If your loved one has started displaying challenging new behaviors such as anger, suspicion or withdrawal, there’s likely a reason behind it. Chief among them: As we age, our bodies and brains begin operating at a more leisurely pace.
“Our synapses are slower, our reactions are slower and our processing can slow a bit,” says Teepa Snow, an occupational therapist with 40 years of experience, in addition to family caregiving experience. Snow specializes in training and supporting individuals with dementia and their caregivers.
Snow says this slowdown, along with any other changes, should happen gradually, noting, “You shouldn’t see huge shifts in ability rapidly, because that signals something else and is not the normal aging process.”
Here, why new difficult behaviors might occur, what they look like and how you can best manage them, according to Snow and other experts.
Why new behaviors may emerge
Snow discourages caregivers from jumping to conclusions that new or difficult behaviors signal dementia, since causes vary and may be treatable. Here are a few potential causes:
Slowing down. As processing and thinking slows, seniors may get frustrated if their abilities diminish or they can’t do things as quickly as they used to.
Life transitions. Major life events, such as losing a spouse, moving into a senior care facility or requiring a caregiver can trigger difficult behaviors, says Dr. Nancy Schoenborn, an associate professor of geriatric medicine and gerontology at Johns Hopkins University School of Medicine. This can happen if the senior is having trouble adjusting emotionally or even experiencing significant changes in day-to-day routines, she adds.
Mood disorders. Symptoms of depression or anxiety can mimic those of early dementia, Schoenborn says. Snow adds that normal grief can turn into depression in some seniors. Other seniors can develop anxiety as life changes, Snow says, which can devastate function and make someone feel vulnerable and irritable. While medications can help, Snow encourages lifestyle changes such as activity, engagement and talking.
Health conditions. A senior who’s become slow, lethargic and grumpy may simply be suffering from poor thyroid function, Snow says, which is easily addressed with medication. An underlying medical condition could be the source of — or a contributing factor to — behavioral changes.
Reactions to medication. As we age, our bodies take longer to process medications, Snow says, so our normal dose may become risky or cause more side effects. For example, Snow says, antihistamines in Benadryl or Tylenol PM can create more next-day fogginess in seniors, which could be mistakenly interpreted as cognitive decline. She says some unsuspecting medicines, like those that treat incontinence, can cause side effects with age, so ask the senior’s doctor or pharmacist to review their medications to see if anything should be adjusted.
Cognitive decline. The onset of dementia or Azheimer’s disease can elicit difficult new behaviors, says Monica Moreno, senior director of care and support at Alzheimer’s Association. Early signs can include irritability, anxiety or depression, Moreno says, but as the disease progresses, behaviors can begin to really challenge and distress caregivers. This can include anger and aggression, agitation, physical or verbal outbursts, restlessness, general emotional distress and hallucinations or delusions.
To determine what’s behind your loved one’s behaviors, Schoenborn recommends taking them to their primary care doctor. “For these types of concerns, as physicians, we really rely on the caregivers to bring it up since the patient may say everything is fine, and they can be quite skilled at hiding things in the earlier stages,” she explains.
Difficult behaviors you may encounter
“It’s common to experience some issues with memory, thinking and behavior as we age,” says Moreno. “However, when changes begin to interfere with daily life, it could be a sign of something more serious.”
These are some of the most common difficult behaviors to be aware of, along with how to manage them depending on the cause:
Anger
What it looks like: Older adults may display angry outbursts, aggression and irritation, and they may direct emotional abuse toward their caregiver.
“When we’re slowing down and a younger person is trying to support or help us, we may come off as getting stubborn, ornery or resistant,” Snow explains. If the senior feels rushed or overwhelmed, they might blurt out something that sounds angry. But Snow says they’re actually just being given too much, too fast, and a protective part of their brain has put on the brakes.
“Some behaviors may be triggered by relatively minor events — the person may be uncomfortable, confused, anxious or have some biological need such as being hungry, thirsty or having to use the bathroom.”
— MONICA MORENO, SENIOR DIRECTOR OF CARE AND SUPPORT, ALZHEIMER’S ASSOCIATION
Anger and aggression can also manifest in dementia or Alzheimer’s patients when something is bothering them and their brain is unable to communicate it, Moreno says. “Some behaviors may be triggered by relatively minor events — the person may be uncomfortable, confused, anxious or have some biological need such as being hungry, thirsty or having to use the bathroom,” she explains.
How to manage it: In adults who are taking longer to process things, the key is patience and flexibility, Snow says, and remembering their brain gets more easily overwhelmed. Bringing in a neutral caregiver can also help since emotional baggage gets exaggerated in these situations, Snow notes.
Schoenborn adds that it’s also helpful to accept that the senior can no longer do certain things, and for family members to take over tasks that have become too much for them. For example, administering medicine, paying bills or grocery shopping.
When anger or aggression surfaces in dementia and Alzhimer’s patients, Moreno says it’s important to address the individual’s underlying emotion or physical need. “Sometimes addressing the behavior can be as simple as changing the environment, reassuring the person through conversation or simply holding their hand,” Moreno explains.
“Sometimes addressing the behavior can be as simple as changing the environment, reassuring the person through conversation or simply holding their hand.”
— MONICA MORENO, SENIOR DIRECTOR OF CARE AND SUPPORT, ALZHEIMER’S ASSOCIATION
Suspicion or paranoia
What it looks like: Some seniors, especially those experiencing cognitive decline, may become suspicious, paranoid or accusatory.
If they start forgetting things or misplacing common items — especially if they have some awareness they should have known where it was — they may blame others, Schoenborn says. “That can come out as anxiety, but it can sometimes be accusatory,” she explains. “I’ve had patients accuse the caregiver of moving things; they’re trying to rationalize it and find explanations, since it’s less scary to think it’s someone else’s fault.”
In more extreme cases, Snow says, some types of dementia can cause hallucinations or delusions that can manifest as paranoia, like thinking their spouse isn’t really their spouse.
How to manage it: “I see caregivers really hurt that they’re putting all this time and effort into caring for this person, and they’re being accused and yelled at,” Schoenborn says. She suggests caregivers recognize it’s the disease talking, not their loved one, and strive to not take it personally.
With dementia, Snow says the disease damages the prefrontal cortex in about half of patients. “This is the part of our brain that controls decision-making, sequencing, cognitive thinking and reaching logical, rational conclusions,” she says. This means the senior isn’t necessarily in denial about their condition or refusing to listen to you, but their brain is losing their ability to be self-aware and think logically. With harmless confusion or delusions, it’s sometimes easiest to roll with it rather than try to reason with them, Snow explains.
Fearfulness
What it looks like: Some aging adults start becoming scared of new places and experiences, new people or being left alone, Schoenborn says.
Snow says dementia can also cause general fear of other people, especially if it seems like others know things they don’t. Seniors who’ve always been smart and confident may also become fearful if they realize they’re in cognitive decline and don’t want to be found out, Snow adds.
How to manage it: Caregivers often make the mistake of pointing out what the person is missing or shove it in their face, thinking that will fix it, Snow explains. “This can cause a deep, powerful emotional reaction from a part of the brain called the amygdala, which is the threat center,” she says. “It gives the person who’s experiencing this a sense that you’re threatening them and their self-image.”
Say your loved one insists they need to get cash at the bank. Snow recommends avoiding saying, “We went to the bank yesterday, and you took out $100, don’t you remember?!” which could generate fear, confusion or anger.
Instead, try, “Hmm, tell you what, will you check in your wallet first, because I thought you had some in there?” Or, if a loved one refuses to put on clean clothes, rather than demanding they change, Snow suggests, “Hey, I really love you in that yellow shirt, would you be willing to put it on for me?” People with dementia pick up on tone, Snow says, and they’re more responsive to support than being bossed around.
Withdrawal
“To the extent that the senior can do something he or she still enjoys, keep them as engaged at the top of their ability, physical as well as social.”
— DR. NANCY SCHOENBORN, JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE
What it looks like: Seniors might start to withdraw and disengage socially. This could indicate clinical depression, Schoenborn says, though it can happen if someone is starting to suffer from cognitive decline.
“Maybe they find that they’re no longer able to play games they used to play,” she says. “Or they used to participate in a social group but now they can’t hold a conversation or remember other peoples’ names, so they’re embarrassed and stop going to some activities.”
How to manage it: Caregivers should find new ways to keep the older adult in their care active. “To the extent that [the senior] can do something he or she still enjoys, keep them as engaged at the top of their ability, physical as well as social,” Schoenborn recommends. “Take walks with them, make sure they don’t stay in the house all day, go listen to music or whatever they like to do.”
More ways you can cope while caring for an older adult
Experts say these strategies can also help manage a broad range of difficult senior behaviors.
Get help
Behavioral issues can put emotional strain on the caregiver and the pair’s relationship. Bringing in a neutral, professional caregiver may reduce conflict and outbursts — and offer the caregiver a much-needed break, Snow says. If that’s not possible, find a resource you can turn to for support. The degree isn’t as important as knowledge and experience, Snow says, so this could be a geriatric care manager, occupational therapist, gerontological doctor or nurse or certified nursing assistant (CNA).
Reduce conflict
When someone with memory problems says something incorrect, don’t argue about the facts or become confrontational, Moreno urges. “For example, if a person expresses a wish to go visit a parent who died years ago, don’t point out that the parent is dead,” she explains. “Instead, say, ‘Your mother is a wonderful person, I would like to see her too.’”
Redirect attention
Seniors experiencing cognitive decline can get stuck in circles and need help disrupting repetitive thoughts and behaviors. Snow suggests redirection by exclaiming, “Hey, just a second, I want to ask you something!” with enthusiasm and then a long pause. It grabs attention and helps them shift gears. Or if they keep asking what’s for dinner, she says, try answering, “Well hey, before we talk about that, let’s go see if we can go pick up things in the yard!” Snow says this helps change the environment, giving your loved one something new to look at or think about.
Coping with troublesome new behaviors can be one of the hardest parts of serving as a family caregiver. But by taking a close look at the root cause of the behavior, and taking steps to treat or manage them, both you — and your loved one — will be much healthier and happier.
