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If this sounds familiar, know that “you are not alone,” says Cleveland Clinic Center for Geriatric Medicine Section Chief Dr. Ardeshir Hashmi. Behaviors like aggression, confusion, sleep problems, and wandering are common, but they can be managed, Hashmi says.

Read on to learn more about these common dementia behaviors in the elderly and to get Hashmi’s advice on how best to handle them as a caregiver — for your sake as much as that of your loved one.

Memory loss and confusion become more common as dementia progresses.

Memory loss can lead to confusion and confusion often manifests as a senior asking the same questions over and over, not recognizing formerly familiar people or places, or becoming disoriented. Caregivers who spend many hours with their loved one may hear phrases and answer questions on repeat: “I want to go home!” “This isn’t my house.” “When are we leaving?” “Why are we here?”

Common causes of confusion

Like many dementia behaviors, confusion can have a number of triggers or root causes. Factors that may contribute to disorientation include the following:

• Sundown syndrome or delirium. Up to two-thirds of dementia patients experience sundown syndrome, an evening behavioral shift characterized by increased memory loss, agitation, confusion, and anger. “It may not exactly happen at sundown, but there’s always this hour — the witching hour — where suddenly the same person may completely change,” Hashmi says.
• An unexpected change. Did your senior loved one just move to a new place? Did their routine change?
• Paranoia and hallucinations. Dementia leads to complex changes in the brain, which can result in delusion. Seniors may see things that aren’t really there, develop false beliefs, or become suspicious of caregivers and loved ones.

Tips for managing your loved one’s confusion

“Simplification is key here,” Hashmi says. To help minimize confusion, he suggests several ways to simplify both the home environment and your interactions:

Provide structure.

• Keep familiar objects around to help reorient your loved one.
• Label drawers and cabinets. This is especially helpful if confusion about where to find things is a common trigger.
• Use tools such as alarms, calendars, and to-do lists to help them remember tasks.

Deliberately use simple, short sentences and ask yes/no questions.

• Normalize their experience. Say, “You’re confused. It’s okay. We’ll figure it out together.”
• Lead with what you think might be happening. For example: “It seems like you’re looking for something.”
• It’s often much easier for your loved one to answer yes or no questions, instead of coming up with the words themselves. “Are you looking for your keys? Are you looking for your glasses?”

Lastly, Hashmi says, it helps if you can learn to accept the confusion. In the moment, he says, whatever your loved one thinks is real is in fact their reality. For example, they might think they’re at work when they’re really at home. If that belief isn’t hurting them or anyone else, it’s OK for you to play along a little bit. Confronting or trying to change the belief often leads to agitation and aggression.

“For us as caregivers, we have to be OK with that confusion,” Hashmi says.

Verbal threats and physical aggression can be among the more serious of the dementia behaviors. These verbal or physical outbursts may occur seemingly out of nowhere. They tend to happen in the latter stage of dementia, when patients can’t communicate their needs.

One study found that more than a third of caregivers reported abuse from a patient in the three months prior.

“I hear very palpably how upsetting that is, how distraught they feel,” Hashmi says of caregivers. “They are trying to make sense of it — ‘Why me? I’m the one who’s here for you? Why are you angry at me? I’m trying to help.’”

Common causes of aggression

Aggression can stem from:

• Confusion. When a senior is feeling disoriented and scared, they may act out with aggression.
• Physical pain or another unmet need. When a senior can’t verbalize or address needs such as hunger, thirst, or pain, it’s common for frustration to build, Hashmi says.
• Emotional pain. Sometimes, agitation can be a sign that someone with dementia feels lonely, depressed, or isolated.
• Discomfort with a specific task. Does aggression come out specifically at bath time, bedtime, or while your loved one is getting dressed? These tasks may be triggers for aggressive behavior.
• Reactions to medications. Has your loved one recently changed medications? Do they experience difficulties with medication management? This might be interfering with their dementia diagnosis, leading to aggression.
• Vision or hearing loss. Issues with vision or hearing can compound the typical disorientation of dementia and can cause seniors to act out in confusion or as a cry for help.
• Sundown syndrome. Does your loved one become aggressive around sunset in particular?
• Fear. People often are confrontational when approached or touched by someone they don’t know. For seniors with dementia, who may not recognize caregivers, doctors, and community residents, many daily interactions can alert a “fight or flight” response.

Tips for handling a senior’s aggression

Most importantly, try not to take the aggressive behavior personally, Hashmi says.

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“The classic line I always use is that this is the disease talking. It is not the person,” Hashmi says. “There is a lack of awareness in that moment. It’s not your mom or dad or spouse saying that. It’s the disease.”

When you are faced with a loved one’s aggression, Hashmi suggests employing these 4 Rs:

1. Reassure. It can be difficult to do in the moment, but start by reassuring your loved one. For example, Hashmi suggests you might say something like, “I’m here for you. I’m still here for you. It’s OK.”
2. Reorient. If they are disoriented, reorient them to their environment and with a familiar object. Say, “Look, we’re at home. Here’s a picture we have.”
3. Redirect. Redirect your senior toward a familiar object, anything that gives them joy and comfort. “It may be family photos, it may be a keepsake, it may be something that has great meaning and value to them,” Hashmi says. “It helps redirect and also helps reorient them.”
4. Reminisce. Help them connect to a long-term memory. E.g., “Remember when Joe was born?”

When they’re feeling calmer, Hashmi says, you can try asking yes/no questions to help determine whether an unmet need is causing the behavior. Ask: Are you hungry? Are you thirsty? Are you in pain? Are you tired?

While quality sleep tends to decrease as you age, people who have dementia experience more sleep disturbances than other seniors. In fact, sleep problems affect as many as a third of seniors with dementia.

Common sleep issues may include:

• Difficulty getting and staying asleep
• Agitation and restlessness when trying to sleep
• Thinking it’s daytime when it’s night, going as far as getting up, getting dressed and wanting to start the day, Hashmi says

Sleep disturbances are hard on patients and caregivers alike, Hashmi says. “It’s physically and mentally exhausting to be up night after night.”

Common causes of sleep problems in dementia patients

Troubled sleep is thought to be a dementia risk factor as well as a behavioral symptom. Here are some factors that may contribute to your loved one’s sleep problems:

• Brain changes. Dementia patients have steeper changes in their brain’s sleep architecture and their circadian rhythms, causing sleep disturbances.
• Over-the-counter medications. Some over-the-counter medications labeled “PM” can disrupt sleep by making patients sleep for a bit but then making them more confused or sleepy at the wrong time, Hashmi says.
• Diet. Caffeine, excess sugar (especially before bed), and alcohol can disrupt sleep patterns, Hashmi says.
• Electronic screens. The blue light from a computer, portable electronic devices, and television screens can delay sleep and disturb sleep patterns, Hashmi says.

Tips to help manage dementia sleep problems

There are ways to help your loved on get a better night’s sleep, Hashmi says.

Avoid things that disrupt sleep.

• Limit caffeine, alcohol, and sugar near bedtime.
• Avoid over-the-counter sleep aids. Instead, Hashmi suggests you talk to a doctor about whether melatonin might help your loved one sleep.
• Remove electronics from the bedroom.

Create a routine that supports sleep.

• Make sure your loved one gets enough daytime light to help with circadian rhythms.
• Change into comfortable clothing, signaling nighttime.
• Consider warm milk, a hot shower, relaxing music or reading before bed.
• Pick a bedtime — not too late — and stick with it every night.

Sixty percent of people who have dementia will wander. As their memory declines, they might leave a confusing situation or suddenly try to find someone and become disoriented and lost.

Such wandering can be dangerous, even life-threatening, yet caregivers often feel guilty for putting in place measures that will keep their loved one safe. The classic quandary that caregivers express is: “I don’t want my mom or dad or spouse to be a prisoner in their own home, and yet this is what I feel I’m doing,” Hashmi says.

Tips for managing dementia wandering

The No. 1 priority is to keep your loved one safe, Hashmi says. He suggests the following actions:

• Secure all doors. Be especially vigilant about doors that lead outside.
• Use technology. Tracking devices and surveillance systems are widely available and affordable.
• Enlist a team. Neighborhood watch groups and local police are often happy to help keep an eye out for your loved one.

In addition to aggression, confusion, sleep problems and wandering, symptoms of dementia can also include delusions, hallucinations, paranoia, depression, apathy and sexual inappropriateness. And, behavioral dementia symptoms tend to occur more frequently as the dementia progresses.

Up to 90% of patients have one or more of these symptoms during the course of their disease, studies show. It is important to discuss all dementia symptoms with your loved one’s physician to rule out or treat any medical conditions that could be causing the behavior.

Dealing with dementia behaviors can quickly wear out a caregiver or family member, causing caregiver burnout.

If your loved one’s dementia behaviors have progressed to the point where you cannot manage them alone, help is available. Senior care options like home care or memory care can help relieve some of the caregiving burden while also helping to keep your loved one safe.

If you are feeling resentment, anxiety, or depression, seek help. A caregiver support group, counselor, friend, or family member can offer camaraderie and advice.

“Other families, other caregivers, are going through the same thing,” Hashmi says. “They have a lot of common challenges and common solutions to share. And often those are the most effective, because they’re going through exactly the same process.”

A Place for Mom and Cleveland Clinic: Supporting seniors and their families

This article was developed in conversation with Ardeshir Hashmi, MD, section chief of the Cleveland Clinic’s Center for Geriatric Medicine, as part of a series of articles featuring expert advice from Cleveland Clinic geriatricians.

Sources

Alzheimer’s Association. “Dementia-related behaviors.”

American Psychological Association. “Living Well With Dementia.”

Johns Hopkins Medicine. “Facing Dementia in the Family.”

National Institute on Aging. “Alzheimer’s and Hallucinations, Delusions, and Paranoia.”

UpToDate. “Management of neuropsychiatric symptoms of dementia”

UpToDate. “Sleep-wake disturbances and sleep disorders in patients with dementia”

UpToDate. “Recognition and management of behavioral disturbances in dementia”

UpToDate. “Safety and societal issues related to dementia”

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