Home > Aggression, Behavior > Verbal Disruptions in Dementia

Verbal Disruptions in Dementia

Image courtesy Michal Morcal @ http://www.freedigitalphotos.comOne of the more common behavioral problems that persons with later-stage dementia exhibit is being verbally disruptive, in some fashion or another.  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 immediately apparent reason, to the man who lays curled up in his bed as he moans softly throughout the night.  And there are many other variations on these themes.  It has been estimated that 25% of those with dementia who still live in the community, and 50% of those who reside in long-term care facilities, exhibit this type of behavior at any one given time. As many as 90% of those with dementia will demonstrate such behaviors at some point during the progression of their disease.

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 kind of medication intended to calm the person down and make their 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% of behaviors, in persons who have dementia, are actually a form of communication.  When one considers the loss of verbal language production that inevitably occurs in the latter stages of the disease, it is no surprise that these individuals must resort to whatever means they can to communicate with the outside world.

The intended message that many of these persons with dementia are trying 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 am presented with a resident who is exhibiting 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/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 beneficial to any extent.  I try to learn as much as I can about the resident’s medical history, as well as family and occupational history.  Of course, it is important to remember that this verbal agitation or disruption is a symptom, and not a disease or condition in itself.

Pain is a very important facet to consider, with this cause being responsible for perhaps as much as 50% of all verbal disruptions.  Many of the elderly have chronic pain, related to conditions such as arthritis, compression fractures, limb contractures, constipation, and so on.  And, when a person reaches a certain stage of dementia, he may be unable to reason how to ask for help to relieve pain, or lack the communicative abilities to do so.  More than one study has shown the benefits of administering a daily maintenance dose of Tylenol or a similar medication to the person with advanced dementia.

Other types of evaluations should also take place in this type of situation:

  1. A physical evaluation should also be conducted.  Has the resident recently been placed on a new medication, or taken off one that he has taken for a while?  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 does he need a change in bedding?
  2. The person’s environment should be surveyed, to determine whether there have been any changes that might be prompting this change in 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?  (However, be aware that understimulation can be just as problematic.)
  3. It is important to also 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.

There are a number of different factors to consider when determining how to treat a behavioral disturbance such as this kind of verbal outburst.  Of course, any form of intervention ultimately depends on the cause of the outburst.  Acute medical issues — as well as pain, dehydration, and hunger — should take precedence over anything else.  Non-pharmacological methods of dealing with behavioral concerns should always be attempted first, before the use of medications to calm the person down or otherwise suppress undesirable behaviors.  These can often take the form of environmental modifications, such as using softer lighting or music, establishing a routine that can provide a calming influence, and so on.

It is not unusual for persons with dementia to show a reduction in agitated behavior in response to music, 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 all of the above strategies have been attempted, and the person with dementia continues to display verbally disruptive behaviors of such a significant nature that they place the person or those around him at risk for harm, then medical intervention may be attempted.  However, there is to date no recognized regimen of this nature for the treatment of verbal disruptions.  Antidepressants and mood stabilizers may have some benefit, as may antipsychotic agents, but the warnings regarding side effects are quite severe.  Use of such agents should be done only after careful consultation between the person’s physician and his family.

Sources:

http://www.clinicalgeriatrics.com/articles/Verbal-Outbursts-a-Patient-with-Dementia

http://www.clinicalgeriatrics.com/articles/Screaming-Patient-Dementia

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