Dementia and behaviours of concern

How does dementia change a person’s behaviour?

People's behaviour can change for various reasons. Dementia happens because the brain undergoes physical changes, which can impact memory, mood, and how someone acts. Sometimes, these changes in behaviour are directly connected to dementia, while other times, they can be influenced by things like the person's surroundings, their health, or the medications they take. As dementia progresses, people may start behaving in ways that others find hard to understand. This can be one of the most challenging aspects of dealing with dementia, both for the individuals with the condition and for those who care for them.

Examples of behaviour changes

Read about common behavioural changes below and tips to help you respond to them appropriately. 

Watch

Dementia Support Australia has 10 short videos describing 10 common changes in behaviour and some useful tips to help you respond to them appropriately.

Take some time to watch the videos to strengthen your understanding of this topic and gain valuable insights that will benefit the individuals with dementia you support. After viewing, take time to reflect on the key points and consider how they can be applied in your workplace.

Activity - Scenario and Reflection

Read the scenario and answer the questions.

You are a support worker in an aged care facility in New Zealand. Your role involves caring for residents with dementia and managing various behavioural changes. Today, you encounter a situation involving one of your residents, Mrs Crag.

Mrs. Crag: She's an 85-year-old resident with dementia. Lately, you've noticed some changes in her behaviour. She becomes verbally aggressive, using offensive language and shouting at staff and other residents. This aggressive behaviour is causing distress to both Mrs. Johnson and those around her.

There are many reasons why a person’s behaviour may change. We know dementia is a result of physical changes in the brain but sometimes behaviour may be related to changes in their health and environment. Understanding the cause will help you to decide which strategies may be helpful. Some carers find that keeping a log or diary helps them to see a pattern of behaviour that may be developing, and this helps them to identify the cause of the changes.

Triggers and other contributing factors

When identifying a trigger for behaviour change it is important to take a holistic approach and consider all possible triggers and contributing factors, including: 

• Physical health
• Medication
• Environment
• Social and emotional history
• Communication

Triggers

A behavioural ‘trigger’ can be any event, action, experience/sensation, thought or emotion that elicits a particular behavioural response. You can identify a behavioural trigger by observing what usually or consistently happens immediately before the behaviour (taking baseline recordings).

For example, if the person consistently cries or shouts immediately after hearing a loud noise, it is likely that loud noises trigger the shouting. If the person usually or consistently becomes agitated when asked to carry out a specific task or activity, it is likely that particular activity triggers their agitation. Triggers can also be identified and used to elicit desirable behaviour. We use verbal requests and reminders, or non-verbal physical prompts to remind or cue the person to do something, for example, touching a person’s arm to remind them to lift their arms when they are dressing; or showing the person a fork with food on it to remind them to open their mouth at mealtimes.

Triggers in Physical Environments

Many people living with dementia become agitated and confused, and exhibit behaviours of concern when features of the physical environment change or disturb them. Bright lights (or darkness), loud noises (or absence of familiar, enjoyable sounds), heat or cold, high levels of activity and lots of people can all trigger behaviours of concern.

Some forms of dementia can make people hypersensitive to changes in light or noise levels, or the presence of too many people. Moving furniture out of familiar positions can also have this effect, as dementia can lead a person to experience confusion about where they are and their surroundings, and changes in the appearance of surroundings can be hard to comprehend and lead to feelings of insecurity.

Triggers in Social Environment

Changes within the person’s social environment, including meeting new people, being in crowded places or unfamiliar social situations, and being expected to conform to social norms that the person may have forgotten, can all contribute to behaviours of concern. Forgetting or being unfamiliar with social expectations, forgetting people’s names and relationships, and being surrounded by too many people can result in feelings of fear, insecurity, confusion, embarrassment and shame, which can lead to behaviours of concern.

Internal Physical Triggers

Behaviours of concern can be elicited by physical discomfort or pain caused by hunger, thirst, cold or heat, pain and nausea. In this case, the behaviour of concern is often directed at getting physical needs met. Dementia itself can affect the body’s physical health, and changes to the brain can also result in a range of symptoms.

Delirium

Delirium is a state of confusion in which a person becomes detached from reality and can experience vivid sensations and events that are not actually happening. Delirium can result from a range of factors and conditions, including infection, dehydration, sleep issues, depression and chronic pain.

Emotional and Psychological Triggers

Emotional and psychological triggers include strong feelings, such as anger, frustration, despair, humiliation, insecurity, fear and grief. These emotions may result from the person’s awareness of their deteriorating capacities, loss of significant roles and loss of relationships; and from the responses and reactions of people around them. Distress arising from such emotions can lead to the display of behaviours of concern.

Communication

Communication can be a key factor in behaviours of concern. The person living with dementia may experience barriers to communication such as short term memory loss, language difficulties (being unable to ‘find the right word’), sensory losses and loss of motor control over speech organs. These barriers can lead to frustration, which can be expressed in behaviours of concern. The way in which other people communicate with the person living with dementia is also a key factor. Being spoken to as if the person were a child, or lacked intelligence, or were unimportant, can trigger angry outbursts or withdrawal into depression and despair. Being asked to do a task that is outside the person’s ‘comfort zone’ can have a similar effect. Negative attitudes are often expressed through non-verbal means, so you will need to be aware of the non-verbal messages that you send to your clients.

Unmet needs

Unmet needs can be defined as any need or desire that is not being adequately met by the person's current care or environment. Here are some ways in which unmet needs can contribute to the progression of dementia:

• Behavioral symptoms: People with dementia may experience behavioral symptoms such as agitation, aggression, and wandering, which can be challenging to manage. These behaviors may be a result of unmet needs such as pain, hunger, thirst, or boredom. Failure to address these needs can exacerbate these behaviors and lead to further decline in cognitive and functional abilities.
• Psychological symptoms: People with dementia may also experience psychological symptoms such as depression, anxiety, and social withdrawal. These symptoms can be a result of unmet needs such as social interaction, meaningful activities, or a sense of purpose. Failure to address these needs can lead to further psychological distress and cognitive decline.

It's important for support workers and healthcare professionals to identify and address the unmet needs of people with dementia, as this can improve their quality of life and reduce the progression of the condition. This can involve a person-centered approach that takes into account the individual needs, preferences, and abilities of the person with dementia and involves the person in decisions about their care and support.

Case study on Analysing and Managing unmet need of an 80 year old client

Mrs. Smith is an 80-year-old woman with moderate dementia who lives in a residential aged care facility. Over the past few weeks, she has been increasingly agitated and restless, often wandering around the facility and becoming upset when staff members try to redirect her. She has also been refusing meals and becoming combative with caregivers during personal care activities.

Analysis

Mrs. Smith's behaviour is an indicator of unmet needs. Her agitation and restlessness may be a result of unmet needs such as a lack of social interaction, meaningful activities, or purpose. She may also be experiencing pain or discomfort, which is causing her to wander and become upset when staff members try to redirect her. Her refusal of meals and combative behaviour during personal care activities may be a result of unmet needs such as hunger, thirst, or a desire for more control over her daily activities.

Intervention

To address Mrs. Smith's unmet needs, a person-centered approach should be taken. This involves identifying and addressing the individual needs and preferences of the person with dementia.

The following interventions may be appropriate:

1. Increase social interaction: Encourage Mrs. Smith to participate in group activities and spend time with other residents. This can help to reduce her restlessness and provide her with a sense of purpose.
2. Address pain and discomfort: Ensure that Mrs. Smith's physical needs are being met, such as providing adequate pain management and addressing any medical issues that may be causing her discomfort.
3. Provide choice and control: Allow Mrs. Smith to make choices about her daily activities and routines, as this can help to reduce her feelings of frustration and increase her sense of control.
4. Address hunger and thirst: Ensure that Mrs. Smith is receiving adequate nutrition and hydration, and consider offering her smaller, more frequent meals throughout the day.
5. Provide individualised care: Work with Mrs. Smith's caregivers to develop a care plan that takes into account her individual needs and preferences, and involve her in decisions about her care and support.

By addressing Mrs. Smith's unmet needs, it is hoped that her behaviour will improve, and she will experience an improved quality of life.

Activity - Quiz

Dementia-friendly environments play a crucial role in enhancing the quality of life and well-being of individuals living with dementia. These environments are designed and adapted to meet the unique needs and challenges faced by people with dementia. Here are some key reasons highlighting the importance of dementia-friendly environments:

Maximising Independence and Safety	Dementia-friendly environments are designed to promote independence and safety. They feature clear signage, uncluttered spaces, and reduced obstacles, which help individuals navigate their surroundings with greater ease and minimal risk of accidents.
Reducing Agitation and Anxiety	Well-designed dementia-friendly spaces can create a calming and supportive atmosphere, minimising triggers for agitation and anxiety. Proper lighting, soothing colours, and familiar objects can help reduce stress and confusion, making it easier for individuals with dementia to feel at ease.
Supporting Cognitive Functioning	Dementia-friendly environments often incorporate elements that stimulate cognitive functioning. This can include memory aids, interactive displays, and engaging activities, which help maintain cognitive abilities and provide a sense of purpose for individuals with dementia.
Promoting Social Interaction	Isolation and loneliness are common challenges for people with dementia. Dementia-friendly environments are designed to facilitate social interaction and engagement with others. Common areas that encourage communication and participation in group activities can foster a sense of community and reduce feelings of isolation.
Empowering Autonomy and Decision-making	In a dementia-friendly environment, individuals are given opportunities to make choices and retain a sense of control over their daily lives. This empowerment can contribute to improved self-esteem and a sense of dignity, despite the challenges posed by dementia.
Supporting Caregivers and Staff	Dementia-friendly environments not only benefit residents but also provide support for caregivers and staff. Well-trained staff can work more efficiently in such environments, and caregivers can experience reduced stress and burnout, leading to better care for individuals with dementia.
Creating a Positive Experience for Families	Families of individuals with dementia often experience emotional challenges when transitioning their loved ones to aged care settings. A dementia-friendly environment provides reassurance that their loved ones are in a safe, supportive, and compassionate environment, easing their concerns and allowing them to focus on fostering meaningful connections.
Enhancing Overall Health Outcomes	A dementia-friendly environment that prioritizes the well-being and mental health of residents can positively impact overall health outcomes. By reducing stress and anxiety, promoting engagement, and providing a supportive atmosphere, residents may experience improved physical health and potentially slow the progression of certain dementia symptoms.

The impact of the environment on people with dementia

The environment plays a significant role in the well-being and quality of life of people with dementia. Environmental factors can impact cognitive and behavioural symptoms, as well as the ability of people with dementia to perform daily activities and maintain social connections.

Here are some ways in which the environment can affect people with dementia:

1. Orientation: People with dementia may experience confusion and disorientation, which can be exacerbated by environmental factors such as poor lighting, unfamiliar surroundings, and a lack of visual cues. An environment that is familiar, well-lit, and provides clear visual cues can help to reduce confusion and disorientation.
2. Safety: People with dementia may be at risk of falls, wandering, and other safety hazards. The environment should be designed to minimize these risks, with features such as clear pathways, secure exits, and non-slip flooring.
3. Social interaction: Social isolation can contribute to cognitive and functional decline in people with dementia. The environment should provide opportunities for social interaction, such as communal living spaces and activities that encourage engagement and socialization.
4. Privacy and autonomy: People with dementia may experience a loss of privacy and autonomy, which can be compounded by environmental factors such as a lack of personal space and overstimulation. The environment should provide opportunities for privacy and autonomy, such as private bedrooms and spaces for personal belongings.
5. Sensory stimulation: People with dementia may experience sensory changes, such as a reduced ability to perceive visual and auditory cues. The environment should be designed to provide appropriate sensory stimulation, such as contrasting colours and textures, and avoid overstimulation.

By designing environments that are supportive of the needs of people with dementia, it is possible to improve their quality of life and reduce the progression of the condition.

Activity - Workplace reflection

Reflect on your workplace environment and assess its dementia-friendliness using the Dementia Friendly Environment Checklist recommended by the Alzheimer’s Society.

Quiet Space

• Do you have a quiet space for someone who might be feeling anxious or confused? A few minutes with a supportive person might be all that’s needed.

Signage

• Are signs clear, in bold face with good contrast between text and background?
• Is there a contrast between the sign and the surface it is mounted on? This will allow the person to recognise it as a sign.
• Are the signs fixed to the doors they refer to? They should not be on adjacent surfaces if at all possible.
• Are signs at eye level and well-lit?
• Are signs clear images or icons?
• Are signs placed at key decision points for someone who is at the building/area for the first time?
• Are signs for toilets and exits clear? These are particularly important.
• Are glass doors clearly marked?

Lighting

• Are entrances well-lit and make as much use of natural light as possible? Avoid using areas with bright light or deep shadows.

Flooring

• Are floors matte in colour without reflections and deep shadows? Reflections can cause confusion.
• Are carpets plain in colour without bold patterns? Plain surfaces are easier; patterns can cause problems for people with perceptual issues.
• Are changes in floor finish flush rather than stepped? Changes in floor surfaces can cause some confusion due to perceptual problems. If there is a step at the same time, you also introduce a trip hazard.

Changing Rooms and Toilets

• Do you have a changing room (where applicable) where an opposite-sex carer or partner can help out if the person needs help with their clothes?
• Do you have a unisex toilet or other facility that would allow someone to have assistance without causing them or other users embarrassment?
• Are toilet seats a contrasting colour to the walls?
• Is the rest of the toilet colour contrasting?

Seating

• Do you have a seating area where people are waiting? This can be a big help.
• Does your seating look like seating? People with dementia will find this easier (for example, a wooden bench would be preferable to an abstract metal Z-shaped bench).

Navigation

• Do you have landmarks around the building to help people navigate? Research shows that people with dementia use “landmarks” to navigate their way around, both inside and outside. The more attractive and interesting the landmark (which could be a painting or a plant), the easier it is to use it as a landmark.