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.