Behavioral Disorders in Dementia

Known only as senility for thousands of years or hardening of the arteries for the past several decades, dementia has become a major health problem for older adults in the developed world and increasingly in the developing world. Behavioral symptoms have been observed in 60% to 98% of patients with dementia. Many individuals with dementia and their families find behavioral disorders to be the most challenging and distressing effects of dementia. These symptoms are often a determining factor in a family's decision to place a loved one in an institution.

Dementia is a decline in mental functions that generally include short- and long-term memory and is often associated with changes in language, logical thinking, and personality. Most dementias are incurable. The termbehavioral disorders describes a large group of symptoms that occur to at least some degree in all individuals with dementia, including delusions (present in 20% to 40% of dementia patients), hallucinations (10% to 20%), agitation (60% to 80%), aggression (30%), depression (40%), anxiety (15%), elation/euphoria (5%), apathy/indifference (40% to 60%), disinhibition (10%), aberrant motor behavior such as pacing (40%), insomnia (50%), and appetite/eating change (35%).

Living with dementia is emotionally painful and financially draining not only for the person who suffers from dementia but also for his or her family. Cost of caring for behavioral disorders in people with dementia accounts for more than 30% of total cost of caring for people with dementia. Although behavioral disorders can be life threatening, there is reason to be optimistic. The person suffering from dementia and his or her family can learn about ways to prevent or reduce agitation and other behavioral symptoms with simple, low-tech, nondrug interventions. There are also medicines that can help. Early diagnosis and treatment are keys to successful outcomes of behavioral disorders in dementia.

Early in the course of dementia, people often recognizes their shortcomings and may feel embarrassed about them. Due to inability to remember simple words during an everyday conversation, they may get frustrated and irate at themselves as well their loved ones. People in this stage also often get depressed and worry about the future. People may experience personality changes such as apathy (lack of motivation for daily activities and self-care but without any emotional discomfort). Some may develop severe depression and even contemplate suicide. However, many people with mild dementia attribute declining memory and other abilities to natural consequences of aging and do not seem to be terribly upset.

In advanced stages, more severe memory problems predominate. People with dementia in moderate to severe stages forget easily and entirely and often become disoriented even in their own homes. Eventually, people with dementia can no longer understand what they read and are unable to follow conversations. People often react to these losses with several daily periods of confusion and fear for no obvious reason. Insomnia is a common source of distress in this stage. Sundowning consists of agitation, confusion, and disorientation that often starts in late afternoon and becomes especially severe at night. Delusions (fixed false beliefs) are often prominent in this stage. People with dementia often become paranoid about money and may fear that their caregivers want to harm them. Hallucinations (seeing nonexistent people or animals) are not uncommon in these stages and may cause anxiety and agitation. People with dementia in the advanced stages may begin to wander around while dressed inappropriately in the middle of the night. People with dementia often get frightened by their loved ones, whom they can no longer recognize. They often respond to this fear with anger and aggression. On the other hand, some may experience long periods of [Page 70]silence. It is common for people with dementia to show significant changes in expression and in general appearance from one hour to the next. Aggressive behavior (e.g., screaming, throwing objects, attempting to hit others) is one of the most frightening behaviors in someone who has dementia. Verbal assaults are more common than physical ones. Fortunately, such hostile behaviors are usually temporary.

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