Uncover What Could Be Behind Behavioral Changes in People With Dementia
| The Behavioral Manifestations of Neuropsychiatric Symptoms (NPS) Can Be Influenced by Many Factors |
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Cognitive decline is the hallmark of dementia, but dementia affects more than cognition.1 NPS are unique and distinct syndromes commonly seen in patients with dementia including delusions, hallucinations, agitation/aggression, dysphoria/depression, anxiety, euphoria, apathy, disinhibition, irritability, and aberrant motor behavior.1 Research has tied NPS to increased caregiver burden, decreased patient functional level, and increased risk of institutionalization.3,4,5 All NPS manifest as changes in behavior in patients with dementia.1 Additionally, certain contributing factors can influence behavioral changes in patients with NPS.2 These factors may include a medical condition, such as pain or a urinary tract infection (UTI), unmet physical or psychological needs, environmental factors, and cognitive symptoms.2 For example, in a recent study examining the effects of isolation due to the pandemic (N=38), about 25% of people with Alzheimer’s disease showed worsening NPS.6 In these specific patients who showed worsening in NPS, the duration of isolation/confinement was correlated with severity of NPS and caregiver distress.6 According to the position statement of the American Association of Geriatric Psychiatry (AAGP) regarding principles of care for patients with Alzheimer’s disease dementia, considering and addressing all contributing factors is a critical part of the development of dementia care.2
| Dementia-Related Hallucinations and Delusions Are Distinct From Other NPS, Such as Agitation and Depression |
| Definitions of some of the NPS syndromes |
| Hallucinations7 Perception-like experiences that occur without an external stimulus and are sensory (ie, see, hear, taste, smell, feel) |
| Delusions7 False, fixed beliefs that are not amenable to change despite conflicting evidence |
| Agitation8 A state of emotional distress in which behaviors such as excessive motor activity, verbal aggression, and physical aggression are exhibited |
| Depression7 The presence of a sad, empty, or irritable mood accompanied by somatic and cognitive changes that significantly affect functional capacity |
The hypothetical cases below illustrate how behavioral changes may co-occur with NPS and/or other contributing factors in people with dementia. These case studies feature behaviors that may co-occur with certain NPS, specifically hallucinations, delusions, agitation, and depression.7,8 Agitation is defined as a state in which certain behaviors are exhibited in association with emotional distress.8 These behaviors include excessive motor activity, verbal aggression, and physical aggression.8 Depression can manifest as apathy, a loss of interest in activities and hobbies, social withdrawal, and impaired thinking.7,8
Case Study 1: Timothy
Timothy has been living with a diagnosis of dementia with Lewy bodies for the past 2 years. Although his cognitive function is largely intact, some days are worse than others. Recent changes in his behavior have made it hard for him to function normally at home. Timothy claims that he sees an unsupervised child playing in the street and will pace back and forth while worrying about the child’s safety. He does this so much that it has worsened the bunion pain in his feet. When Timothy’s wife, Karen, asks him if he wants to sit, he will yell and curse loudly at her to leave him alone and do something to help the child. But Karen is convinced that the child is not really there. Making matters worse, Timothy has been making frequent trips to the bathroom, which has exacerbated the pain in his feet. Timothy’s behavior has also affected his neighbors. He has recently become convinced that they are breaking into his garage to steal his golf clubs, and he can’t be persuaded otherwise. In retaliation, he has started throwing old newspapers into his neighbors’ yard.
Timothy, 71
Diagnosis: Dementia With Lewy Bodies
Montreal Cognitive Assessment Score: 21 (mild impairment)
Click on the tiles below to investigate factors that co-occur with each behavior
Pacing
- Hallucinations
- Pain
- Excessive motor activity
Throwing objects
- Delusions
- Physical Aggression
Yelling
- Hallucinations
- Pain
- Verbal Aggression
Frequent urination
UTI
Case Study 2: Helen
Helen is a resident at an assisted living community and has been living there for the past 2 years. Recently, the staff at the assisted living community has noticed that Helen’s behavior and personality have changed. Normally, Helen enjoys interacting with the other residents at mealtime; however, she has been frequently complaining that the other residents have been poisoning her food, and she has been skipping meals. As a result, she has become socially isolated, and she spends most of her time by herself. Recently, Helen has become convinced that the staff have been allowing strangers into her room, and she becomes fearful and starts crying when staff members try to help her with activities of daily living. Last week, a staff member found Helen wandering around the community. She seemed confused about her surroundings, and when the staff member helped her back to her room, Helen claimed it wasn’t hers. Helen’s family and friends have been trying to explain to her that the staff aren’t mistreating her, but she can’t be convinced otherwise.
Helen, 85
Diagnosis: Dementia Unspecified
Montreal Cognitive Assessment Score: 15 (moderate impairment)
Click on the tiles below to investigate factors that co-occur with each behavior
Skipping meals
- Loss of interest
- Delusions
Crying
- Depressed mood
- Delusions
Spending time alone
- Social Withdrawal
- Delusions
Wandering
- Cognitive symptoms
- Delusions
References
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- Cummings J, et al. Neurology. 2009;44(12):2308-2314.
- Lyketsos CG, et al. Am J Geriatr Psychiatry. 2006;14(7):561-573.
- Mohamed S, et al. Am J Geriatr Psychiatry. 2010;18(10):917-927.
- Porter CN, et al. SAGE Open Medicine. 2016;4:1-9.
- D’Onofrio G, et al. Current Alzheimer Research. 2012;9:759-771.
- Boutoleau-Bretonnière C, et al. J Alzheimer Disease. 2020;76:41-47.
- APA. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
- Cummings J, et al. Int Psychogeriatr. 2015;27(1):7-17.
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