by Paul Raia, Ph.D.
Not sleeping or eating, trying to escape, aggressive sexual activity, lashing out verbally, making lots of noise, wandering off, extremely repetitive speech — are these burdensome activities an irrevocable part of the Alzheimer’s landscape or is there another way to regard them?
Make a leap of faith with me. Let’s assume that such problematic behaviors, common during mid-stage Alzheimer’s disease, are not just random acts. Let’s assume that these activities are triggered by something, and that they are an attempt to convey a significant psychological message. Let’s assume they are neither mysterious nor unfathomable, and that, like Sherlock Holmes, we can discern the reasons behind them with a little systematic sleuthing. Just as in any Sherlock Holmes adventure, evidence must be gathered and analyzed, timelines established, witnesses questioned, and hypotheses tested.
Consider the following case:
Mr. Jones is a nursing-home resident with Alzheimer’s disease who has been hitting other residents in the face for no apparent reason. The staff reports each hitting incident in the resident’s chart and notifies his family. Often in cases such as this, the nursing home’s reaction is to call a doctor for medications to suppress the behavior, without ever trying to understand why it’s happening.
When we looked at this case in a systematic way, using a behavioral log that records the four “W’s” (what happened, when and where it happened, and who was around at the time), we began to uncover the fifth “W” — why the hitting began — and we were able to introduce a behavioral remedy.
By charting Mr. Jones’ behavioral log, we deduce the following facts: The hitting never occurred at night; it occurred only in the activity room; the hitter never struck the same person twice; and the hitting did not happen every time the hitter was in the activity room, but only when he was seated on one particular side of the room.
Consulting our log, we were able to see patterns from which we could draw conclusions. We recognized that Mr. Jones was only hitting other people when he was seated in the activity room beneath a window where bright sunlight tended to stream directly into his face. Could it be that the sun in his eyes was causing his aggressive behavior? So, we tested our hypothesis by simply drawing down a shade over the “offending” window, and it worked. The hitter’s aggressive tendencies abated.
Understanding the cause of behavior is not always this easy, nor this straightforward, but the principles of behavioral sleuthing are nonetheless the same.
- Every behavior has a trigger, a cause.
- Triggers can be internal (that is, in the mind or body of the person with Alzheimer’s disease), or external, in the environment.
- Most difficult behaviors are attempts to communicate something to us.
- When dealing with a person with mid-stage Alzheimer’s disease, we cannot expect that person to change. We can only change how we interact with the person or the external environment.
That said, when faced with a behavior that you don’t understand, I suggest that you start a behavioral log, charting just that one behavior, over a week or two. Then look for any pattern in your accumulated evidence.
Here is a series of questions that can help you when sleuthing. Was the behavior caused by:
- A sudden change in the person’s behavior?
- Your approach with the person?
- The communication methods you were using?
- Too much or too little stimulation?
- The task that you asked the person to perform?
Once you have an idea what the trigger may be, you need to determine the simplest way to undo its influence. Remember, all interventions require you to change what you do or change the environment. In other words, people with mid-stage AD are not able to resolve the behavior themselves.
If the intervention does not completely eradicate the unwanted behavior, consider how to tweak the remedy so you can see more benefit. It may be that medications are needed to get the best results, but hopefully you can lessen the problematic behavior by locating and removing the offending trigger first.
Generally, if you’re unable to isolate a behavioral trigger, your loss may be twofold: You miss the opportunity to remedy the behavior and you may miss something your loved one is trying to communicate.
If you need personalized help in developing strategies for the best possible symptom management and communication, we extend our free Care Consultation services to the In Care of Dad community. Call our helpline at 800.272.3900 or click here to get in touch with our trained consultants.
Paul Raia is the Director of Patient Care and Family Support for the Alzheimer’s Association’s Massachusetts/New Hampshire chapter.
Thank you, Paula Bailey, for contributing your photo.