How to Manage Challenging Behaviours in an Elderly Person with Dementia

When Grandma refuses to wash, when Father becomes aggressive at mealtimes, or when Mother wanders through the house at night, every family caring for a senior with dementia faces the same question: what did we do wrong? The short answer is: nothing. Difficult behaviours in dementia are not stubbornness or spite – they are ways in which the person is trying to communicate a need, a fear, or a discomfort they can no longer express in words.

Over 200,000 Romanians live with various forms of dementia, and every family providing care discovers, often through trial and error, that ordinary communication strategies no longer work. Moments of behavioural crisis can be emotionally and physically exhausting, but there are concrete techniques, grounded in an understanding of dementia, that can transform these situations from daily confrontations into calmer moments.

This practical guide offers you real tools to understand and manage difficult behaviours, whilst protecting your own wellbeing and preserving the dignity of your loved one.

Contents

1. What difficult behaviours in dementia are and why they occur
2. Non-pharmacological techniques you can apply at home
3. How to communicate effectively during a crisis
4. When behaviour becomes a medical warning sign
5. How to protect yourself emotionally and physically as a carer
6. Preventive strategies for reducing crises
7. Frequently asked questions

What difficult behaviours in dementia are and why they occur

Difficult or disruptive behaviours in dementia encompass a wide range of manifestations that go beyond a family's usual capacity to cope: constant agitation, verbal or physical aggression, repeated wandering, outright refusal of personal care, shouting, accusations, day–night reversal, or repetitive behaviours with no apparent purpose.

The reasons they occur are multiple and interconnected. As dementia affects the brain regions responsible for emotional regulation, memory, and orientation, the person gradually loses the ability to express their needs in conventional ways. Aggressive behaviour may signal physical pain that cannot be communicated verbally. Agitation may be an expression of confusion or fear in an environment they no longer recognise.

Common triggers for difficult behaviours

• Unmet physical needs: hunger, thirst, pain, the need to use the toilet, extreme fatigue
• Sensory overstimulation: loud noise, harsh lighting, too many people at once
• Changes to routine: sudden changes of carer, environment, or daily schedule
• Medication: some treatments can have behavioural side effects
• Infections or acute illness: urinary tract infections, severe constipation, dehydration
• Communication frustration: the inability to make oneself understood generates growing anxiety

Understanding that these behaviours always have a cause – even if it is invisible to us – is the first step towards empathetic and effective management.

Non-pharmacological techniques you can apply at home

Before reaching for additional medication, there are practical strategies that families can implement straight away. These non-pharmacological techniques respect the dignity of the person and reduce the risks associated with psychoactive medications in older adults.

Redirecting attention

When a person with dementia becomes agitated or fixated on an idea (I want to go home, I have to go to work), logical counter-arguments do not work. Instead, gentle redirection towards a pleasant activity can break the cycle of anxiety: suggest a walk, offer a familiar object to handle, play their favourite music, or start a simple activity together.

Validating emotions

The validation technique involves acknowledging the person's emotion without correcting their distorted reality. If your mother tells you she needs to visit her long-deceased parents, rather than painfully reminding her that they are no longer alive, validate the feeling: "You miss them very much, don't you? Tell me about them." Validation soothes, whereas correction worsens agitation.

Structured, predictable routine

A person with dementia feels safer within a repeated daily schedule. Structure the day around consistent reference points:

• Waking and going to bed at the same times
• Meals at regular intervals
• Fixed activities (the morning walk, coffee at 10 o'clock)
• Evening rituals that signal bedtime

Creating a calm and safe environment

The physical environment directly influences behaviour. Reduce background noise (television, radio), ensure good but not glaring lighting, remove hazardous objects whilst keeping familiar items that provide comfort. A simplified environment reduces confusion and, in turn, agitation.

How to communicate effectively during a crisis

Communicating with a person with dementia during a behavioural crisis requires a completely different approach from ordinary conversation. Tone of voice matters more than words – a person with dementia loses the ability to process things logically, but remains highly sensitive to emotional tone.

Principles for communicating during a crisis

1. Calm, positive non-verbal approach: approach slowly, from the front (not from behind), with open body language and a gentle facial expression
2. Quiet, warm voice: speak slowly, using short, simple sentences, and avoid a condescending tone
3. One instruction at a time: "Here's your coat" followed by a pause, then "Let's put it on" – do not overload with information
4. Offer simple choices: "Would you like the apple or the banana?" (not "What do you want to eat?")
5. Avoid "why" questions: replace "Why did you do that?" with "I can see you're upset – how can I help?"

What to avoid during a crisis

• Directly contradicting or reasoning logically
• Raising your voice or showing frustration
• Rushing the person or using physical force
• Taking accusations or insults personally
• Forcing eye contact if they are avoiding it

If the crisis escalates, the best strategy is to create physical and temporal space – step back to a safe distance, make sure the environment is safe, and allow a few minutes for the emotional intensity to subside naturally.

When behaviour becomes a medical warning sign

Not all difficult behaviours can be managed at home, and some require urgent medical attention. It is essential to recognise the warning signs that point to an acute medical problem, rather than simply the progression of dementia.

Consult a doctor urgently when

• Behaviour changes suddenly and significantly (for example, a calm person becomes extremely agitated overnight)
• Persistent physical aggression puts the person or their carers at risk
• Refusal to eat or drink lasts more than 24 hours
• Signs of physical pain appear: grimacing, moaning, guarding a part of the body
• Confusion and disorientation increase suddenly, or new or worsening hallucinations appear
• The person has a fever, difficulty breathing, or other physical symptoms

Urinary tract infections, for example, are a very common cause of acute behavioural changes in older adults with dementia – and are easily treated with antibiotics. Some medications can also interact and produce adverse behavioural effects. A geriatric specialist or neurologist can adjust treatment and rule out treatable medical causes.

When to seek specialist assessment

If difficult behaviours become constant, exhausting for the family, and risk the safety of everyone involved, it is time for a comprehensive multidisciplinary assessment. This may include a psychiatric consultation, neurological evaluation, review of current medication, and a personalised management plan. In some cases, home care with professional support, or placement in a specialist facility, becomes necessary for the wellbeing of everyone involved.

How to protect yourself emotionally and physically as a carer

Managing difficult behaviours on a daily basis takes an enormous toll on the family carer. Studies show that carers of people with dementia experience higher rates of depression, anxiety, and physical health problems. Looking after yourself is not selfish – it is an essential condition for being able to continue looking after your loved one.

Emotional protection strategies

• Accept your limitations: you cannot cure dementia, and you cannot control every behaviour – you can only do what is possible each day
• Distance yourself emotionally from accusations: when the person accuses you of theft or says hurtful things, it is the dementia speaking, not the person you love
• Seek peer support: carer support groups offer validation, understanding, and practical advice from people living through similar situations
• Allow yourself to feel frustrated: it is normal and human – find healthy ways to release those feelings (cry, write, talk to someone)

Physical protection and preventing burnout

Round-the-clock caring without breaks inevitably leads to complete exhaustion. Put these protective measures in place:

1. Schedule regular respite: a few hours each week when someone else takes over the caring – whether another family member or professional respite services
2. Maintain your own health: regular medical check-ups, adequate sleep, a balanced diet
3. Learn safe moving and handling techniques: to prevent back injuries when helping the person to move
4. Recognise the signs of burnout: chronic fatigue, emotional detachment, neglecting yourself – and ask for help immediately

There is no medal for the carer who carries on alone until they collapse. Support systems – whether professional home care services, day centres, or help from the wider family – are not a sign of failure, but of wisdom.

Preventive strategies for reducing crises

Whilst you cannot entirely prevent difficult behaviours, you can significantly reduce their frequency and intensity through preventive strategies applied consistently.

A behavioural diary

Keep a simple diary for one to two weeks, noting when difficult behaviours occur, what happened beforehand, the context (time, place, people present), and what helped to calm the situation. This diary can reveal invisible patterns: agitation occurs systematically in the afternoon when she is tired, aggression at bath time is linked to fear of falling, nocturnal wandering begins when she has slept too much during the day.

Meaningful daily activities

Offer the person with dementia simple activities that give them a sense of purpose and satisfaction: folding towels, arranging flowers, listening to music, looking through photo albums, short walks. Boredom and lack of stimulation can generate difficult behaviours out of sheer frustration.

Attending to basic physical needs

Proactively ensure that the person:

• Eats and drinks regularly (dehydration and low blood sugar affect behaviour)
• Has a regular toileting routine (bladder and bowel discomfort cannot be communicated)
• Gets enough sleep at night (extreme tiredness reduces tolerance to frustration)
• Has comfortable clothing, an appropriate temperature, and a comfortable position

Many behavioural crises can be prevented simply by proactively meeting basic physical needs that the person can no longer express verbally.

Frequently asked questions

My mother with Alzheimer's constantly accuses me of stealing from her – what should I do?

Accusations of theft are extremely common in dementia and reflect the loss of memory and logical reasoning. Do not defend yourself logically and do not get upset – validate the emotion ("I understand you're worried you can't find the box"), offer to help search for the item, and redirect her attention. Keep duplicates of important items that are frequently lost.

When my father becomes physically aggressive, how do I protect myself without hurting him?

The priority is the safety of both parties. Maintain a safe physical distance, use objects (a pillow, a blanket) as a protective barrier if necessary, and never attempt to physically restrain an agitated person on your own. If aggression becomes frequent and dangerous, consult a doctor urgently for assessment and specialist management, and consider training in de-escalation techniques for yourself.

Is it normal to feel guilty when I get angry at her behaviour?

Absolutely normal, and deeply human. Caring for someone with dementia is enormously emotionally demanding, and frustration, distress, or exhaustion do not make you a bad carer – they make you human. What matters is how you manage these emotions: acknowledge them, talk them through with someone you trust, and actively seek support before they become overwhelming.

How long does a phase of difficult behaviours in dementia last?

There is no universal answer – it varies enormously depending on the type of dementia, the stage of the condition, the triggers involved, and the effectiveness of the strategies applied. Some behaviours appear episodically and then fade, others become chronic but manageable, and others evolve as the dementia progresses. Regular medical review helps to adapt strategies along the way.

When is it time to accept that I can no longer manage at home on my own?

When the safety of the person or your own safety is constantly at risk, when your physical or mental health is seriously affected, or when you can no longer provide the quality of care the person needs – these are clear signals. Placement in a specialist facility or extensive professional home care services is not abandonment; it is an alternative form of care when needs exceed what the family can provide.

Can medication help with difficult behaviours, or is it dangerous?

Psychotropic medications (antipsychotics, anxiolytics) may be necessary in severe situations, but carry significant risks in older adults with dementia and must be used with great caution, at the lowest effective dose, and for limited periods. They are not the first line of treatment – non-pharmacological approaches should be tried first. The decision rests solely with the specialist doctor following a full assessment.

Conclusion

Managing difficult behaviours in dementia is a daily challenge that demands patience, empathy, and concrete strategies. You will not succeed perfectly every day – and that is all right. What matters is understanding that these behaviours always have a cause, that practical techniques can help, and that you, as a carer, deserve just as much compassion and support as the person you are caring for. If you feel the situation is becoming too much to handle, speak openly with your GP or a geriatric specialist – there are resources and solutions available, and asking for help is a sign of strength, not weakness.

This article is for informational purposes only and does not replace medical advice. For specific situations, please consult a specialist in geriatrics, neurology, or geriatric psychiatry.