How to Handle Difficult Behaviors

These 15 behaviors can challenge any family caregiver.
By Paula Spencer Scott, Caring.com senior editor

Won't Bathe
Possible causes:
Modesty, privacy feels invaded, dislikes bathing aide, uncomfortable (too cold, afraid of water), feels unsafe (afraid of falling), had a prior bad experience, dementia makes him or her unaware of need to bathe or forgetful about basic hygiene
What to do:

• Start by asking in a friendly, nonaccusatory way, "Why not?" That will give you insights into how you can help. Fear of falling down? Water too hot or cold? A lack of awareness of his or her hygiene (could flag dementia)?
• Make sure the bathing process is comfortable, in a warm, safety-proofed bathroom that includes a shower chair and grip rails.
• Provide as much modesty and privacy as possible. It may be time to switch from showers to baths, or from baths to sponge-bathing. Allow the person to remain partially clothed (or robed) if that's more comfortable.
• Allow the person as much control over the process as possible; take care not to "baby." As much as is reasonable, let your loved one choose how to bathe.
• Find out how to help someone with Alzheimer's who refuses to bathe.

Won't use walker or cane

Possible causes:
Almost always, the device makes the person feel old or disabled and is therefore ignored.
What to do:

• Enlist peer pressure. It works at any age! The more your loved one sees others (especially those perceived as peers or younger) using assistive devices, the more normal they appear. Arrange chance "encounters" with a dapper, active, respected friend of roughly the same age who use a cane. Even watching movies set in locations when canes are commonplace (lots of foreign movies set in Europe, for example) can have a positive subliminal effect.
• Talk up the benefits. Canes and walkers are seen as symbols of disability. Remind your loved one that they actually promote movement, which will increase the odds of better mobility over time. They also reduce the odds of a fall -- which can cause serious injury and further limit mobility.
• Look for noninstitutional models. Many men prefer a sturdy, stylish wooden cane to an aluminum model, for example. Walkers also come in a variety of types; search online for walker or look at medical equipment companies.
• Try compromising. Maybe your loved one will use a walker in certain circumstances (shopping) but prefers to lean on a companion's arm in others (church).
• Supply the device wordlessly. Rather than nagging ("Get your cane!"), just provide it.
• Consider having a third party, such as a physical therapist or doctor, lay out the costs of ignoring a cane or walker.
• See a physical therapist's tips for encouraging someone who refuses to use a walker or cane

Won't change clothes

Possible causes:
Apathy, disinterest, depression, dementia
What to do:

• Ask yourself what the real problem is -- the clothes or your sensibility? If the person agrees to washing favored outfits regularly, the same outfit over and over is simply an aesthetic choice that may conflict with your ideas. If the clothes are filthy, that's another issue.
• When your loved one bathes, immediately put the clothes in the washer and start it.
• If your loved one prefers certain items, make them available in multiples and cull the closet of everything else. No harm done. (Hey, it worked for Steve Jobs.)
• Know that wearing the same clothes repeatedly is a common Alzheimer's behavior, the result of memory loss and impaired decision-making skills.

Apathetic; doesn't want to do anything

Possible causes:
Lack of opportunity, changing skill level, depression, dementia
What to do:

• Make sure your loved one has plenty of opportunities for social outings. It's easy to become a shut-in -- and therefore appear apathetic -- when you lack transportation, or when friends no longer call because they've moved, died, or are also suffering from health problems.
• Also be aware that some older adults lose interest in former activities because they can no longer participate in them the same way. For example, an artist may not want to paint anymore if holding a brush is painful or the results aren't as satisfying. Modify activities according to ability, if you can, or introduce related hobbies or outings that are more manageable (visiting an art museum, helping kids with art).
• If there are opportunities but your loved one doesn't want to partake -- ever -- be sure to look at possible underlying causes. Loss of initiative or interest in many things is a common early symptom of dementia, such as Alzheimer's. It's also a common sign of clinical depression. Treatment for these conditions can lift apathy.

Finicky eating

Possible causes:
Loss of appetite due to underlying illness, boredom, loss of taste, dementia
What to do:

• Focus on what your loved one likes to eat rather than your idea of perfect nutrition. Changing taste buds may make foods seem particularly bland. Unless there are strong medical reasons for a specific diet, once someone reaches a certain age and is losing weight, it's usually more important that he or she eats for pleasure and gets enough calories.
• Make available a variety of reasonably healthful high-calorie choices, such as puddings, shakes, smoothies, and cereal.
• Season liberally with herbs and other flavorings to make foods more enticing.
• Avoid nagging. Making a big deal about eating only sets up a battle of wills.
• Serve micro-meals throughout the day rather than the "big three." Your loved one may not feel like eating much at a single meal.
• Mention the behavior to the doctor, especially if new, to rule out a medical cause. Ask whether nutritional supplement drinks are appropriate.
• Realize that some older adults forget to eat because of memory problems. Find out how to solve eating problems common to people with Alzheimer's and other dementias.

Hoarding

Possible causes:
May have a compulsive disorder. Or may be bored or lonely and like to see, for example, the UPS man who delivers what's ordered from catalogs or the TV. Some people are simply pack rats who hang onto things for sentimental reasons. Hoarding can also be a symptom of dementia.
What to do:

• Focus on safety. Clear pathways of paper or boxes to prevent falls. Make sure countertops are clear enough so that essentials such as medications or the telephone can be found. Remove fire hazards.
• Surreptitiously clear refuse when the person can't see you. Getting rid of what seems like junk to you can be traumatic for the hoarder.
• Offer to take pictures of favorite objects and create an album, then box up these "extras" that there's no space for.
• Try introducing more activities to preoccupy your loved one, such as bingo, painting, woodwork, or even simple household tasks -- anything that occupies hands and mind.
• If the behavior is new or becoming extreme, mention it to a doctor. A mental health professional may be able to help in cases of true hoarding.

Argues

Possible causes:
Boredom (getting a rise out of others becomes a sport), habit, dementia (misperceives and can't be rationalized with)
What to do:

• Realize that your loved one knows better than most how to push your buttons! This can only be annoying to the extent that you let it get to you. Remind yourself that this is just the other person's coping mode; you can't always change it, but you don't have to take it personally.
• Tell yourself, "Here we go again," but avoid showing annoyance or bickering back and forth.
• Stay calm, but refuse to go further in cases where the issue is a necessity. For example, you can't drive the car unless she buckles up. You won't fix breakfast until he takes his medication. Explain that these are nonnegotiables.
• If your loved one has dementia, know that arguing is especially futile because the person is cognitively unable to follow rational thinking. Find out more about dealing with aggression and dementia.

Quick to anger

Possible causes:
Frustration over life in general, distress over a perceived wrong, personality changes due to dementia
What to do:

• Resist the natural impulse to feel defensive or yell back. You'll wind up in a downward spiral.
• Calmly tell your loved one that you can see he or she is upset about something (name it, if you know), and ask what it is and how you can help: "I can tell you're upset that the doctor didn't call back; what would you like me to do?" Feeling understood often defuses the anger. Then you can move to constructive solutions.
• If the verbal abuse continues, explain that you're willing to listen, but only if your loved one stops shouting at you. Be respectful but firm.
• Understand that an angry person usually sees the world as unfair, either because of an immediate wrong or a past one. Try verbalizing this by saying something like, "I know you don't think it's fair that the doctor doesn't respect your time. How can I help?"
• See more on how to handle a hothead.

Disrobes, walks around not fully dressed

Possible causes:
Typically, the root cause is disinhibition (loss of inhibition, or a loss of a sense of public versus private behavior), most often due to dementia. The person may be feeling nervous or sexual, and those feelings become translated into disrobing behaviors.
Other possible causes: Your loved one suffers from incontinence or is uncomfortable -- too hot, too cold, or sensitive skin is making clothing feel scratchy and uncomfortable.
What to do:

• Look for patterns. What's happening right before or after these episodes? Does it happen after eating (maybe the person has to use the bathroom and wants to be ready, so he unzips his pants)? Are you noticing other signs of forgetfulness? This can help you figure out the cause.
• Ignore the behavior to the best of your ability. Although disrobing isn't usually done to get your goat, your raging disapproval may only egg the person on.
• Try distraction: Move to another room or activity while casually covering the person up without comment.

Rudeness to aides and visitors

Possible causes:
Can be a sign of mild-stage Alzheimer's, as the person tunes out others while trying to valiantly focus on maintaining his or her own mental skills. A crotchety demeanor can also stem from his or her personality (especially if the person has always been like this), or from frustration or dissatisfaction with life.
What to do:

• Decide how excusable the behavior is: If the person has dementia, grant a wider berth than otherwise, while explaining this effect of the condition to aides and visitors.
• If dementia isn't involved, show some empathy but also recognize that the person should know better. Set boundaries about what's acceptable: "I know you hate being in the wheelchair, but I can't help you unless you're civil to Mr. Smith."
• Work to make sure your loved one feels some sense of control over his or her life. Sometimes rudeness is borne of feeling helpless. The person is unconsciously retaliating for a loss of control.
• Retrain your loved one by responding to kind words and acts and ignoring rude ones.
• Find out more about how to cope with rude behavior as a result of Alzheimer's disease

Paces restlessly

Possible causes:
Pacing is often an expression of boredom, agitation, or even insecurity. Shadowing (trailing you around the house) may be linked to dementia.
What to do:

• Look for a trigger. Does the pacing happen at a certain time of day? If it happens in late afternoon, it may be the result of boredom. Does it occur when certain people are around or certain events (such as bath time) are underway? That may flag anxiety.
• Consider going for walks together, playing music and dancing, or finding other forms of physical activity to help the person channel restless energy.
• Make sure favored pathways are clear of clutter or scatter rugs that can lead to tripping or accidental falls.
• Find out how to handle restless pacing and wandering in someone with dementia.

Resists help

Possible causes:
A reaction to loss of independence or control; dislike of a particular helper.
What to do:

• Show empathy. The person may be trying to maintain an illusion of independence by exerting one of his or her remaining powers, that of using the word no. Express that you understand and appreciate that it's difficult to need help.
• Be creative. Call an aide a "housekeeper." Find a personal assistant who also does hair, and pitch her services through that description.
• Get a persuasive third party involved. Your loved one may ignore your help but listen to the appeals of a neighbor, friend, clergyperson, or more senior relative.
• Extol the benefits. Help your loved one get past viewing help as being symbolic of loss by talking up what he or she will gain. "If you let me automate your bills, you'll probably make fewer errors and have more time for things you like to do, like reading." Or, "If an aide helps you with bathing, we won't argue so much over the way I do it, and that's a big plus for both of us."

Night waking

Possible causes:
Bladder or prostate problems, sleep apnea, sundowning or night waking due to dementia
What to do:

• Ask the person these five questions about insomnia to help you identify the problem.
• Mention the issue and the answers to the above questions to the person's doctor, to rule out or treat a medical cause.
• If waking to use the bathroom is the cause, cut back on liquids for three hours before bedtime. Avoid caffeine, which stimulates the bladder.
• Keep the path to the bathroom lit with nightlights -- so it's illuminated enough for safety without the full-on brightness of overhead lighting, which can disrupt the ability to return to sleep.
• Practice basic sleep hygiene for older adults.

Mixes up day and night

Possible causes:
Oversleeping during the day, boredom, dementia (sundown syndrome), a vision problem
What to do:

• Monitor the person's overall sleep habits. Are there lots of catnaps by day? Does he or she rise later and later, and then stay up later?
• Don't allow your household to fall victim to an older adult's topsy-turvy schedule. Minimize naps by day by waking your loved one and initiating an activity. Turn off the TV at night.
• Create an evening routine that helps flag that it's time for sleep. Include a snack that promotes sleep, such as warm milk; play gentle music; turn down the lights around the house.
• Don't keep a TV in your loved one's room if it's viewed all night. Keep the room dark and quiet to encourage sleep.
• Mention the problem to the person's doctor. You may be asked about other signs of dementia. In extreme cases, medication may be prescribed.
• See more tactics to ease the burden of sundown syndrome.

Won't take medicine

Possible causes:
May have "medication overload" -- balking at the sheer number of doses that must be swallowed in a day. May dislike the taste. May have trouble swallowing. May dislike being reminded of his or her health problems.
What to do:

• Start by going over, with the person's doctor, all medications and supplements taken. Ask if any can be safely eliminated or reduced.
• Find out if any medications can be given in alternate formulations. Some pills can be crushed or liquefied and concealed in foods (such as pudding, applesauce, or ice cream) or beverages. Always check with the doctor or a pharmacist first; modifying doses yourself is a potentially dangerous medication mistake.
• Try offering medications first thing in the morning when the person is still a little groggy and cooperative (for those meds that can be given on no food at that time).
• Have everyone in the household take his or her own pills (even if it's just a vitamin) together at the same time, to normalize pill-taking and reinforce the habit.
• Try not to nag, but do point out the benefits of each drug.
• See a geriatrician's perspective on how to handle someone's refusal to take medications.

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