Challenging behavior  is common in people living with dementia and is considered one of the most difficult issues facing staff in residential care and caregivers at home. It is important to try and understand why the person is behaving in a particular way and remember that it is the behavior that is challenging and not the person.
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Caring for people living with dementia poses many challenges. As the disease progresses, personality and behavior changes often occur.

Challenging or concerning behavior is used to describe behavior that interferes with a person’s daily life. It is common in people living with dementia and is considered one of the most difficult issues facing staff in residential care and caregivers at home.

Challenging behavior is distressing for both the person exhibiting the behaviour and for those that care for them. It is important to try and understand why the person is behaving in a particular way and remember that it is the behavior that is challenging and not the person.

Related: 10 Communication Strategies for Dementia Care

10 Common Behavioral Problems

Common behavioral problems for people living with dementia include:

1. Catastrophic reaction
Over-reaction to trivial matters; this may result in weeping, screaming or unreasonable accusations.

2. Repetitive behaviour
Compulsion to follow relatives or staff asking the same questions over and over.

3. Hoarding
Hoarding all sort of items for safe keeping. Often accusing others of stealing their precious possessions.

4. Inappropriate sexual behaviour
Loss of inhibitions and the consequent lack of awareness of the rules of appropriate behavior.

5. Aggressiveness
Physical (pushing, hitting) or verbal (abusive language)

6. Paranoia/Suspicion
Often suspicious of staff and neighbours; they imagine that people are plotting against them.

7. Wandering
Aimless or purposeful wandering that can result in getting lost, leaving a safe environment or intruding in inappropriate places.
Related: How to manage wandering behaviour

8. Restlessness
Pacing and fidgeting; this could be due to thirst, pain, medication side effects or even boredom, stress, noise, lack of exercises.

9. Screaming and shouting
Calling out continuously or weeping and whimpering for extended periods of time. (Sometimes this behaviour is a result of brain damage or hallucinations and medical assistance is needed)

10. Sundowning
An end-of-day confusion and restlessness that manifests as dusk approaches.
Related: 14 Ways to Manage Sundowning

Understanding the Person Behind the Dementia

The more you know about the person with the challenging behavior the more likely you are to understand them. Assessment of the behavior should be functional and comprehensive. It should include:

  • Time of the behaviour
  • Frequency
  • Intensity
  • Duration
  • Identification of triggers and the likelihood of environmental aspects that could or would escalate the behavior.

12 Common Triggers to Challenging Behavior

Sometimes problematic behaviors are caused by changes in the brain as dementia progresses and sometimes by triggers in the environment. Triggers could include:

  1. Anxiety
  2. Feeling frightened
  3. Dehydration
  4. Fatigue
  5. Frustration
  6. Insomnia
  7. Physical discomfort
  8. Pain
  9. Inappropriate environment (noisy, crowded room, chaotic gathering)
  10. Depression
  11. Medication
  12. Illness

10 Ways to Respond to Challenging Behavior

  1. Approach in a calm, respectful manner.
  2. It is best not to touch the person by leading or holding their arms; it may aggravate the situation. Instead talk in a consoling and empathetic manner and offer your arm: "Here, take my arm, let’s go to the dining room/bedroom/veranda."
  3. Try not to over-react even if the behavior is embarrassing; remember that it is the illness causing the behavior.
  4. Avoid arguing; remember the person is not deliberately trying to upset you. Their logic and reasoning are impaired by the illness and it is up to you to comfort and reassure them.
  5. Be flexible; if the behavior is about a shower they don’t want to have, leave this task for later when the person has calmed down.
    Related: Communication Board for Dementia Care
  6. Observe the person and what their body language is conveying. Give them time to calm down while offering solace.
  7. Validate their feelings. If a 95 year old man is very agitated ands asks you whether you have seen his mother it is no use to point out to him that she is dead. Go along with him, say something like: "No, I haven't seen her. Was she a great cook? What did she cook that you loved?"
  8. Be mindful and 'in the moment'. If you are talking to the person and your thoughts are elsewhere there is a good chance you won’t get the best result. Often your body language and demeanor will speak louder than your words. Use a soft tone of voice and some physical touch to add emphasis to the communication.
  9. Offer a distraction such as a walk or a board game.
    Related: Games for People Living with Dementia
  10. When you identify a strategy that works, write it down so other staff can use it too.

Understanding what may be causing the challenging behavior and learning how to respond to it will enable carers to take control of situations when they arise and diminish the occurrence the behavior.

Related: Goal-Directed Behavior

10 Best Care Practices

People living with dementia that exhibit challenging behaviors are trying to communicate needs that have not been met.

Cultivating work practices to treat the individual and not just the illness for best results.

Related: Person-Centred Care

  1. Implement individually tailored, flexible routines.
    Related: 15 Activities for Late-Stage Alzheimer's
  2. Recognize that it is important to get to know the person beyond the diagnosis.
  3. Remember that nutrition and hydration are important factors.
  4. Aim to reduce anti-psychotic medication wherever possible.
  5. Strive to anticipate concerning behaviors.
  6. Schedule activities that promote creativity and satisfaction.
    Related: The Benefits of Coloring-in for the Elderly
  7. Provide guidance and reassurance with compassionate overtones.
  8. Implement behavior management strategies with an emphasis on dignity and respect.
  9. Gentle touch and physical contact is important and can reduce fear and anxiety.
    Related: Tips for One-on-One Visits with Seniors
  10. Ensure there is a collaborative partnership between carer and patient.

Good Luck!

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Comments   Post a Comment

Susan 17th Mar 2020 Activity Director
Here is another idea
Periodically I would have a kindness group
Ask the residents what it means to be kind
Ask them to give examples of how they are kind
I have found that some residents can be mean without meaning to be and just a friendly reminder of being kind is very helpful here are some kindness activities
World kindness day is in November but you could have a kindness day every month or every week to remind the residents especially your resident with difficult behaviors to be kind to everyone
Forgiveness day is in August but you could also have that as part of your calendar as well here are some ideas for that
Leslie 15th Mar 2020 Activities
I’m an activities director at a memory care facility and I have one resident who is a true narcissus. She throws fits to get her way. Her memory is still very good. She’s incredibly rude to other residents, going so far as saying those kind of people don’t deserve activities their brains are gone. All she thinks about is herself. Our facility is attached to a residential care facility and she always wants to do activities with the residents on that side and will throw a fit screaming and crying until she gets her way. The residents on the assisted living side don’t like her, the rudeness, telling everyone they are stupid she knows everything, and being very loud during activities. How do I handle this my new admin says to give into the fir throwing and let her do activities with the assisted living residents, but then those residents will not participate in the activity, they will leave the room when she comes in. I feel stuck in the middle help please
Solange 15th Mar 2020 Diversional Therapist
Hi Leslie, the resident seems to be in the early stages of dementia and deeply unhappy with her lot. Still, the facility is home to many residents who wish to live harmoniously. What I would do is to take it to a meeting to explain the situation. Your management/senior staff should understand that the resident is obnoxious and non-compliant and that it is disrupting your Activity Program. Inform them that the residents’ own peers don’t want her around, and proceed to explain what happens when she is around them. One course of action we did in the past was having a serious talk with the resident; myself and an accompanying senior staff or the manager. The resident would be told that her behaviour was not going to be tolerated without consequences (by consequence I mean we asked the resident if she/he would like to move to another facility where they would be happier - they never did). Of course, you do it with compassion but firmly; your goal is to discover whether there is a reason for the behaviour and if you can help her to overcome it.
Don’t despair, we all have these experiences along the course of our careers.
Susan 15th Mar 2020 Activity Director
Yes Leslie this is a difficult situation
Have you tried positive reinforcement??
Find out what she really likes and reward her when her behavior is appropriate
You may have to do this in small increments
Perhaps you can reward the assisted living residents for letting her participate in their activity even though they don’t want her to be there
When she leaves give them some kind of treat that you know they will like
Also maybe you can have a two-part activity
Tell the assisted living residence that this person will join them for the first half and then you’ll take a break and just the assisted living residents will partake in the second part
The better the behavior is of the problem resident the longer you can have the first half last
Perhaps some of these ideas will help you too
The truth of the matter is that sometimes no matter what you do the problem behavior will still exist but give it time and try your best
You can contact your supervisor about the situation maybe this person has some ideas
Good luck
Annie 4th Nov 2015 Life-style co ordinator/PCA
Hello Effie and Amanda,
I also have a resident who spits constantly some days are worse than others but I was surprised to see that during her 80th birthday celebrations, her family came in and she didn't spit at all! I'm not sure if the cards will help, will certainly give it a go...also other residents find it hard being in the same room as her so she spends a lot of time in her room. I wish there was something I could do to change her environment.
Really appreciate any help with this.
Many thanks Annie
Jo 5th Mar 2015 activities coordinator
HI everyone, I am a activities coordinator in a hospital looking after the longterm elderly conditions patients. On average 3/4 of my patients have Alzheimers/dementia and the majority are looking for lost handbags, keys, purses, hankerchiefs, wallets. What I do is go to all the charity shops in my area and stock up on handbags, wallets, purses, and ask my friends if they have any spare keys. I now don't have any problems with them looking for things. I have even picked up a few cheap rings, watches and bracelets. It makes the patients so happy.
Amanda 17th Oct 2014 Diversional Therapist
Hi Effie, Would a writing board help this client to communicate or perhaps a coaster sized book of pictures for him to be able to point out what he is trying to convey such as a picture of a toilet or drinking cup. Just a thought.
Effie 8th Oct 2014 Community Services Facilitator
Hello, We have a 40 yrs old mainly non-verbal male client, intellectual impairment/dual diagnosis who is Spitting.
When going out he will spit a lot in the car and at the carer.
Spits on changeover of carers, mostly on his shirt but sometimes at carers and people.
It appears at times attention seeking behaviour or anxious/excited about something, his way of communicating..
What would be a way to handle this behaviour..?
any thoughts would be appreciated.
Amanda 2nd Apr 2014 Diversional Therapist
Hi, I have read the above articles and am just wondering if it might help finding out a particular item this lady client keeps stating is missing, e.g. a watch and getting hold of a cheap one which might re-assure her or is this going to open up a can of worms?
Solange 7th Nov 2013 Diversional Therapist
Hi Heather,

It is common for people living with dementia to be suspicious of neighbours and staff. Sometimes they come up with unreasonable accusations. You may try validation therapy; ask questions about the item that is missing; how she used it, for what purpose, if the item reminds her of someone and so on. If this fails, use some strategic distraction; something that worked in the past or invite her for a game or visit someone she likes. Unfortunately, sometimes nothing works and they stay miserably for a while. You must remember that it is the illness that brings this sort of behaviour; they can't help it.

All the best,

Thanks for answering. I love this website x
Solange 7th Nov 2013 Diversional Therapist
Hi Lee, I am not an expert, but think that if a person was a bona fide narcissist before the onset of dementia they wouldn't know how to carry on the trait after diagnosis. They may carry on for a while but the illness is relentless and sooner or later cognition and memory are impaired. The illness is known to affect people in different ways; some cope better than others. Every residential care facility has challenging residents. The only advice I can give you is to take a break if it is all too much. Don't feel guilty or embarrassed. It is better to take a break than lose patience with them. All the best!

Lee 6th Nov 2013 Live in caregiver
Your reasoning is based on the person having behavioral challenges as a result of the disease. You don't take into account the fact that the person may have been a bona fide, literal narcissist before the onset of dementia; and, their behavior is an extension of who they really are. What then?
heather 6th Nov 2013 DIVERSIONAL THERAPIST
Hi I am working wit a lady with dementia going through the stages. Memory really bad. How do I help her when she is adamant that personal belongings are not there....they actually have not been around for 30 odd years. It's a constant asking process an I do not know what to say or help her reason. these things have not been with her since year dot.
Solange 12th Oct 2012 Diversional Therapist
Hi Anne, Dementia and wandering behaviour is very common. The first thing I would recommend is to talk to health professionals in your facility, (nurse, doctor, and physiotherapist) for an assessment. Also make sure the environment is as safe as possible for your client to wander. Increasing exercises during the day may improve wandering in the afternoon and eliminating foods high in sugar and caffeine may help too. Remember that despite wandering being unsafe for people with dementia it also has some benefits such as promotion of circulation and oxygenation, exercise, and prevention of muscle rigidity. Talk to his family and try to find out what interests and hobbies were missed when the 'Resident Profile' was done and create an activity based on the result. Here are a couple of things you may try:
- Escort your client on a walk to burn energy three times a day
- Take client to a sensory room to wander, a multi-sensory experience may reduce restlessness
- See if he is interested in pruning shrubs, watering plants, taking a dog for a walk
Anne 5th Oct 2012 Activities Co-Ordinator
What would you suggest for a male person in his 80's who has dementia,is not ambulant.
He will not sit for any length of time in a chair or bed.
He keeps trying to get up and walk.
I have tried various distractions to no avail, he is not interested in any activity at all.
Every time this person tries to walk he falls over and injures himself.
Could you help me please.

regards Anne
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