Alzheimer's blog

Unmet needs and negative behaviors: Part 2

By Angela Lunde July 24, 2012

Last week I attended the Alzheimer's Association International Conference in Vancouver, British Columbia, Canada. A focus of this year's conference was social, behavioral and care research in Alzheimer's. It was wonderful to see attention and emerging research in this area. It also validates our recent discussions about effective strategies in easing behavioral disturbances in people with dementia.

As highlighted in my last blog, it is important to see challenging behaviors as symptoms instead of problems. Think about this analogy: You have an infection and develop fever. The fever is a symptom of the infection. If we simply see your fever as the problem, we will only treat the fever. While this might reduce some of your discomfort for a time, the fever will eventually return and you will get worse because nothing was done for the real problem — the infection. Similarly, to better manage behavior symptoms in a person with dementia, we need to uncover and address the real source of the problem.

I am sure as a caregiver this can seem like one more role to take on — that of a detective assigned to uncover the real problem. Yet the goal here is not to add more burden or pressure to the caregivers. If caregivers can identify triggers, learn some techniques and skills, and are willing to employ them, the result will be fewer unmet needs and consequently fewer behaviors that challenge and wear down caregivers. In this regard, the quality of life for the caregiver can improve.

Just what potentially are these unmet needs, the real problems? Unmet needs generally fall into one of three broad areas:

  • Personal health
  • Physical environment
  • Social environment

In other words, behaviors can be an expression of a health need or an outcome of the interaction between the person with dementia and their physical or social environment.

Let's start with physical health. Persons with dementia are often limited in their ability to identify, understand or articulate when they are in pain, feel uncomfortable, are sad or are disorientated due to physical limitations. The following represent some common health issues that are often overlooked in people with dementia as potential problems leading to behavior symptoms:

  • Fatigue due to poor sleep
  • Presence of a medical condition such as an infection (for example, urinary tract infection)
  • Clinical depression
  • Vision loss or lack of proper eyeglasses
  • Hearing loss or lack of working hearing aid (check batteries)
  • Constipation
  • Dehydration
  • Need to urinate
  • Hunger

It is important to always consider these and other health conditions that may be contributors to the behavior symptoms. It would make sense that if a person is fatigued, hungry or in pain, and is unable to articulate or take care of the need independently, that they would express anger, agitation or even aggression.

Behavior symptoms also can be related to the physical environment. We now understand how powerful environmental factors are in triggering behavioral symptoms. Individuals with dementia experience increasing vulnerability and a lower tolerance to stress in their environments. I like to think of the environmental contributors to stress in persons with dementia in three areas: physical space, daily routine and structure, and sensory stimulation.

The good news is that we, as caregivers, can use the environment to our advantage because we can control and modify the environment. This means that we can play a significant role in reducing environment-related stress. We can often prevent problems, and therefore behaviors, by creating a supportive environment. In addition, we can sometimes manage a behavior (unmet need) by altering the environment in some way.

As we think about how someone with dementia interprets and perceives their environment, we can make some basic modifications to help that person feel less confused and more in control.

Strategies such as placing a clock and calendar in plain sight, reducing clutter, and keeping household objects and furniture in the same places will reduce confusion and maintain a feeling of control. Displaying familiar objects and photographs will offer a sense of security. Labeling spaces with signs, pictures or colored arrows will help people with dementia find their way around the house.

Ambiance, sound and light can all play a role in whether a person with dementia experiences a sense of calm or stress. Well lit spaces without confusing glares or shadows, low noise levels and generally quiet surroundings can reduce confusion and stress for a person with dementia.

Some levels of activity can be over-stimulating for person with dementia and a potential trigger for irritability. On the other hand, a person with dementia may be irritable because they are bored or lonely, and lack sensory stimulation. An environment that appropriately stimulates the senses, including sight, sound, taste and smell, offers a unique opportunity to ensure the overall well-being of the person with dementia (thus decrease behavior symptoms).

The use of aromatherapy is a growing field of complementary therapy. Essential oils used in aromatherapy have been found to be safe and have shown some positive results for promoting a sense of calm and even reducing agitation.

Music has a way of having a positive impact on people with dementia. Certain types of music calm and relieve tension and anxiety, while other types of music can be uplifting and improve mood.

People with dementia benefit from routine and consistency. Keeping regular times for activities, such as waking up, mealtimes, bathing, dressing, exercising and bedtime. can help orientate the person and offer a sense of security. Similarly, offering cues to distinguish the different times of day can be done by opening the curtains in the morning to let the light in. An evening ritual like playing meditative music or the use of aromatic oils may help to signal the end of the day.

Sometimes, we simply cannot prevent a behavior but we can accommodate it instead. For example, wandering or pacing is common in persons with dementia and can be a symptom with many causes. Caregivers can accommodate this by creating a safe physical space where the loved one can pace or wander with minimal risk.

Dementia is clearly a condition where a person's ability to maintain his or her own well-being is compromised. This results in expressions of distress. I have provided some examples of the contributing factors that can lead to distress for people with dementia.

However, I have not yet talked about one of the most powerful and immediately effective approaches to minimizing stress in persons with dementia — adapting an effective communication style (part of social environment). Stay tuned.

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Jul. 24, 2012