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Just a Bad Day With Dementia or Is It More Serious?

Questions to help caregivers know when behavior changes deserve attention


Judy has Alzheimer’s disease and lives at home with her daughter. One morning, Judy wakes up more irritable than usual. She doesn’t want to get dressed, goes back to bed and sleeps through breakfast. When she finally gets up and wanders into the living room, she drinks half her coffee and then falls asleep in her recliner instead of watching her favorite TV show.

Judy’s daughter wonders to herself, “Could this be just one of mother’s bad days or does she need medical attention?”

Situations like this confront family caregivers often. In fact, a study that followed 136 persons with dementia over six months found that 74 percent of their caregivers reported at least one episode of new or worsening confusion. It also found 65 percent reported decreased activity, 57 percent noted new or worsening agitation, and 44 percent reported the person was not eating or drinking well.

What to Do When You’re Unsure

Symptoms or behaviors such as these can be particularly stressful for the family caregiver. It’s not easy to decide what they mean or what to do, especially if the person with dementia can’t clearly express feelings with words.

To make matters even more difficult, medical experts have found that it’s not always possible to pin down a single cause when someone with dementia seems or acts different.

Here are some questions caregivers might ask to help them decide what to do:

Ask: Are there signs the person is sick?

  • Does the person have a fever or other changes in vital signs, such as blood pressure, pulse and respiratory rate?
  • Does the person have any other signs or symptoms, like a new cough, runny nose, rash or pain?
  • Does the person have changes in urinary habits that might suggest a urinary tract infection?
  • Has the person been around someone who is sick?

Ask: Could the person be in pain from arthritis, indigestion, a headache, or some other cause that can be easily treated at home? People with dementia, especially those who have trouble communicating, may not express pain in typical ways. Aside from their behavior change, consider:

  • Did the person have a history of pain in one or more areas that could be bothering him or her now?
  • Has the person received his or her usual pain medication?
  • Is the person moving differently than usual? For example, is the person tensing up, rubbing a body part or walking differently?
  • Is the person moaning, crying or whimpering?
  • Is the person using words like “ache,” “not right” or “broken down”?
  • Is the person making facial expressions that could mean he or she is in pain, like shutting eyes tightly or furrowing eyebrows?

Ask: Might the person have reduced energy due to dehydration? Older people often don’t drink enough, and many are mildly dehydrated all of the time. Dehydration can quickly become a problem. Consider:

  • Has the person been eating or drinking less than usual?
  • Has the person been losing fluids through sweating, fever, vomiting or diarrhea?
  • Is the person showing signs of dehydration such as dry mouth, urinating less than usual, or seeming weak, confused or sleepy?

Ask: Could the person be suffering from a medication side effect? Older people are sensitive to medication side effects and medications can change behavior, so it’s important to consider:

  • Did the person recently start a new medication?
  • Did the person have a recent change in medication dose?
  • Did the person miss a dose or doses of a regular medication?

Ask: Could the problem be explained by sleep disturbance? It’s hard for most healthy adults to function well with lack of sleep, and for a person with dementia, poor sleep can wreak havoc. Think about:

  • Has the person had a poor night’s sleep or a change in their sleep routine?
  • Has the person’s sleep environment or routine recently changed? For example, is he or she in a place that is loud or unfamiliar? Is there a new mattress? Were the curtains left open at night?

Ask: Has the person been in an unusually stressful situation? Sometimes, behavior changes are related to a physical or sensory need. This is particularly true if the person has had a change in environment or routine. Consider:

  • Has the person had an unusual schedule change, such as visiting grandchildren?
  • Could the person be hungry, cold or hot, or wet?
  • Are the person’s hearing aids and glasses working properly?
  • Are the activities the person is involved in not stimulating enoug, or too stimulating?
  • Has the person had caffeine or alcohol in a different amount than usual?

The Solution May Be Simple

By thinking through these potential issues, caregivers can have a better handle on what might be causing the changes they observe and can decide what to do about them. In some cases, a relatively simple fix — like encouraging fluids or moving the person to a calm environment — will resolve the problem.

However, if the behavior changes are severe, last more than a day, are accompanied by signs that the person may be getting sick or if the person has vital sign changes, consult a health care provider.

Doctors tell us that vital signs are a critical clue to whether a serious illness is developing. For this reason, it’s important for caregivers to learn to take vital signs. Free video instruction on vital signs is available at: http://alzmed.unc.edu/videos.

By Dr. Philip Sloane
Dr. Philip Sloane is the Elizabeth and Oscar Goodwin Distinguished Professor of Family Medicine and Geriatrics at the University of North Carolina at Chapel Hill, where he also co-directs a research program on aging, disability and long-term care. A nationally recognized researcher on Alzheimer’s disease, he is recipient of the prestigious Pioneer Award from the Alzheimer’s Association. His most recent book, The Alzheimer’s Medical Advisor (©2017, Sunrise River Press), provides guidance for family caregivers on how to assess and manage common medical and behavioral symptoms in persons with Alzheimer’s disease and other dementias. It is available from major retailers like Barnes & Noble and Amazon, and from Sunrise River Press.

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