To know what to do when a difficult behavior occurs is a mystery to even the most experienced healthcare professional. Yet on March 29, Lena Smith, Ph.D., an instructor at Webster University in New Mexico, explained how to deal with some of the most difficult behaviors associated with this disease, including wandering and aggression. The presentation was one workshop of many presented at American Society on Aging/National Council on Aging conference in Washington, D.C.

"Dementia," she explained, "is a syndrome of acquired intellectual impairment produced by brain dysfunction." Clinically speaking, it results in the compromise of three or more areas of mental activity: memory, perception, calculations, personality, language, praxis, conceptual knowledge, emotional awareness and executive functioning.

The more difficult behaviors associated with dementia relate to anxiety, suspicion, fear, paranoia, hostility, depression and insecurity. Categorically, they are either physical or verbal, aggressive or non-aggressive.

Physically, non-aggressive behaviors might in include disrobing, eating inappropriate items, handling, moving, hiding or hoarding things, or wandering. And physically, aggressive behaviors might be sexual advances, attempts to hurt oneself or others, throwing things, grabbing, pushing, hitting, spitting, kicking or biting staff or other residents.

Verbally non-aggressive behaviors may include complaining, a generally negative attitude, repetitive questions, moaning, crying or constant requests for help. Verbal, aggressive behavior would be cursing, distress sounds, screaming, or sexual comments.

It should be noted that none of these actions are typical of the individual or intentional in the sense that the person means to do harm, but rather the result of the disease and the consequential damage it is causing to the brain. Yet in each case, there are prudent, dementia-specific actions that staff and family can take to successfully intervene.

Key questions should be:

• Is the behavior appropriate or inappropriate from the viewpoint of the person with dementia?
• Is there a need that explains the behavior, perhaps not immediately apparent to the observer (such as pain, thirst, hunger, toileting needs, fatigue, medication side effects, discomfort due to infection or temperature)?

"The better one is able to understand the cause, the better the intervention," Smith explained.

She also pointed out that even the most inappropriate or unusual behaviors are temporary. That said, however, once they go away they may be replaced by other behaviors. Yet knowing the disease and knowing the person are key to empathetic and effective intervention. As such, staff may be able to anticipate certain behaviors and take pre-emptive actions, such as offering snacks between meals for someone who acts out hunger, or more frequent bathroom breaks for those who may wander in search of the bathroom. Most importantly, such behaviors should not be considered "attention-getting." They are disease-based and are as uncomfortable for the person as they are for the staff or caregiver.

Within Alzheimer's care facilities, successful dementia programs can be developed. They should be based on the disease process itself, incorporate specialized approaches, and identify irritating impacts of the environment. With more difficult behaviors and individuals goals should be set; there should be ongoing assessment; and, when appropriate, medicine should be considered as part of the combined approach.

Specialized programs should also incorporate specialized environments, care routines, activities, staff training, family programs, hydration and meal plans. Smith emphasized, "For people with dementia in a care community, quality of life depends on the quality of the relationships with the direct care staff."

"Not all difficult behavior is bad behavior," she explained. For example, though certain types of wandering can be very dangerous, simple meandering can improve socialization, provide exercise and environmental changes (allowing someone to move from a stressful environment to one that is more comfortable).

Some difficult behaviors, when no real harm is being done, may be better off with no intervention at all. Rummaging, for example, may be viewed by the individual as a very purposeful activity. Are they solving a problem? Would a "constructive" alternative work for them, such as counting silverware?

On the other hand, reactions to fears, such as paranoia, can be very upsetting and harmful. It should be noted that such concerns are very real to the individual. Seeing or hearing long-deceased family members or friends, for example, or believing that people within the facility are stealing from them, are as real as the person sitting next to you.

In the case of physical or verbal agitation, Smith says, "Always try a change of environment first." It may be that the present surroundings are simply overwhelming, too stimulating and too stressful. This may the only way the person knows to express themselves and relieve themselves of the immediate upsets. Approach the person and attempt to solve the problem. Would a distraction, such as a snack, work? What is the person's favorite snack - might a slice of apple pie help?

Another important point is for staff to know as much as possible about the life of each resident; their story, likes and dislikes, abilities and inabilities.

In every case, with each individual, behaviors are unique and the strategies to deal with them equally special. The process should include a flexible, problem-solving approach, designed to recognize the cause and prevent problems before they occur. Smith emphasized, "Anticipate needs before they happen."

With any new behavior, underlying medical or physical causes should always be considered. And any such changes should be reported to a doctor.

Among the possible intervention strategies are alternative activities and distractions, and only as a last resort, medications. But most importantly, try to see through the eyes of the person. And when all else fails, Smith says, "empathy buys you time to be creative." Responses like, "I agree,""You're absolutely correct," can buy valuable seconds. "Empathize, never criticize."

For more information on managing difficult behaviors or to have Dr. Smith speak to your organization, you can contact her at lenasmith88@webster.edu.