Reducing and managing behaviour that challenges
Many carers find they’re able to manage situations where the person’s behaviour changes, and that the behaviours stop over time.
- Changes in behaviour
- What causes changes in behaviour?
- You are here: Reducing and managing behaviour that challenges
- Agitation including restlessness
- Repetitive behaviour and dementia
- Shouting and screaming
- Sleep disturbance and waking up at night
- Sundowning and dementia
- Hiding, hoarding and losing things
- Trailing, following and checking
- Losing inhibitions
- Behaviour changes - useful organisations
However, there may be times when you need support from professionals.
Sudden changes in behaviour are often caused by physical health problems – especially when the person seems to be more agitated, confused or distressed.
As a first step it’s always a good idea to visit the person’s GP to rule out any physical problems (such as an infection, pain or constipation). Ask the doctor to review all of the person’s medication, including any medication they’ve bought over the counter. (See ‘Physical needs’ in the previous section for more on how this can affect a person’s behaviour.)
Mental health problems such as depression may also contribute to changes in behaviour. These can often be managed with medication and non-drug strategies. If the GP has checked for any health problems and the person continues to behave in ways that challenge, they may refer the person to a specialist.
Ways to reduce behaviour that challenges
There are things that you and the person with dementia can do to help them to meet their needs and reduce behaviours that challenge. For example:
- helping them stay in touch with other people
- encouraging them to do things they enjoy or find useful
- making changes to their environment if necessary. For example, reducing noise and improving the lighting
- keeping familiar, comforting or personal items close to them, such as a favourite jumper or keepsake
- keeping their sleeping environment comfortable – for example, making sure it isn’t too hot or cold
- being aware of their beliefs and thoughts and trying not to argue with them. For example, if they believe they need to go and collect their children from school, don’t tell them they’re wrong. Instead ask them to tell you more about their children.
Ways to support a person to meet their needs
When someone’s behaviour changes in a way that causes difficulties for them or you, there are a number of ways to support them. Many of these don’t involve drugs and should be considered first, including:
- supporting them to take part in activities they enjoy or find useful (for example making music or exercising)
- spending time with them – having a cup of tea and a chat with them, or doing something together
- helping them to have a daily routine
- psychological therapies with professionals, such as cognitive stimulation therapy or reminiscence therapy
- adapting the environment if this is affecting the person (for example if it’s too hot, cold, loud or bright).
Some people find other non-drug therapies helpful. Many of these are activities to engage their senses. These may include aromatherapy and massage, light therapy, art (such as colouring or crafts), therapy with animals such as dogs, or doll therapy. However, there isn’t enough evidence at the moment to know for sure that these therapies work. (Some people find them helpful, but there is a need for more evidence.)
Antipsychotic drugs often used to be prescribed for people with behaviour that challenges. However, while they can help in some situations, they often don’t help with what’s causing the behaviour. They may also add to the person’s confusion.
Antipsychotic drugs should only be prescribed by a doctor as a last resort when absolutely necessary if other treatments have been tried and didn’t work. Medical guidelines state they should only be used in the first instance if there is evidence of delusions (believing something that isn’t true) or hallucinations (seeing or hearing something that is not really there) and the person is severely distressed, or if there is a risk of harm to them or those around them. If antipsychotics are used, the doctor should monitor how they’re affecting the person and regularly review whether they should continue taking them. If possible they should be stopped after 12 weeks.
Drugs for behavioural and psychological symptoms
Read about drugs for behavioural and psychological symptoms in dementia
Steps for managing behaviour that challenges
It may be helpful to manage behaviours in steps. A professional (such as a dementia specialist nurse or dementia support worker) can help you follow the steps below.
1 Identify the problem:
- Is it the behaviour of the person with dementia that is causing the problem?
- Is it the reaction or attitudes of other people?
- Is it the person’s living situation?
- What are the other factors? For example:
- Is the person in pain?
- Are they getting enough stimulation?
- Is their environment somewhere they are comfortable and stimulated?
2 Look at the situation:
- When and where does the problem happen?
- Does the person always act in the same way in the same place?
- Does it always happen with the same person or in similar circumstances?
- Who are the other people involved? For example they may be visitors, a family member, or a friend.
- Look for patterns in the behaviour. It may be helpful to make a diary of when the behaviour occurs, noting down everything that was going on at that time that could have triggered the behaviour.
3 Look at how the person is feeling when they behave this way:
Is the person with dementia:
- unwell, in pain or uncomfortable?
- tired, getting too much stimulation, scared, anxious or frustrated?
- embarrassed, ignored, misunderstood, feeling patronised?
- depressed or having delusions or hallucinations?
- bored, under-stimulated, lacking in social contact?
- in an environment that makes them feel uncomfortable – for example, is it too hot or cold?
4 Identify anything the person could be reacting to:
Use what you know about the person to think about whether they could be reacting to:
- something unpleasant happening
- something they dislike or are scared of
- a memory
- being provoked, or a conflict with someone’s personality.
5 Develop a strategy to offer support:
Talk to the person with dementia and other people they spend time with to come up with a plan. Start to make some changes and see whether or not they have made a difference to the person’s behaviour. You may need to try different things and find what works. Look at making different changes, such as changing the way you talk to them when you’re providing personal care or helping them do something. Also consider making changes to the environment. Focus on what is in the best interests of the person with dementia, and what particularly helps to support them.
Managing behaviour that challenges – general tips for carers
Here are some things you can try to support the person. See ‘Types of behaviour’ in the next section for more tips on managing specific behaviours.
- Ask the person’s GP to check for any physical causes and treatments.
- Try to remember that the person is not behaving this way on purpose. Try not to take it personally. Their sense of reality may be very different from yours and they are responding to their own needs.
- Think about what you know about the person and their life. For example, if you know someone used to work night shifts, it might explain why they want to stay awake or go out at night.
- Think about how the person has coped with situations in the past. This may affect how they deal with things now. For example, a person who has always been anxious may become more anxious about things now they have dementia.
- Even though a person with dementia may have problems with their memory, they still feel and respond to emotions. Think about how they are feeling, what they are trying to express, and how you can support them emotionally. It may help to respond directly to how the person is feeling (for example by saying ‘I can see that this is difficult for you’.)
- People with dementia are likely to respond to your behaviour and communication, so if you’re frustrated or angry it may make things worse. Offer the person gentle reassurance, or try stepping away from the situation. Look at their body language and try to understand what they might be feeling at that time. Give yourself and them space to calm down.
- Consider whether the behaviour is really a problem. If it is disrupting a particular activity such as washing or dressing, ask yourself if this task really needs to be done right now or if you could come back to it later. Sometimes it’s best to leave the person to do what they want (if the environment is safe).
- The person should have their eyesight and hearing tested, and wear glasses and a hearing aid that are clean and working properly, if they need them.
- Support the person to be independent and do as much as they can for themselves. The behaviour may be the person’s response to the feeling that they are not able to contribute or are not valued by others.
- If you think the person is bored, support them to find things to do that are engaging and mean something to them. Try to include these as much as possible day to day.
- Try to adapt to the situation as it is. Trying to get things back to the way they were before, or expecting too much of the person, can cause more problems.
- If you are exhausted by the person’s behaviour, ask friends or family members to spend some time with them so that you can have a break. You may want to find out about other ways to get a break including local day centres, clubs or respite care. For more information see factsheet 462, Replacement care (respite care) in England, W462, Respite care in Wales or NI462, Respite care in Northern Ireland.
- Find someone to talk to about the situation and how you are feeling. This might be a dementia support worker, friend or family member.
- If the person continues to behave in ways that are difficult to understand, talk to your GP.