Common changes in behavior
Many people find the changes in behavior caused by Alzheimer's to be the most challenging and distressing effect of the disease. The chief cause of behavioral symptoms is the progressive deterioration of brain cells. However, medication, environmental influences and some medical conditions also can cause symptoms or make them worse.
In early stages, people may experience behavior and personality changes such as:
In later stages, other symptoms may occur including:
Help is available
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Events or changes in a person's surroundings often play a role in triggering behavioral symptoms.
Change can be stressful for anyone and can be especially difficult for a person with Alzheimer's disease. It can increase the fear and fatigue of trying to make sense out of an increasingly confusing world.
Situations affecting behavior may include:
- Moving to a new residence or nursing home.
- Changes in a familiar environment or caregiver arrangements.
- Misperceived threats.
- Admission to a hospital.
- Being asked to bathe or change clothes.
Identifying what has triggered a behavior can often help in selecting the best approach to deal with it.
Medical evaluation for contributing factors
Everyone who develops behavior changes should receive a thorough medical evaluation, especially if symptoms appear suddenly.
Difficulty with communication
Because people with Alzheimer's gradually lose the ability to communicate, it's important to regularly monitor their comfort and anticipate their needs.
Even though the chief cause of behavioral symptoms is the effect of Alzheimer's disease on the brain, an examination may reveal other treatable conditions that are contributing to the behavior.
Contributing conditions may include:
- Drug side effects. Many people with Alzheimer's take prescription medications for other health issues. Drug side effects or interactions among drugs can affect behavior.
- Discomfort from infections or other conditions. As the disease gets worse, those with Alzheimer's have increasing difficulty communicating with others about their experience. As a result, they may be unable to report symptoms of common illnesses. Pain from infections of the urinary tract, ear or sinuses may lead to restlessness or agitation. Discomfort from a full bladder, constipation, or feeling too hot or too cold also may be expressed through behavior.
- Uncorrected problems with hearing or vision. These can contribute to confusion and frustration and foster a sense of isolation.
Non-drug approaches to managing behavior symptoms promote physical and emotional comfort.
Many of these strategies aim to identify and address needs that the person with Alzheimer's may have difficulty expressing as the disease progresses. Non-drug approaches should always be tried first.
Steps to developing successful non-drug treatments include:
- Recognizing that the person is not just "acting mean or ornery," but is having further symptoms of the disease.
- Identifying the cause and how the symptom may relate to the experience of the person with Alzheimer's.
- Changing the environment to resolve challenges and obstacles to comfort, security and ease of mind.
- Monitor personal comfort. Check for pain, hunger, thirst, constipation, full bladder, fatigue, infections and skin irritation. Maintain a comfortable room temperature.
- Avoid being confrontational or arguing about facts. 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. Instead, say, "Your mother is a wonderful person. I would like to see her too."
- Redirect the person's attention. Try to remain flexible, patient and supportive by responding to the emotion, not the behavior.
- Create a calm environment. Avoid noise, glare, insecure space and too much background distraction, including television.
- Allow adequate rest between stimulating events.
- Provide a security object.
- Acknowledge requests, and respond to them.
- Look for reasons behind each behavior. Consult a physician to identify any causes related to medications or illness.
- Explore various solutions.
- Don't take the behavior personally, and share your experiences with others.
Our online social networking community can also help you. Join ALZConnected and learn tips for coping with a loved one’s behavior and find support from other caregivers.
Medications for non-cognitive (behavioral and psychological) symptoms
If non-drug approaches fail after being applied consistently, introducing medications may be appropriate for individuals with severe symptoms or who have the potential to harm themselves or others. While prescription medications can be effective in some situations, they must be used carefully and are most effective when combined with non-drug approaches.
The following general principles can help guide appropriate use of medications:
- Know the risks and benefits. It's important to understand the potential benefits and risks of a medication before making treatment decisions.
- Target a specific symptom. Effective treatment of one core symptom may help relieve other symptoms. For example, some antidepressants may help people sleep better.
- Start with a low dose of a single drug and monitor closely for side effects. Side effects can be serious, and drugs can occasionally even worsen the symptom being treated. Dosage should not be increased without a careful evaluation by a healthcare professional.
Learn more: Alzheimer's Association Statement Regarding Treatment of Behavioral and Psychiatric Symptoms (PDF)
FDA-approved medications for individuals living with dementia
The example below represents “on label” use, a medical practice in which a physician may prescribe a drug for a condition that has been approved.
Suvorexant (Belsomra®), approved for treatment of insomnia, has been shown to be effective for that purpose in people living with Alzheimer’s disease (mild to moderate). It works by blocking the activity of a chemical messenger involved in the sleep-wake cycle.
Brexpiprazole (Rexulti®) is the only atypical antipsychotic that is FDA-approved for agitation associated with dementia due to Alzheimer's. Atypical antipsychotics are a group of antipsychotic drugs that target the serotonin and dopamine chemical pathways in the brain. Many antipsychotics are used "off label" to treat agitation and other related behaviors. The FDA requires that all atypical antipsychotics carry a safety warning that the medication has been associated with an increased risk of death in older patients with dementia-related psychosis.
The examples below represent "off label" use, a medical practice in which a physician may prescribe a drug for a different purpose than the ones for which it is approved.
Antidepressants for low mood and irritability:
- Citalopram (Celexa®)
- Fluoxetine (Prozac®)
- Paroxeine (Paxil®)
- Sertraline (Zoloft®)
- Trazodone (Desyrel®)
Anxiolytics for anxiety, restlessness, verbally disruptive behavior and resistance:
- Lorazepam (Ativan®)
- Oxazepam (Serax®)
Antipsychotic medications for hallucinations, delusions, aggression, agitation, hostility and uncooperativeness:
- Aripiprazole (Abilify®)
- Clozapine (Clozaril®)
- Haloperidol (Haldol®)
- Olanzapine (Zyprexa®)
- Quetiapine (Seroquel®)
- Risperidone (Risperdal®)
- Ziprasidone (Geodon®)
Based on scientific evidence, as well as governmental warnings and guidance from care oversight bodies, individuals with dementia should use antipsychotic medications only under one of the following conditions:
The decision to use an antipsychotic drug needs to be considered with extreme caution. Research has shown that these drugs are associated with an increased risk of stroke and death in older adults with dementia. The FDA has ordered manufacturers to label such drugs with a “black box” warning about their risks and a reminder that they are not approved to treat dementia symptoms.
Behavioral symptoms are due to mania or psychosis.
The symptoms present a danger to the person or others.
The person is experiencing inconsolable or persistent distress, a significant decline in function or substantial difficulty receiving needed care.
Antipsychotic medications should not be used to sedate or restrain persons with dementia. The minimum dosage should be used for the minimum amount of time possible. Adverse side effects require careful monitoring.
Although antipsychotics are the most frequently used medications for agitation, some physicians may prescribe a seizure medication/mood stabilizer, such as:
- Carbamazepine (Tegretol®)