Apr 8, 2010

When Behavioral Issues Hurt

By Angil Tarach-Ritchey
Alzheimer's Reading Room

Many articles are born from a question, and this one is no exception. Bob’s article Dotty Gets a Haircut-I Use My Ace in the Hole, initiated a comment from Jocelyn regarding a loved one shaving several times a day to the point his face is raw. Jocelyn asks for ideas to stop this behavior.

Subscribe to the Alzheimer's Reading Room

Alzheimer’s patients can get fixated on certain thoughts or actions. Many times the thoughts or actions cause no harm either physically or psychologically, so there is no real need to redirect or change the thought and/or behavior. But when the thought or action causes distress or physical harm there needs to be an intervention.

If a thought or behavior is causing anxiety, fear, or anger it is best to redirect at the first sign of those types of emotions. Signs of emotional distress can be seen in facial expressions, heard in tone of voice or words, and change in activity or personality. Excessive fidgeting, pacing, pulling at hair, or clothing, are all signs of distress. It is much harder to intervene as these emotions escalate. Intervention may be as simple as changing the subject to guide the focus to something more pleasant. Redirect your loved one to something they enjoy or towards pleasant memories in their earlier years.

Engaging the person in a physical task surrounding the conversation typically has a better outcome. For instance, if the person traveled, you can begin talking about a specific geographic area they loved and ask them to show you the souvenirs, or get the photo albums out.

Conversational redirection may not be enough, and in that case it is important to guide the person to another physical location with a positive and calm approach. Never tell them to stop talking about it, or try to reason with the thoughts they have. This only causes more problems. Do not ask yes or no questions, such as would you like to go into the kitchen or would you like to go for a walk. You will almost definitely get a no response.

Using language like “it’s time to” go for our walk, or providing choices such as “do you want to eat lunch or go for our walk first?” will initiate a more positive response.

It is important that you understand the background of the person you are caring for to be able to quickly divert their attention to a conversation or task that brings them joy.

When your loved one is fixated on behaviors that are dangerous or detrimental to their well being, such as Jocelyn described Paul shaving several times a day, you have to take control of the situation. Paul is at risk for a skin infection since his excessive shaving has compromised his facial skin. Removing the razors is necessary to keep him from excessively shaving. If you know what times of day or what triggers these repeated behaviors than change the routine for that time of day.

You may have to make up a reason for not allowing him to excessively shave, and it may be difficult to divert him to another activity, but I would expect his focus on shaving will decrease after time. You may even use an excuse like “the pharmacist or doctor said you need to change to an electric razor because of the medications you’re on. Some medications have a serious bleeding risk.” I am not a proponent of lying but sometimes you need to make the person believe a person of authority made the decision, and not you.

Developing a positive and productive routine for a person with dementia is beneficial for their memory and to avoid destructive thoughts and behaviors.

When a behavior puts the person in imminent danger you must stop it immediately. Although I don’t really like the comparison to children, no one would allow a child to run in the street and put their child in harm’s way of being hit by a car. The same goes for a person with dementia. You will have to do what is necessary to remove the imminent danger. The outcome may be difficult but as long as the danger is removed you will have to utilize other approaches to deal with the difficulty at hand.

Any time you attempt to intervene in a negative thought pattern or behavior, be as calm, gentle, and as reassuring as possible. Keep your side of the conversation as simple as possible with short statements or questions. Keep noise and stimulation to a minimum because noisy, chaotic, anxious environments and people will only add to the problem.

If a repeated thought, action or behavior is not causing the person any emotional or physical harm, don’t worry about it. Caregiving is very difficult, so it is important to let the little things go and work on getting excellent at developing a positive routine, and intervention techniques for the real problems. As Bob said, it takes practice, trial and error to understand what will work and what won't.  Remember, when you are stressed, angry and anxious, your loved one will also be stressed, angry and anxious. They need you to be calm, soothing, patient and relaxed to feel safe, loved and cared for.

You can find additional behavioral management techniques at HelpGuide.org

Related Articles in the Alzheimer's Reading Room
Original content Angil Tarach-Ritchey, the Alzheimer's Reading Room