When caregivers report behavioral and psychological symptoms we begin with an evaluation of the nature of the symptoms, level of distress they are causing the patient, and level of distress they are causing the caregiver. Based upon this evaluation, the initial decision is made whether or not to treat the symptoms. For example, a commonly reported repetitive hallucination is one of a child playing in a corner. In some instances, this hallucination may have a delusional quality, that is, the patient believes it is really happening; in other instances, the patient may realize at some level that it is not real. In either case most patients are not disturbed by this hallucination, nor are caregivers. In these situations we will typically not suggest any treatment. In contrast, if the repetitive hallucination is of a man breaking into the house, it may be terrifying for the patient and upsetting for the caregiver, and therefore warrants treatment.
Important Principles for Treating Behavioral and Psychological Symptoms of Dementia—The 3Rs:
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Reassure
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Let patients know that they will be cared for and their wishes will be respected.
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Reconsider
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Consider how things look from the patient’s point of view.
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Redirect
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Do not confront patients when they are wrong, frustrating, or delusional.
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Distract them by moving to a different activity or topic of conversation.
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General Behavioral Strategies for Managing Behavioral and Psychological Symptoms of Dementia
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Manage the environment
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Keep routines and other things as constant as possible.
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Use pictures liberally in signs and other written communication.
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Use night-lights and other lighting at night.
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Keep the patient safe
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Alzheimer’s Association/Medic Alert “Safe Return” bracelet
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GPS tracking system for the watch or car
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Locks on doors, gates, and cabinets
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Disconnect the stove
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Remove or lock up weapons and power tools.
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Redirect the patient
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Change the topic of conversation
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Participate in safe and familiar activities
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Listen to old music
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Watch old movies
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Look at photo albums
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Discuss past events
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Fold laundry.
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Walk or drive with the patient.
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Care for the caregiver (see also Chapter 22 )
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Support groups
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Counseling/therapy—individual and family
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Educational activities
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Respite care
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Online chat rooms, blogs, and message boards.
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Dealing with Specific Behavioral and Psychological Symptoms of Dementia
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Apathy
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Involve the patient in preferred activities.
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Simplify the activities if needed.
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Do not trade apathy for agitation.
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Depression
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Avoid asking the patient to “snap out of it”
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Encourage social interaction.
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Seek counseling/therapy.
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Psychosis: delusions and hallucinations
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Delusions are common.
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Stealing possessions
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Infidelity
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House is not their home
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Spouse is not their spouse.
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Hallucinations
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Visual hallucinations are common early in dementia with Lewy bodies.
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Hallucinations can occur in other dementias in the middle or late stages.
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Some hallucinations require medical investigation.
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Behavioral interventions
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React calmly.
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Help the caregiver to understand the patient’s experience.
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Avoid denying the patient’s experience or confronting the patient regarding the experience.
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In most cases we first try to treat behavioral and psychological symptoms of dementia using behavioral (non-pharmacological) techniques. If this approach is not successful we then move on to supplementation with drugs (see Chapter 24 ).
Before discussing techniques for the treatment of specific behavioral and psychological symptoms, we would like to discuss some general principles.
Some General Principles for Treating Behavioral and Psychological Symptoms in Dementia: The 3Rs
Caregivers often experience difficulty when attempting to determine if, when, and how to intervene when behavioral and psychological symptoms occur. They struggle between trying to accommodate two basic needs that are often in conflict:
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The need for the patient to be safe, and
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The need for the patient to be content (happy).
One general approach to managing behavioral and psychological symptoms of dementia has become commonly known as the 3Rs: reassure, reconsider, redirect.
Reassure
One reason the person may be unwilling to give up a particular activity—driving, for example—is that he or she is fearful of the loss of the ability to do the things they find necessary (going to the supermarket) or enjoyable (visiting a friend). In any discussion where a loss of an important activity may be involved, it is important for the caregiver to reassure the patient that there will be alternative ways in which the patient can continue doing what they need and like to do.
One of the most contentious discussions we have ever had about driving was with a patient who was a World War II veteran. Despite several minor accidents, becoming so lost he had to be brought home by the police, and losing his car in a parking lot, he would not even entertain the possibility of not driving. His family could not even broach the subject with him without significant agitation including yelling and throwing objects. The family asked for our help, and, after several frustrating meetings, we made no progress. We finally decided to ask him to keep a daily log of where he drove. He was willing to do this task, and what emerged was that there was one place he went to nearly every day: the American Legion Post that was only a few miles from his home, but too far to walk. Other use of the car was sporadic. When we discussed with him a plan for getting him to the American Legion Post on a daily basis, his resistance to quitting driving disappeared. What we did here was to let the patient know (reassure him) that he was in a loving environment where people cared for him, respected his needs, and would do what was necessary to meet these needs.
Reconsider
Ask, “How do things look from the patient’s point of view?”
In many cases simply trying to understand how the patient with diminished cognitive capacity might perceive the situation can be used to remediate the behavioral problem.
Several years ago we encountered a patient who was exhibiting inappropriate sexual behavior toward a female caregiver who visited to help with his care three times a week. His wife was quite upset when the patient would inappropriately touch the caregiver during the course of the day. The patient’s wife was also surprised because this type of behavior was entirely uncharacteristic for the patient. After considerable discussion with the patient and caregiver, we all came to realize that the genesis of this troublesome behavior was that one of the responsibilities of the caregiver was to help the patient bathe. The patient interpreted touching during bathing as sexual touching and thus in his view his touching the caregiver during the day was reciprocal and entirely appropriate. We rearranged the bathing schedule so that he was no longer bathed by a woman, which resolved the behavior.
Redirect
Perhaps the single most important piece of advice we can provide to a caregiver is not to be confrontational. And while this advice is easy to give, in many cases it may not be so easy to follow.
We follow a patient who was once an excellent cook, but now has great difficulty in the kitchen. As such, her husband, the primary caregiver, has taken over the duties in the kitchen. While he has become a competent cook, his main challenge is now to keep his wife out of the kitchen. The patient understandably continues to want to be engaged in activities in which she was once quite accomplished. The problem is that she would often cause difficult and potentially dangerous situations, such as putting a metal bowl in the microwave or putting a dish towel on the burner. These difficulties led to many confrontations and arguments. Her husband solved this problem by getting the patient her own oven—in this case a toy oven—and giving her a specific job during meal preparation that she cheerfully carries out.
Interacting with a demented patient—even when the patient is a spouse or parent—can be quite frustrating for the caregiver. The caregiver needs to strike a balance between what the patient wants to do and what is safe. When these conflict, there can be frustration and agitation for both patient and caregiver.
In general, we advise caregivers to carefully pick their battles. When a patient asks a caregiver for the tenth time in 15 minutes where they are going for lunch that day, it is tempting—and probably cathartic—for the caregiver to say, “Don’t ask me again! I have already told you the answer 10 times in the last 15 minutes!” Unfortunately, this response will likely lead to the patient experiencing either anger and agitation or sadness and depression. A better solution is to redirect the patient to another activity that they can accomplish independently and that will distract them from focusing on lunch. In the case above, the astute caregiver took a situation that was potentially confrontational and turned it into a positive activity.
Of course, there are instances in which the caregiver must intervene more directly. These are generally cases in which safety is an imminent issue. For example, when a patient who is known to become lost in the neighborhood and cannot safely cross streets is walking out the front door, a direct approach may be necessary.
Other general strategies for dealing with behavioral and psychological symptoms in dementia using behavioral techniques are summarized in Box 23-1 (for review see ). Note that the positive benefit of music for patients has become increasingly recognized, and these benefits can improve caregiver well-being and their coping capacity ( ; for review see ).
Related posts:
Approach to the Patient with Memory Loss, Mild Cognitive Impairment, or Dementia
Jakob-Creutzfeldt Disease
Progressive Supranuclear Palsy
Legal and Financial Issues in Memory Loss, Alzheimer’s Disease, and Dementia
Evaluating the Behavioral and Psychological Symptoms of Dementia
Other Disorders That Cause Memory Loss or Dementia
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