All behavior is triggered by something. It does not come out of the blue. Therefore the first thing to consider is what happens before the behavior takes place. Some people find it valuable to keep a notebook in which to enter observations. The simplest way to make observations is to note in your notebook what happened before the behavior, describe the behavior that concerns you and then note what happens after the behavior. It may be that some change in the physical environment, that you may not even notice, causes confusion. It may be something you said or something someone else said that triggered the behavior. Once you know that, changing those antecedent conditions may suffice. It also may be that the behavior produces certain consequences and changing those consequences may suffice. However keep in mind that what works today, may not work tomorrow. Troubling behavior is often influenced by multiple factors and so the key is to be flexible. Your loved one will have good days and bad days and so will you. That is one reason why you’re behavioral notebook can be a valuable asset. You should keep it each and every day, not just when troubling behavior occurs, but also when it is not occurring. You may learn a lot from the conditions that are described in your notebook, on days in which few if any problem behaviors occur.
Wandering
Patients with dementia may very well wander for a variety of reasons including boredom, medication side effects or because they are looking for someone or something. They may be trying to fulfill a biological need like thirst, hunger or the need to use a toilet. Since people are built to move around, they may be walking, quite simply, because they need the exercise. So we should make time for regular exercise each and every day and not expect them to sit is in the same place or lie in bed for hours and hours. If you are concerned that they may wander away and harm themselves consider installing new locks that require a key. You may position the locks high or low since often dementia patients will not look beyond eye level. You may want to consider a barrier like a curtain or simply place a stop sign at the door. Some people have found that placing a black mat or even painting a black square on the front porch, may stop the patient, since it may appear like a hole. You can use child safe plastic covers over the door knob or if your loved one will not go out unless they have a coat, a purse or glasses you may want to put those away. Be sure to tell your neighbors about the risk of wondering and make sure they have your phone number then tell them call you immediately. If you can afford it consider a home security system that will respond to movement and sound an alarm. New digital devices that use global positioning systems can be a valuable backup enabling you to immediately locate your loved one. You may also want your relative to wear an ID bracelet.
Incontinence
As dementia progresses there may be a loss of bladder or bowel control. At times accidents may result from environmental factors, such as the patient not being able to remember the location of the bathroom, or they simply cannot get to the bathroom in time. While memory is impaired, the sense of dignity on such occasions is not. It can be a major source of humiliation. If an accident occurs your understanding and your reassurance will be needed. The best course is a plan that will allow you to avoid such circumstances. You can use signs marking the route to the bathroom and to indicate which of the doors is the door to the bathroom. Establish a routine for using the toilet. Try reminding the person, and assisting her to the bathroom every two hours. Carefully control fluid intake and limit fluid intake in the evening before bedtime. Keep in mind the risk of dehydration and avoid drinks with a diuretic effect like coffee, tea, Cola or beer. A commode, which can be obtained in a medical supply store, can be left in the bedroom at night to ensure easy access. Incontinence pads and products can be purchased at a pharmacy or at the supermarket. A urologist may be able to prescribe special products that can be of help. You should use easy to remove clothing with elastic waist bands or Velcro closures and clothes that are easily washable.
Agitation
Agitation refers to a range of behaviors associated with dementia including sleeplessness, irritability and verbal or physical aggression. Often these behaviors increase as the disease progresses from mild to more severe. The need for control continues, in spite of dementia, and often agitation is triggered when a person feels like control is being taken away. A good place to begin with your family member is to reduce the intake of caffeine, sugar and junk food. Reducing noise and clutter can be helpful and often, having too many people in the room, can be a triggering event. Unfamiliar things can be a trigger while familiar objects and photographs may offer a sense of security. A gentle touch, soothing music or going for a walk can often quell the agitation. Only speak in a reassuring tone of voice and beware of trying to restrain the person since this can result in panic and even more dramatic agitation. Be sure to keep dangerous objects well out of reach to avoid the risk of impulsive acts. Confrontation may actually increase anxiety, and, thus increased agitation. Acknowledge the frustration with loss of control. Often the best way to deal with agitation is distraction. Offer a snack or some kind of preferred activity. By encouraging as much independence as possible we reduce the likelihood of agitation as a product of diminished sense of control.
Sleeplessness and Sundowning
Disorientation, restlessness and agitation often get worse at the end of the day and may even continue throughout the night. Experts call this behavior pattern sundowning. It is caused by a combination of factors such as exhaustion from the days events, changes in the patient’s biological clock and resulting confusion between day and night. Often increasing daytime activities including physical exercise and discouraging inactivity and napping during the day, can be most helpful. It is useful to eliminate or restrict caffeine, sugar and junk foods too early in the day if at all. Plan smaller meals throughout the day and a very light meal, such as half of sandwich, before bedtime. Late afternoon and evening activities should be quiet and calm. However, structured and quiet activities such as a stroll outdoors, a simple card game or listening to music can be helpful. Turning on the lights well before Sunset and closing the curtains will minimize shadows and perhaps reduce confusion. At a minimum, keep a night light in the person’s room, in the hallway and in the bathroom. Block off stairways with gates and put away dangerous items. As a last resort, consider talking to the doctor about medication that would help your family member relax and sleep. We say as a last resort because sleeping pills and tranquilizers may solve one problem and create others. For example the patient sleeps at night but is more confused the next day.
Bathing
People with dementia often forget essential grooming activities. As children we are taught that certain activities are highly private, are to be undressed and cleaned, even by another family member, can be embarrassing and humiliating. As a result bathing is often a source of major distress. Begin by recalling your family members historical hygiene routine. Did they take baths or showers? Were they in the morning or at night? Did she have her hair washed at a salon or did she do it herself? Was their favorite scent, lotion or talcum powder that was always used. To the extent possible adopt the past bathing routines, because the familiarity will be calming. If your loved one has always been modest accommodate by making sure doors and curtains are closed. Whether in the shower or the bath keep a towel over the front of the body, lifting it to wash as needed. Always have towels and a robe nearby and ready immediately when they get out of the shower or tub. Notice the environment including room temperature and water temperatures. Older adults are more sensitive to both heat and cold. Nonslip floor bath mats, grab bars and bath or shower seats can be most helpful. If possible install a hand-held shower to give more control to you and the patient. Older people are often afraid of falling so help them feel secure. Never leave a person with dementia unattended in the bath or shower. Have all the things you’ll need laid out beforehand. If you draw the bath water first you can reassure the patient by pouring a cup over the hands before they step in. If the tub or shower is consistently traumatic a towel bath maybe considered. This uses a large bath towel and washcloths dampened in a plastic bag of warm water and no rinse soap.
