Behaviour changes

2. Managing and reducing out-of-character behaviour

When managing a situation where a person with dementia is behaving out of character, it is important not to see the behaviour as just another symptom that needs treating. A problem-solving approach is needed to try to work out why the person's behaviour has changed (see 'Strategies for carers').

Out-of-character behaviours often resolve over time and are often successfully managed by carers. However, there may be times when input from professionals is needed.

Sudden changes in behaviour, particularly those where a person with dementia becomes noticeably more agitated, confused or distressed, are often the result of physical health problems.

In the first instance, it is always a good idea to visit the GP to rule out any physical problems (eg an infection, pain, constipation or poor eyesight or hearing). Side effects of medication or taking several different medicines can also cause behaviour change. A doctor should review all of the person's medication. Mental illnesses such as depression may also contribute to out-of-character behaviour. These can often be managed with medication and non-drug strategies. If health problems have been ruled out and the person is still behaving out of character, the GP may refer them to a specialist.

Reducing the likelihood of out-of-character behaviour

Many things can reduce the chance of a person with dementia developing out-of-character behaviours in the first place. Simple measures include:

  • ensuring continued social relationships
  • encouraging the person to engage in meaningful activities
  • reducing unnecessary noise and clutter
  • providing people with familiar personal items
  • maintaining a comfortable sleeping environment.

General approaches to managing out-of-character behaviour

If someone does develop changes in behaviour, there are several non-drug treatments that should be tried. These general approaches should be considered first, before any drugs. These general approaches may include:

  • engaging the person in enjoyable and meaningful activities - this could range from making music to exercising
  • spending quality time with the person - perhaps chatting or sharing a task together
  • developing a structured daily routine
  • hand massage - especially for agitation
  • aromatherapy and light therapy (although evidence that these are effective is weak).

It used to be that antipsychotic drugs were frequently prescribed to people with 'challenging' behaviour. While these may be appropriate and helpful in some situations, they can suppress behaviour without addressing the cause, and may add to the person's confusion. They should only be prescribed by a doctor when absolutely necessary. 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 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, they should be regularly reviewed and monitored.

Strategies for carers

Carers may find a step-by-step problem-solving approach can help them to manage out-of-character behaviours. Carers may want to talk to a professional (such as a dementia specialist nurse or dementia support worker) about ways to implement a problem-solving approach.

Firstly, define the problem:

  • Is the person's behaviour really a problem?
  • Is the problem actually the reaction or attitudes of others towards the person or the behaviour?
  • Is it a response to an interaction with the person?

Secondly, consider the situation and look at the circumstances contributing to the problem.

  • When and where does the behaviour happen?
  • Are there notable instances when the behaviour doesn't happen?
  • Does the person always behave the same way in the same place?
  • Are there patterns to the behaviour?

Thirdly, assess the person in the situation, and whether they seem to be:

  • in pain or discomfort, or unwell
  • tired, overstimulated, bored, lacking in social contact or anxious
  • embarrassed, ignored or misunderstood
  • hallucinating, delusional or depressed
  • responding to an unpleasant incident, a change or a provocation.

Once all these have been considered, you may be able to develop a strategy to manage the behaviour. Talk to the person and those around them and come up with a plan. Start to make some changes and review whether they have made a difference. It might take some trial and error to find effective solutions. Make sure the interests of the person with dementia are always at the centre of any solution.

Managing out-of-character behaviour: general tips for carers

The following tips are general approaches that can be tried to support a person who is behaving differently. In the 'Types of behaviour' section there are tips on managing more specific behaviours.

  • Try to remember that the person is not being deliberately difficult; don't take it personally. Their sense of reality may be very different from yours and they are responding to their own needs.
  • Knowledge of the person and their history will help. 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.
  • Even though a person with dementia may have difficulties with their memory, they still retain emotions. This means they are more likely to respond to the emotional aspects of a situation. It's important to think about how they are feeling, what they are trying to express, and how to support their emotions. It may help to validate the person's feelings (eg 'I can see that this is difficult for you'.)
  • People with dementia are likely to respond to your behaviour and communication, so if you are frustrated or angry it may exacerbate the situation. Offer the person gentle reassurance. Alternatively, try stepping away from the situation, look at the person's body language and try to understand what they might be feeling at that time. Give yourself and the person 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 ensuring a safe environment and leaving the person to do what they want may be the best option.
  • The person should have their eyesight and hearing tested, and if necessary should wear glasses and a hearing aid. Support the person to be independent and do as much as they can for themselves. The behaviour may be a response to the person 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 engaging and meaningful pastimes. Try to include these as much as possible day to day.
  • Try to adapt to the present situation. Insisting that things can go back to how they were before, or expecting too much of the person, can create further problems.
  • If you are exhausted by the person's behaviour, ask friends and relatives to spend some time with the person so that you can have a break.
  • If the person is frequently or persistently behaving out of character, consult the GP.