally lash out or try to hit or hurt someone.

Most of the time, these behaviors happen for a reason. When they happen, try to find the cause.

For example, the person may have:

  • Pain, depression, or stress they cannot understand.
  • Too little rest or sleep.
  • Constipation.
  • Soiled underwear or diaper.

Other causes of agitation and aggression:

  • Sudden change in place, routine or person.
  • Missing something, like driving or caring for children.
  • Too much noise or too many people.
  • Being pushed to do something difficult for them, like bathe or remember things.
  • Being lonely, not having enough contact with other people.
  • Medication.

Coping with agitation and aggression

Look for the early signs of agitation or aggression. If you see the signs, you can help before problems start.

Try to:

  • Find a solution. Doing nothing can make things worse.
  • Find the cause of the behavior. If you deal with the causes, the behavior may stop.
  • Slow down and relax if you think your worries may be affecting the person with AD. If you can, take a break from caregiving.
  • Help the person with AD keep as much control over life as possible.
  • Distract the person with a favorite snack, object or activity.

You can also:

  • Speak calmly, listen to concerns and frustrations and show that you understand if the person is angry or fearful.
  • Keep favorite objects and photographs around the house. This can make the person with AD feel more secure.

In addition, you can:

  • Reduce noise, clutter or number of people in the room.
  • Try gentle touching, soothing music, reading or walks.
  • Have quiet times and activities each day.
  • Limit caffeine, sugar and "junk food."

Elder Depression

What is depression?

We all feel unhappy at times, but depression is not the same as feeling sad or your thoughts, feelings, behavior and physical health. Symptoms of depression include:
  • Loss of interest of pleasure.
  • Persistent feelings of sadness, anxiety or emptiness.
  • Feelings of hopelessness or pessimism.
  • Feelings of guilt, worthlessness or helplessness.
  • Loss of energy, feeling fatigued or slow.

You may also have other signs of depression including:

  • Difficulty concentrating, remembering or making decisions.
  • Trouble sleeping or sleeping too much.
  • Loss of appetite or overeating.
  • Thoughts of death or suicide; suicide attempts.
  • Persistent physical symptoms that don't get better with treatment.

In older adults, symptoms of depression may include:

  • Increased irritability.
  • Delusions (wrong ideas that aren't based in reality).
  • Hallucinations (seeing or hearing things that aren't there.)

How common is depression in later life?

Depression is a serious medical condition that affects more than 6.5 million of the 35 million Americans who are 65 years or older. Many older adults with depression:
  • Have suffered from episodes of the illness for much of their lives. For others, depression can occur for the first time late in life.
  • Have depression from being dependent or disabled and not being able to function in daily life.
  • Suffer, but also cause problems for people who care about them.

Less than one-third of depressed people seek treatment.

What causes depression in older people?

The causes of depression are complex and involve many different factors. Research suggests that some people inherit a tendency to be depressed. This can be triggered by other factors such as stress, loss or a major life change.

Researchers have found brain chemicals, or neurotransmitters, they believe are involved with depression. Some medications can cause depression or make treatment for depression less effective. Your doctor should know about all your medications, including over-the-counter drugs and supplements (vitamins, herbal remedies).

Health conditions and procedures that can be associated with depression include:
  • Stroke and heart attack
  • Hip fracture
  • Loss of vision
  • Bypass surgery
You may suspect depression if you:
  • Lose the ability to manage daily activities because of a health condition.
  • Have a long recovery from a health problem or refuse treatments.
  • Become more dependent on others and need to change your living arrangements.

How is depression diagnosed?

Your healthcare provider should examine you to rule out medical conditions or medications that could be causing your symptoms.

Your doctor can rule out other causes after a medical history and laboratory tests. Your doctor may suggest a psychological (mental health) evaluation.

What are the treatments?

A number of studies show that depression is under-treated in the elderly. Many people think depression is a normal part of aging and don't seek treatment. 

People often don't understand or recognize the symptoms of depression or mistake them for signs of dementia. Some older adults may blame themselves or be ashamed of their illness and feel that they should be able to get over it without treatment.

There are many effective treatments for depression in older adults. These include:

  • Psychotherapy (counseling)
  • Medication, with or without counseling
  • Electroconvulsive (shock) therapy

Many new medications for depression have fewer side effects than older treatments. Counseling can also help if you are going through a crisis, don’t have very much social support or need to develop coping skills.

If medication, psychotherapy (counseling) or both don’t help depression, electroconvulsive therapy (ECT) may be useful. ECT, formerly known as "shock therapy," once had a bad reputation. In recent years, it has greatly improved and can help people with severe depression who don’t feel better with other treatments. It is safe and well tolerated by many people.

Like diabetes or arthritis, depression can be a chronic (long-term) disease. It is important to know if you have depression so you can benefit from the safe and effective treatments available.