EP42: How to Manage Repetitive Behaviors in Alzheimer's Disease

How to Manage Repetitive Behaviors in Alzheimer's Disease "Look for a reason behind the repetition."— Melissa Batchelor, PhD, RN, FNP, FAAN  Are you wondering why a person with dementia develops repetitive behaviors like asking you the same question, telling you the same story, or doing the same thing over and over again? Knowledge is power. In this episode, I'll walk you through brain development, what's lost and retained in Alzhiemer's disease, and help you problem-solve how to manage repetitive behaviors in a person with dementia using the C3P Problem-Solving Framework to explain. Part One of 'How to Manage Repetitive Behaviors in Alzheimer's Disease' To put it simply, your brain develops from the back to the front.  The back part of your brain is where your feelings and emotions are (the amygdala). The amygdala controls our emotional responses when we encounter anything threatening, and activates the sympathetic nervous system with the fight, fright, or flight response.  The front part of your brain is called your frontal lobe, and it doesn't fully develop until you're about twenty-five years old. This part of your brain is basically the "stop sign" - meaning when something comes to mind that you want to say, your frontal lobe might say, "No, don't say that quite yet (or don't say it at all)."  What happens with Alzheimer's disease is the brain loses its ability from the front to the back. So you lose your ability to control impulses, use and understand language but  your emotions remain intact throughout the disease process. "Focus on the emotion, not the behavior." — Melissa Batchelor, PhD, RN, FNP, FAAN  To give you a visual image of what happens to the brain in Alzheimers. Imagine a grape, that's what a healthy brain looks like. When your brain is healthy, all of the messages can get back and forth without a problem. But what happens with Alzheimer's disease is the brain begins to shrink and shrivel.  Alzheimer's disease basically turns your brain into a raisin. Imagine a raisin. There are deep crevices, and those crevices make it hard for the messages to get back and forth. This is why people lose their memory, decision-making ability, and the hardest thing is that they lose their ability to use and understand language. So our words basically end up sounding like Charlie Brown's teacher -  So words don't work anymore; but the person does pick up on our emotions and our non-verbal behavior. They will "mirror" us. Part Two of 'How to Manage Repetitive Behaviors in Alzheimer's Disease' Let's talk about the C3P Problem-solving Framework focused on Changing the Person, Changing the People, or Changing the Place. The reason this is important is because there isn't one thing that will work for any specific behavior. You will have to try different things for behaviors because what works today,  may not work tomorrow. You need a "bag of tricks" and a way to think through the three levels that will help you find a solution. Change the Person (with Dementia): Look for a reason behind the repetition. Does the repetition occur around certain people or surroundings, or at a certain time of day? Is the person trying to communicate something? Is the person trying to do something? Trying to understand what the underlying reason is can be helpful. Focus on the emotion, not the behavior. Rather than reacting to what the person is doing, think about how he or she is feeling. Try to figure out the root cause of his or her anxiety can help them manage their anxiety and maybe resolve it. For example, if an older adult said something fifty times already, rather than saying "you've already told me that 50 times!" [in a frustrated voice], say something like, "It sounds like you're anxious." [in a calm voice]. Turn the action or behavior into an activity. Give them something to do and focus on, something meaningful. If they are picking at their skin or fiddling with their clothes, give them a laundry basket of things to clothes. Ask the person to help you get this "work" done. Change the People (Caregiver Approach) Stay calm, and be patient. One of the gifts that Alzheimer's gives people is that they live in the present moment. On the other hand, it's hard for caregivers to do that because they're living in the future thinking about all the things that they need to do.  Be aware of the impact of your own emotions in the moment. Caregivers may get very upset that this person can't do today what they could do yesterday. Patience is essential because while that person's feelings remain intact, their ability to pick up on your feelings also remains intact. If you express feelings of being frustrated or mad, that energy is in the room and they are also going to pick up on that.  Demonstrate what you want them to do. Another part of the brain that remains intact is the ability to "mirror" us; meaning whatever emotional state we come into a room with, the person will mirror it back to us. This is also why mimicking a behavior you want the person to do works - they understand our non-verbal communication better than when we use words. Reassure the person with a calm voice and gentle touch.     Don't use so many words. Don't argue or try to use logic; Alzheimer's affects memory, and the person may not remember he/she asked the question already.   Provide an answer. Give the person the answer that he or she is looking for, even if you have to repeat it several times. If the person with dementia is still able to read and comprehend, it may help to write it down and post it in a prominent location.    Accept the behavior, and work with it. If it isn't harmful, don't worry about it. Find ways to work with it. Go with what the person can or wants to do in the moment. Resistance is usually met with resistance. As caregivers, we often have our own agenda. Things we want and feel like we need to get done. Pushing our agenda on someone else is likely to be met with resistance. If we push harder, they resist harder. So if this happens in an interaction, stop pushing and it's very likely the person with Alzheimer's disease will stop resisting. Wait until another time and come back and try again. Flexibility is key for this one. Share your experience with others. Find your own support group, a group of people that you can talk to and share your experiences with. Learning from other people is going to be helpful. What worked today may not work tomorrow and this can be frustrating. Be sure you have the emotional support that you need. "Turn the action or behavior into an activity." —  Melissa Batchelor, PhD, RN, FNP, FAAN  Change the Place (Environment) Use memory aids. If the person is calling you every day asking the same questions over and over again, try to use visual cues to offer reminders.  Using notes, clocks, calendars or photographs, if these items are still meaningful.  None of us can remember everything, so that might be another strategy that could help with a repetitive question. Manage Noise. Too much noise or activity can also raise a person's level of anxiety. Sensory overload can increase their anxiety and end up with a behavior that they didn't really mean to get.  Some behaviors do have the same solution though. One patient that I cared for a long time ago had daily repetitive verbalizations. He would get started up in the afternoon and you could hear him all over the building. When he did this, all of the staff knew it was time to take him out for a cigarette. He calmed right down after he smoked, until the next time he wanted one. And while I don't think smoking is a great idea, in this case, it was the lesser evil than giving him a medication that would have likely caused greater harm. If you'd like me to talk about another topic related to Alzheimer's disease, send me a question on the "Contact Melissa" section of this website and I'll get to it as soon as I can. Thanks for listening ~ and reading!  About Melissa: I earned my Bachelor of Science in Nursing ('96) and Master of Science in Nursing ('00) as a Family Nurse Practitioner (FNP) from the University of North Carolina Wilmington (UNCW) School of Nursing (SON). I truly enjoy working with the complex medical needs of older adults. I worked full-time for five years as FNP in geriatric primary care across many long-term care settings (skilled nursing homes, assisted living, home and office visits) then transitioned into academic nursing in 2005, joining the faculty at UNCW SON as a lecturer. I obtained my PhD in Nursing and a post-Master's Certificate in Nursing Education from the Medical University of South Carolina College of Nursing ('11) and then joined the faculty at Duke University School of Nursing as an Assistant Professor. My family moved to northern Virginia in 2015 and led to me joining the faculty at George Washington University (GW) School of Nursing in 2018 as a (tenured) Associate Professor where I am also the Director of the GW Center for Aging, Health and Humanities. Find out more about her work at https://melissabphd.com/.