Handling Verbally Disruptive Behavior in Patients With Dementia

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Verbal behavior that others consider disruptive is common in later-stage dementia. This behavior can range from a man who follows his nurse around asking repetitive questions, to the woman who sits in her chair and screams loudly for no apparent reason, to the man who lies curled up in bed, moaning softly through the night.

And there are many other variations on these themes. It has been estimated that 25 percent of those with dementia who still live in the community, and 50 percent of those who reside in long-term care facilities, exhibit this type of behavior at any given time. As many as 90 percent of those with dementia will demonstrate such behaviors at some point.

There are a number of different types of dementia-producing illnesses that can lead to screaming and other verbally disruptive behaviors. These include Alzheimer’s type dementias, vascular, Lewy Body, and frontotemporal, as well as the less common prion diseases, metabolic imbalances, and other degenerative conditions. Disinhibited behaviors are often associated with frontotemporal dementia, but they can be due to other diseases as well.

Often, sadly, the typical response to these disruptive individuals is to administer some medication intended to calm the person and make the behavior more manageable. However, in most cases there are non-pharmaceutical interventions that not only work much better, but also produce fewer side effects. I have heard it said that up to 95 percent of behaviors in people with dementia are actually a form of communication. When one considers the loss of verbal language production that inevitably occurs in dementia’s latter stages, it is no surprise that people with this disease resort to whatever means they can to communicate with the outside world.

The messages they seek to convey tend to fall into a few common categories: 1.) “I’m in pain,” 2.) “I’m lonely/frightened/bored,” 3.) “I don’t want to be here,” and 4.) “I need/want something.” At times, it is readily apparent what the person is trying to say. But, more often than not, the person’s caregivers need to do a little detective work to decipher the meaning behind the verbal outburst.

When I work with a nursing home resident with dementia and  consistently problematic behavior, I first attempt to define the behavior more clearly. What exactly does the resident do? What times of day does this occur? Are there any other events and circumstances associated with the behavior—occurring immediately before or after the behavior, for instance? What else is going on in the environment? It is also helpful to know what interventions have been attempted in the past for dealing with the behavior, and whether these interventions have proven at all beneficial. I try to learn as much as I can about the resident’s medical, family and occupational history. It is important to remember that this verbal agitation or disruption is a symptom and not a disease or condition in itself.

Pain, often related to conditions such as arthritis, compression fractures, limb contracture, and constipation, is responsible for perhaps as much as 50 percent of verbal disruptions. Because people with advanced dementia may lose the ability to ask for pain relief, administering a daily maintenance dose of Tylenol or a similar medication can be helpful.

In addition, I recommend doing the following to assess what might be causing discomfort:

  • Conduct a physical evaluation. Has the resident recently been placed on a new medication, or taken off one? Is there any sign of infection, injury or other medical issues? Is there pain related to arthritis, a toothache, constipation, etc.? Is the resident hungry or thirsty or in need of a change in bedding?
  • Survey the person’s environment to determine if any changes may have prompted the behavior. This could be a change in the routine, a new caregiver or a new roommate. Perhaps the hustle and bustle of getting the unit ready for Christmas is too much for the person to handle. Has there been an upsetting visit from a family member? (Also be aware that understimulation can be just as problematic.)
  • Assess the caregivers in this particular situation. Caregivers, both professionals in long-term care facilities, and family members in a home environment, are subject to a great deal of stress. This stress may not be directly related to the situation at hand. It could be that a nurse has had to place her own husband in the hospital, or has just learned that a son is having trouble in school. And if the caregiver is feeling stressed, it is likely that her charges will pick up on this as well.

Any form of intervention ultimately depends on the cause of the outburst.  Treating acute medical issues—and addressing dehydration or hunger—should take precedence over anything else.  Next,  consider environmental modifications, such as using softer lighting or music, establishing a routine that can provide a calming influence, and so on.

Music is associated with reduced agitated behavior, especially during bathing or meals. Light physical exercise can prove to be a pleasant distraction for the person. Other possible interventions can include pet therapy, massage, white noise, photographs of family or familiar people and places, and attention to any personal needs the person may have.

If you’ve tried all these strategies, and the person with dementia continues to be disruptive, possibly posing a risk of self harm or harm to others, then antidepressants, mood stabilizers and antipsychotic agents may provide some benefit. But, given that the side effects can be severe, opt for such agents only after careful consultation with the person’s physician and family.

Jami L. Hede, MS, CCC-SLP, is a private practitioner and affiliate of  ASHA Special Interest Group 15, Gerontology. This post was adapted from her blog, “Exploring Dementia.” 

Speech Therapy and Aging: Implications for Our Approach to Communication Disorders

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This post is the beginning of a monthly series by Betty Schreiber, M.M.S. CCC-SLP, on Aging, Communication, Cognition, and Speech Therapy.

Thank you for allowing me to be a new blogger on ASHASphere. I currently supervise Graduate Students at the Ladge Speech and Hearing Clinic at LIU/Post in Brookville, New York. Along with my wonderful business partner, Gail Weissman MA. CCC-SLP, and amazing programmers at Objectgraph LLC, I am also creating Apps designed specifically for our older clients.

As I am at the younger end of what would be considered the “baby boomer” generation, and currently working with adults who have begun to age and suffer communication disorders, I am particularly sensitive to the effect of aging and the social impact of communication disorders amongst this population.

As people get older, it is a fact that health and physical mobility are crucial elements in their ability to function in daily life, interact, and participate normally in society. Even older people who have simply aged with no other issues experience increasing isolation. Their spouses and friends move or pass away, leaving fewer opportunities for social interaction.

The baby boomers are aging and will become a large part of the population in the next 20 years. The Center for Disease Control in collaboration with the Merke Company Foundation has developed information on aging in America with a state by state assessment.

They listed 15 key indicators of older adult health:

  • Physically Unhealthy Days
  • Frequent Mental Distress
  • Oral Health: Complete Tooth Loss
  • Disability
  • No Leisure-Time Physical Activity
  • Eating ≥ 5 Fruits and Vegetables Daily
  • Obesity
  • Current Smoking
  • Flu Vaccine in Past Year
  • Ever Had Pneumonia Vaccine
  • Mammogram Within Past 2 Years
  • Colorectal Cancer Screening
  • Up-to-date on Select Preventive Services
  • Cholesterol Checked in Past 5 Years
  • Hip Fracture Hospitalizations

These factors have an impact on our aging family members ability to attend the therapies they need, maintain cognitive function, communicate and be self-sufficient. The majority of our elderly prefer to stay in a familiar environment even if it means living alone or with some outside help.

According to the United States Department of Health and Human Services Profile of Older Americans 2011, about 29% (11.3 million) of noninstitutionalized older persons live alone (8.1 million women, 3.2 million men), almost half of older women (47%) age 75+ live alone. The number of Americans aged 45-64, (I’m in that batch) who will reach 65 over the next two decades increased by 31% during this decade. Over one in every eight, or 13.1%, of the population is an older American. This demographic information along with changes in the federal budget and insurance reimbursement should be of concern to us, as professionals. Not only in terms of how we will make a living, but how will we be able to provide needed support and efficient services so that treatment approaches do not have to cost more money. Therapy can be more effective if we address communication and interaction within the framework of the aging living situation as a whole.

In one of the blogs on our website, I told a story of my own family experience. My grandmother, who was about 83 at the time, was placed in the middle of the livingroom while family and friends spoke to each other around her. (I was about 26 and a SLP for 3 years) She was able to hear well enough, and speak well enough, but the attitudes of the younger people were such that unless she made a ruckus, no one felt it was necessary to include her in the conversation! This isolation while surrounded by a bustling family, negatively affected her attention to her surroundings.

Part of my therapy approach with adult clients is to educate and include the families and caregivers in the therapeutic process as much as possible. Our family questionnaire includes questions such as: How many times do you talk to (our client) during the day. We also ask about the client’s speaking interactions at home or in a group of people. I have found that some family members want us to “fix” their husband or wife and want no additional responsibility. But we can talk to them to help them slowly understand that their situation will be better if they are aware of how they can help and use the adaptive tools we are giving them. We are not asking them to do the therapy or practice. We help them with resources in our community and teach them about paired communication and listening. The families, caregivers, even SNF staff should be encouraged to develop a communication routine that allows interaction not mere reaction.

There will be more on this topic in subsequent postings. Any of the Indicators of Older Adult Health frequency may impact our therapy attendance and reimbursement. What does this mean in terms of available services, advocacy, health care coverage, families and caregivers education/training? How can we, as Speech Language Pathologists recognize and support individuals and families in distress and facilitate communication awareness, not only with our clients who are coming for therapy, but for our aging population as a whole?

Betsy C. Schreiber, MMS, CCC-SLP, received a BA  in Psychology and MMS Master of Medical Science in Speech Pathology from Emory University in Atlanta, Georgia. Her CCC was earned during the 3 years she worked at Hitchcock Rehabilitation Center in Aiken, South Carolina where she had the opportunity to learn about NDT and Sensory Integration with the original, Jane Ayres, working with LD and CP children and neurologically impaired adults. She is currently a clinical supervisor at Ladge Speech and Hearing Clinic at LIU/Post on Long Island, and a partner at Hope 4 Speech Associates, P.C. She has also served as an ASHA Mentor and hopes to participate in ASHA’s  Political Action Committee in the coming year.