Changes in behavior occur in most people living with dementia. These changes are referred to as behavioral and psychological symptoms of dementia (BPSD) or neuropsychiatric symptoms of dementia (NSP).

Controlling and suppressing inappropriate behaviors is an important social skill that we practice every day. The loss of this ability—disinhibition—causes a lack of restraint, disregard for social convention, impulsiveness, poor safety awareness, and an inability to stop strong responses, desires, or emotions.

Managing difficult behaviors in a person living with dementia requires patience and compassion, and sometimes, the skill of a detective to uncover the cause of the behavior. Anyone who has worked with someone living with dementia is familiar with many of these difficult behaviors.

Although some behaviors are associated with brain changes, others are caused by frustration, loss of control, discomfort, pain, and the inability to communicate needs. In general, successfully managing challenging behaviors means:

• understanding what is causing the behavior
• creating a safe and comfortable physical environment
• learning how to divert the person’s focus to an object or activity
• encouraging regular physical activity

2.1 Common Symptoms and Behaviors Associated with Each Stage

A symptom is an internal change in the body or the mind. Symptoms change as a person’s dementia progresses and can often cause behavioral changes. For some people symptoms worsen quickly. For others, symptoms progress more slowly.

We associate certain symptoms and behaviors with stages. The type of dementia, along with a person’s general physical and psychological health, can affect symptoms and behaviors as much as the stage of a person’s dementia.

2.1.1 Mild Dementia

In early, mild Alzheimer’s disease, plaques and tangles appear in the part of the brain called the hippocampus, which is responsible for memory and learning. This part of the brain helps a person form and store recent, short-term memories. The hippocampus converts short-term memories into long-term memories by organizing and retrieving memories when needed.

The inability to recall something that just happened (short-term memory) is a common symptom in a person living with mild dementia. Spatial memory can also be affected. This means a person might get lost in a new environment, forget where they put things, and not be able to understand the layout of their surroundings. Logical thinking and judgment are often mildly affected.

In the early stage, a person can experience a little confusion with complex tasks. People naturally try to hide their mild confusion from friends, coworkers, and family, which can be tiring and frustrating.

Even when symptoms are mild, a person’s behavior can begin to change, especially in Alzheimer’s disease and some other types of dementia. People often know something is wrong, creating depression, stress, mood changes, and anxiety.

2.1.2 Moderate Dementia

As symptoms progress to the moderate stage, plaques and tangles spread forward to the areas of the brain involved with language, judgment, and learning. Many people are first diagnosed with Alzheimer’s or another type of dementia during this time.

In the moderate stage, work and social life becomes more difficult and confusion may increase. Damage affects the areas of the brain involved with:

• speaking and understanding speech
• logical thinking
• safety awareness
• judgment
• planning
• ethical thinking

At this stage, because of memory problems and confusion, for the person living with dementia, travel, work, and handling personal finances may become more difficult.

Behavioral changes become more obvious to caregivers. Inappropriate behaviors such as cursing, kicking, hitting, and biting can occur. Some people may begin to repeat questions, call out, or repeatedly demand your attention. Sleep problems, anxiety, agitation, and suspicion can develop.

A person with moderate dementia is usually still able to walk. This is because the part of the brain that controls movement is not affected. Wandering can become a safety issue. More direct monitoring is needed than during the early stage of dementia. A person may no longer be safe on their own.

2.1.3 Severe Dementia

In severe Alzheimer’s disease, because so many areas of the brain are affected, a person’s ability to communicate, recognize family members and loved ones, and care for self is severely affected. A person living with severe dementia is easily confused, indecisive, and often unable to communicate their needs clearly. Sleep disturbances, emotional outbursts, and frustration are very common.

All sorts of challenging behaviors can occur at this stage, especially if caregivers (including professional caregivers) are poorly trained, easily frustrated, or highly stressed. Bouts of paranoia, as well as delusions or hallucinations, can occur.

At this stage, a person living with severe dementia may wander, rummage, or hoard. Screaming, swearing, crying, shouting, loud demands for attention, negative remarks to others, and self-talk are common. These outbursts are usually triggered by unmet needs such as frustration, boredom, loneliness, depression, cold, heat, loud noises, or pain.

Inappropriate and impulsive behaviors are particularly common in someone with a type of dementia that affects the front part of the brain (frontotemporal dementia). For a person living with this type of dementia, socially inappropriate behaviors are common, together with perseveration*, loss of empathy, apathy, and cognitive inflexibility.

*Perseveration: repetition of a word, phrase, of thought. The inability to shift from one idea to another.

In the severe stage, a great deal of independence is lost, and around-the-clock care may be needed. Caregivers will likely need to oversee and directly assist with eating, bathing, walking, dressing, and other daily living activities.

2.1.4 Symptoms and Behaviors at the End of Life

At the end of life, many people living with dementia are completely dependent on caregivers. They often have trouble communicating their needs and desires using speech. They may become bedridden, or nearly bedridden.

Often there are complications such as immobility, swallowing disorders, and malnutrition. Because people at this stage are much less active than in earlier stages of dementia, there is an increased risk of developing acute conditions that can lead to illness or death. Pneumonia is a particular concern. It is the most common cause of death among older adults who have Alzheimer’s or other dementias.

At the end of life, it is likely that both short- and long-term memory are affected. Sensory changes such as loss of vision and hearing mean a person can be startled by loud noises and quick movements. Depending on the type of dementia, a person may experience agitation, psychosis,* delirium,** restlessness, and depression.

*Psychosis: loss of contact with reality.

**Delirium: a sudden, severe confusion that can be caused by infections, a reaction to medications, surgery, or illness.

2.2 General Problem-Solving Approach to Challenging Behaviors

Problem solving is an important skill for caregivers and healthcare providers to develop when working with a person living with dementia. Practicing compassion, reassurance, and active listening can reduce or even prevent agitation and other challenging behaviors. It can also reduce the use of antipsychotics and other medications used to manage challenging behaviors.

The “ABC” model emphasizes data gathering and problem-solving. This approach helps staff and caregivers understand when and how often a particular behavior occurs. It is particularly effective when successful strategies are shared by staff, caregivers, and family members.

The ABC Approach considers:

A (Antecedent) What caused the behavior?

B (Behavior): What is the behavior?

C (Consequence): What are the consequences of a behavior?

The ABC approach also encourages caregivers and healthcare providers to examine their own behaviors and responses. Understanding your own biases, frustrations, and triggers helps you to be patient and compassionate when you approach a person struggling with dementia.

2.3 Strategies for Addressing Common Challenging Behaviors

Caring for a person experiencing cognitive and sensory changes due to dementia requires training, strategies, and techniques that change as a person’s dementia changes. Because dementia is progressive, strategies that work with mild dementia may not work in the later stage of a person’s dementia.

Challenging behaviors can be addressed with proper staffing, pet therapy, social engagement, simplifying tasks, and good communication. Unfortunately, much of the frustration people living with dementia experience is due to negative environmental influences, including staff attitudes, behaviors, and care practices in addition to unmet needs, frustration, boredom, pain, or untreated medical or medication issues.

Although this is not all-inclusive, certain behaviors are common in people living with dementia. This can include agitation, aggression, psychosis, wandering, rummaging, hoarding, sleep disturbances, and apathy.

2.3.1 Agitation and Aggression

Agitation, aggression, and psychosis are labels on behaviors that are often caused by environmental or personnel approaches rather than being due entirely to the person’s brain changes. These reactions should be viewed as an expressive communication of a possible unmet need.

Teepa Snow, STOP Treating Behaviors with Restraining Medications

Agitation and aggression are among the most common and challenging symptoms in older adults living with dementia. These behaviors worsen a client’s daily functioning, increase the risk of injury, and increase the likelihood of hospitalization and long-term care placement. They also impose a significant burden on caregivers and healthcare providers (Lichwala et al., 2026)

Agitation has a range of causes. When a person is agitated, they are restless, worried, and unable to settle down.

Agitated behaviors can include:

• irritability and impatience
• pacing
• confusion
• loud demands, shouting
• using obscene language
• repetitive behaviors

Aggression involves physically or verbally threatening behaviors. Aggressive behaviors can include:

• hitting, punching, kicking, pushing
• throwing objects or using objects to hit or lash out
• engaging in inappropriate sexual advances or touching
• client-to-client aggression, verbal aggression

Agitated and aggressive behaviors often occur during personal care tasks involving close contact. A person may feel threatened or feel their personal space is being violated. Depending on the type and severity of a person’s cognitive changes, agitated and aggressive behaviors may become more pronounced as a dementia progresses.

To manage aggressive behaviors, staff and caregiver training are essential. Psychosocial and environmental interventions, and recognition of personal habits and patterns, can reduce or even eliminate agitated or aggressive behaviors.

Try the following tips to help manage these symptoms:

• Speak calmly and actively listen.
• Reassure the person that they are safe.
• Try to distract by offering an activity or chore.
• Reduce noise and clutter.
• Consider physical and medical causes.

Antipsychotic medications are often used to treat agitated and aggressive behaviors in people living with dementia. They should be used for the shortest possible time and only as a last resort.

2.3.2 Dementia-Related Psychosis

Dementia-related psychosis occurs when a person experiences symptoms such as delusions, paranoia, or hallucinations.

A delusion is a false belief or a misinterpretation of a situation. For example, a daughter might be confused with the person’s mother or the person living with dementia might accuse someone of stealing something they have misplaced.

Paranoia is a type of delusion in which a person may believe—without a good reason—that others are lying to them, being unfair, or are “out to get me.” A person may become suspicious, fearful, or jealous of other people. Paranoia can sometimes include caregivers, family, or friends.

Hallucinations can occur when a person hears, tastes, smells, sees, touches, or feels something that is distorted or not there. For example, they may see shadows, cats running through the room, or images of threatening people or things (Fischer, 2022).

Visual hallucinations can occur in the moderate to severe stage of dementia and are particularly common in people with Lewy body dementia.* While atypical antipsychotics are sometimes used off label to manage hallucinations, in a person with Lewy body dementia, antipsychotic medications can make hallucinations worse.

*Lewy body dementia: a type of dementia in which a person experiences cognitive decline, “fluctuations” in alertness and attention, visual hallucinations, and slowness of movement, difficulty walking, or rigidity (stiffness).

For a person with new onset of visual hallucinations, the number one cause is medication side effects. For this reason, all medications the person is receiving should be regularly and carefully reviewed.

Acute health issues such as urinary tract infections or environmental factors such as poor lighting or sensory overload can cause delusions and hallucinations. Changes in the brain can contribute to these behaviors, especially changes related to sensory awareness, memory, and decreased ability to communicate or be understood.

The first step in the management of delusions and hallucinations is to rule out delirium or another acute medical cause. Observing a person’s behavior and listening to what they have to say often helps a caregiver address the root cause of the delusion or hallucination.

When communicating with someone who is expressing paranoia or delusions, understand that the delusion is very real for that person. Do not argue or try to correct the person. Explaining the truth of the situation does not work. Do not agree or validate the paranoia or delusion—try to respond to the person’s emotion. For hallucinations, it is often helpful to decrease auditory and visual stimuli as well as evaluating the person for a visual or hearing impairment.

2.3.3 Wandering

Wandering and exploring are activities that almost everyone enjoys. But, because a person living with dementia might be at risk for falls or injury, providers and caregivers often see wandering as a problem and try to control or prevent this behavior. However, preventing a person from safely wandering creates other problems, such as boredom, loss of social interaction, stigma, loss of conditioning, pain and discomfort, and even skin breakdown.

Wandering can involve moving to a specific location, lapping, or circling along a path, pacing back and forth, or wandering at random. People may wander out of habit or because they are convinced something needs to be done. They may want to return home after work, cook dinner, walk the dog, exercise, or search for something they think they have misplaced. The most important goal is to prevent a person from wandering into unsafe areas, or eloping* from a home or facility.

*Eloping: When a person wanders away or leaves a facility or home unsupervised or unnoticed.

Wandering is a common behavior seen in people living with almost all types of dementia. Nearly 60% of people living with dementia will wander during the course of their disease. Wandering can happen at home or in the community. In institutional settings, wandering occurs in about 40% of clients (Anu et al., 2024).

Wandering can be more common in someone who has experienced stressful events throughout their life or a person who responds to stress by engaging in physical activities. People with an outgoing personality, who enjoy music, and who were socially active throughout their life are more likely to wander than less active, introverted people.

Managing wandering behaviors in a person living with dementia requires a thoughtful and creative approach. Understanding the reasons for wandering should include regular review of medications to make sure wandering is not the result of medication side effects, overmedicating, or drug interactions.

Address wandering by:

• redirecting a person to a purposeful activity
• providing safe, looping wandering paths with interesting rest areas
• installing rails and grab bars for safety
• providing regular exercise
• offering to wander with the person

Engaging someone in simple chores such as folding laundry or assisting with dinner can give them a sense of purpose and fulfillment. Electronic devices attached to the person’s ankle or wrist can be used to alert staff or family members when someone has wandered out of a designated area. Subjective barriers such as grid patterns on the floor in front of exit doors, camouflage, and concealment of doors and doorknobs can discourage a wanderer from exiting a building.

For a person in the later stage of dementia, especially someone who is unable to walk safely, lowering the seat on the wheelchair allows a person to wander safely by propelling the wheelchair with their feet. If the chair cannot be lowered, a “drop seat” can be installed, which has the added benefit of allowing the addition of a good-quality pressure-relief cushion. The wheelchair should be adjusted to equalize pressure wherever a person’s body meets the seat, back, sides, or cushion. Daily skin monitoring is essential.

Did you Know. . .

For people who wander away from their home or care facility, the immediate action is to call 911. Florida maintains a Silver Alert program for cognitively impaired older adults who become lost while driving or walking. The Silver Alert program is activated by law enforcement and broadcasts information to the public so they can assist in the rescue of the endangered person and notify law enforcement with useful information. For more information, contact the Silver Alert information line, local law enforcement, or the Florida Department of Law Enforcement, either online or by phone, at 888 356 4774.

2.3.4 Rummaging and Hoarding

Rummaging and hoarding are behaviors in which a person gathers, hides, or puts away items in a secretive and guarded manner. Rummaging and hoarding are not necessarily dangerous or unsafe, but these behaviors can be frustrating for caregivers.

Hoarding is associated with insecurity, fear, and anger and may be an attempt to hold onto possessions and memories from the past. A person might hoard because they fear losing money or possessions. They may feel a lack of control or a need to “save for a rainy day.”

Memory loss, poor judgment, and confusion contribute to rummaging and hoarding. Rummaging through familiar items can create a sense of safety and security. Confusion can lead to rummaging through another person’s belongings, which can be particularly frustrating for them.

To address rummaging and hoarding behaviors, try to determine what triggers the behavior and look at the consequences, if any. The reason for rummaging and hoarding may not be clear to you but there may be a perfectly good reason why someone living with dementia is rummaging.

The rummaging impulse might be satisfied by creating a rummaging room or a bag or drawer of items that the person can pick through. Rummaging through another person’s belongings can be prevented by installing locks on drawers and closets. Restricting all rummaging and hoarding can be frustrating for a person who enjoys these activities.

For a person living at home, place important items such as credit cards or keys out of reach or in a locked cabinet. Consider having mail delivered to a post office box and check wastepaper baskets before disposing of trash. Look for patterns and carefully observe the person’s hiding places.

In facility settings, reduce clutter and label cabinets, doors, and closets (with words or pictures). Poisonous items should be stored away from common areas in locked cabinets.

Rummaging and hoarding are obsessive/compulsive behaviors. A person who feels a strong need to rummage or hoard can be remarkably persistent, secretive, and patient, making it difficult for caregivers to address this conduct.

2.3.5 Sleep Disturbances

More than half of people living with dementia experience some sort of sleep disturbance due to comorbid medical conditions and environmental factors. Common sleep problems include insomnia, fragmented sleep, obstructive sleep apnea,* rapid eye movement sleep behavior disorder,** and restless legs syndrome. Individuals may have trouble falling asleep or staying asleep due to altered circadian rhythms*** and increased confusion during the night (Mukherjee et al., 2024).

*Obstructive sleep apnea: a syndrome caused primarily by the collapse of the upper airway during sleep.

**Rapid eye movement sleep behavior disorder: a sleep disorder in which individuals physically and/or vocally act out vivid, often unpleasant dreams and sudden, involuntary arm and leg movements during REM sleep.

***Altered circadian rhythms: disruption in the body’s sleep-wake cycle.

Comorbid medical conditions that can affect sleep in older adults living with dementia include:

• cardiovascular disease
• diabetes
• depression and anxiety
• thyroid disorders (hypothyroid and hyperthyroid)
• untreated or poorly treated pain

In 2024, the Center for Medicaid and Medicare Services (CMS) published guidelines that require non-pharmacologic interventions for sleep disturbances must be tried and documented before using sedatives or psychotropic medications in a person living with dementia (CMS, 2024).

Non-pharmacologic treatments can include (Mukherjee et al., 2024; CMS, 2024):

• cognitive-behavioral therapy for insomnia
• minimizing environmental disruptions (reducing nighttime noise and excessive light).
• avoiding stimulating activities close to bedtime
• encouraging good sleep hygiene (a regular bedtime routine and a warm comfortable sleeping environment)
• restricting caffeine, nicotine, and alcohol

In addition to affecting the health and quality of life of the person living with dementia and their caregivers, sleep disturbances can contribute to some challenging behaviors. CMS requires that sleep disturbances be evaluated when a person exhibits agitation, anxiety, wandering, or changes in cognition. This includes looking for potentially treatable causes such as pain and discomfort, hunger and thirst, the need to urinate, infections, and adverse drug reactions.

Sleep disturbances can lead to “sundown syndrome,” a set of symptoms or behaviors that emerge in the late afternoon or early evening. Managing sundown syndrome involves a combination of environmental, behavioral, and medical interventions. A consistent daily routine, regular physical activity, soothing and familiar activities in the late afternoon, and a calm and comfortable environment can improve sleep and decrease sundowning (Mukherjee et al., 2024).

Benzodiazepines, which have a hypnotic sedative effect are currently the most widely prescribed medications for sleep disorders in older adults. Despite their widespread use, concerns remain regarding their potential for tolerance, dependence, and adverse effects such as cognitive impairment (especially in older adults) (Chavez-Mendoza, 2025).

Benzodiazepine dependence has been associated with severe depression and anxiety and impaired cognitive and psychosocial function. In older adults, increased sensitivity to benzodiazepines can increase the risk of confusion, disorientation, and falls (Chavez-Mendoza, 2025).

Recently, non-benzodiazepine hypnotics, commonly known as Z-drugs, have been suggested as effective alternatives due to their similar mechanism of action. They may improve sleep quality, lower dependency risks, and reduce adverse effects compared to benzodiazepines (Chavez-Mendoza, 2025).

Importantly, sleep disturbances can contribute to some challenging behaviors, particularly anxiety, increased confusion, wandering, and sundowning. Sundown syndrome is the emergence or worsening of neuropsychiatric symptoms in the late afternoon or early evening. It has long been recognized as an aspect of dementia and is well known among most of healthcare providers involved in the care of persons with dementia.

Treating sleep disturbances involves looking for potentially treatable causes. This includes treating pain and discomfort, hunger and thirst, the need to urinate, infections, and adverse drug reactions.

Non-pharmacologic treatments that can improve sleep include:

• light therapy
• exercise and individualized social activities
• caffeine, nicotine, and alcohol restriction
• comfortable beds with enough pillows for back and neck support
• good temperature control in rooms
• noise reduction

2.3.6 Apathy

Apathy is a lack of interest or emotion, loss of motivation, indifference, and a blunting of emotions. It is one of the most common neuropsychiatric features of dementia, affecting 50% to 70% of people with the condition (Baber et al., 2021).

The presence of apathy in people with Alzheimer’s disease is associated with increased functional impairment, a greater likelihood of rapid functional decline, and a lower self-reported quality of life. It is also associated with poorer performance in basic and instrumental activities of daily living, more rapid disease progression, and increased mortality (Dolphin et al., 2023).

Apathy is often under-recognized, under-diagnosed, and poorly managed. Caregivers often find it frustrating when it appears that a person living with dementia can do a task but simply does not bother or will only do so with strong encouragement (Baber et al., 2021).

Non-pharmacologic interventions are the first choice to treat apathy and other challenging behaviors associated with dementia. Four approaches are recommended (Oba et al., 2022):

• Behavior-oriented approaches.
• Emotion-oriented approaches (reminiscence therapy, validation therapy, and supportive psychotherapy).
• Cognition-oriented approaches (reality orientation and skills training).
• Stimulation-oriented approaches (recreational activities, group art therapies, exercise, and music therapy).

Regular one-on-one personal contact tailored to a client’s particular skills or interests has also led to improvements in apathy in people with dementia (Dolphin et al., 2023).

A review on pharmacological treatments for apathy in various dementia types showed no convincing proof for the effectiveness of any drug treatment. A meta-analysis failed to find a significant treatment effect for apathy in favor of any drug (Theleritis et al., 2023).

2.4. Physical and Chemical Restraints

When—if ever in the eternal dementia care merry-go-round of staff shortages, budget limitations, regulatory approvals, mandates, or penalties—will we focus on the people we are supposed to be serving without turning first to medications?

Teepa Snow, STOP Treating Behaviors with Restraining Medications

The Omnibus Budget Reconciliation Act of 1987 (OBRA 87) established a resident’s right to be free of physical or chemical restraints in nursing homes when used for the purpose of discipline or convenience and when not required to treat the resident’s medical symptoms. Uncooperativeness, restlessness, wandering, or unsociability are not sufficient reasons to justify the use of a restraint (GovTrack, 2020).

Use of restraints should be (GovTrack, 2020):

• reserved for documented indications
• time limited
• frequently re-evaluated for their indications, effectiveness, and side effects

In most states the use of physical and chemical restraints on nursing home patients is illegal. In Florida, the Nursing Home Bill of Rights states that a nursing home resident has

. . . the right to be free from mental and physical abuse, corporal punishment, extended involuntary seclusion, and from physical and chemical restraints, except those restraints authorized in writing by a physician for a specified and limited period of time or as are necessitated by an emergency. In case of an emergency, a restraint may be applied only by a qualified licensed nurse who shall set forth in writing the circumstances requiring the use of restraint, and, in the case of use of a chemical restraint, a physician shall be consulted immediately thereafter. Restraints may not be used in lieu of staff supervision or merely for staff convenience, for punishment, or for reasons other than resident protection or safety (Florida Statutes, 2025).

2.4.1 Physical Restraints

A physical restraint is any manual method, physical or mechanical device, material, or equipment attached to or adjacent to a person’s body that the individual cannot remove easily and which restricts freedom of movement or normal access to one’s body.

Physical restraints can include:

• chair belts, any belt restraint
• mittens, limb restraints
• soft wrist and ankle restraints
• vest and jacket restraints
• bedrails, bed sheet restraints
• geriatric chairs and recliners
• wheelchair safety bars or locked tables
• lapboards

Use of physical restraints can cause agitation, confusion, deconditioning, pressure ulcers, strangulation, suffocation, and even death. Restraints affect a person’s sense of well-being, causing feelings of low self-worth, depression, withdrawal, humiliation, and anger. The use of physical restraints in older adults is considered a violation of their human rights.

Restraint can include using (or threatening) force or restricting a person’s movements—even if they do not resist. Forced isolation (such as locking a person in their bedroom) is also a type of restraint.

A restraint-free environment should be the standard of care and goal for adult day care facilities. Restraint reduction programs can significantly reduce the use of restraints. Healthcare providers can lead the way by educating themselves about the dangers of restraints and sharing this knowledge with family caregivers.

Person-centered care focuses on practices that respect the dignity of each individual. Collaborating with family members and the person living with dementia allows the development of an individual care plan that addresses issues that affect a person’s safety and wellbeing.

The use of physical restraints can be reduced or eliminated by creating an environment that is friendly toward older adults, embraces aging with compassion, promotes safe mobility by making the physical environment accessible to people with disabilities, and caters for the needs of older people (Atee et al., 2023).

2.4.2 Chemical Restraints

The term chemical restraint refers to the use of antipsychotic, antianxiety, antidepressant, or sedative medications for the purpose of controlling or restricting a person’s behavior or movement. Unfortunately, a decrease in the use of physical restraints has been linked to the increased use of chemical restraints (Cain et al., 2023).

In 2023, the American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults stressed the need to avoid antipsychotics and other medications for behavioral problems of dementia and delirium because their use is frequently associated with harm (AGS, 2023).

Between 2011 and 2019, psychotropic drugs* were prescribed to about 80% of nursing home residents. Higher use of psychotropic drugs was associated with nursing homes with lower ratios of registered nurse staff to residents. Nursing homes with a higher percentage of low-income residents were also associated with higher use of these drugs (OIS, 2022).

*Psychotropic drugs: antipsychotics, anticonvulsants, mood stabilizers, and central nervous system agents.

Behavioral interventions are the preferred management strategy for treatment of challenging behaviors associated with dementia. The decision to use or not use a chemical restraint should always be made in collaboration with the client and family members (AGS, 2023).

A provider may choose to prescribe an antipsychotic medication when symptoms are severe, dangerous, or cause significant distress to the client. These medications may be effective in some cases. However, the provider must disclose to the client and family that the medication is being used off label* meaning a drug has not been approved by the Food and Drug Administration (FDA) for treatment of behavioral symptoms of dementia. The provider must obtain permission from the client or family member to use these drugs for behavioral symptoms of dementia.

*Off label: prescribing medications for an unapproved indication, age group, dose, or form of administration.

2.4.3 Alternatives to Restraints

There are many alternatives to the use of physical and chemical restraints. Some alternatives practices enhance safety and comfort for all clients, such as increasing staffing levels, removing hazards, providing safe areas for walking, and training staff on how to identify and respond to unmet needs (CANHR, 2025).

Other alternatives include adapting and tailoring chairs to improve comfort and safety, using pads and pillows to support comfortable and safe body positions, providing therapy and restorative care to improve a resident’s abilities to move safely, adjusting care and caregiver assignments to a resident’s preferences, and using low beds and floor padding to safeguard against harmful falls from bed (CANHR, 2025).

Establishing a routine, including a toileting schedule, improves comfort and reduces challenging behaviors. Regular exercise, a comfortable place to rest, and establishing a schedule for napping also help. On a regular basis:

• Address hunger, thirst, and discomfort.
• Review medications for adverse effects.
• Treat all underlying causes, including pain.
• Assess hearing and vision.
• Relieve impaction.

An uncluttered, home-like environment reduces the need for physical restraints. All areas, both in the home and in a facility, should be free of equipment and obstacles. Providing wall rails, grab bars, and transfer poles in rooms, bathrooms, hallways, and common areas promotes independence and reduces caregiver stress and worry.