Managing Difficult Behaviors in Patients with Dementia

Abstract

Dementia is a condition in which individuals progressively lose cognitive function and, as a result, often develop difficult behaviors that cause stress for both patients and their caregivers. These behaviors, collectively known as behavioral and psychological symptoms of dementia (BPSD), include screaming, wandering, resisting care, hitting, and psychological symptoms such as depression, psychosis, and sexual disinhibition [1]. BPSD is prevalent in nursing homes where 67-78 percent of patients have dementia and, of them, 76 percent exhibit BPSD [1]. In fact, it is common for patients to be institutionalized because of BPSD, so clinicians must become proficient in assessing and managing these symptoms. AssessmentBuhr and White state that the first critical step in managing BPSD is taking a detailed patient history and physical [2], which can uncover treatable medical illnesses, such as delirium, urinary tract infection, medication side effects, depression, and changeable environmental factors that contribute to the symptoms. Physicians must also look beyond the history for connections between patient experiences and behavior. The authors provide an example in which an 80-year-old woman with Alzheimer's disease was agitated and yelled at the staff [3]. When asked why she was angry, her answers did not address the question. Over time the staff realized that the patient grimaced and yelled out whenever her knees were manipulated. The lesson of this case was that pain and discomfort are not always reported by a patient and may only manifest behaviorally (e.g., in grimacing). When behavior suggests that pain may be present, though unreported by the patient, regular doses of acetaminophen can be scheduled to alleviate the pain. BPSD may also be exacerbated by auditory or visual misinterpretations and can be lessened by the appropriate use of hearing aids or glasses [2].In attempting to identify patterns or triggers of BPSD, physicians should ask that detailed records be kept of the frequency, duration, intensity, time of day, and antecedents [2]. Examples of BPSD-associated patterns are over-and understimulation; an environment that lacks activity can cause a patient to be lethargic, whereas an environment with too much activity (such as noise) may trigger BPSD. Medications, caregivers, or even hunger can also be triggers [1].