3. Behavior Management
Alzheimer’s disease, as well as other dementias, are often described as progressing in stages . The stages can be described as mild, moderate, and severe, or early, middle, and late. Even though disease progression differs from person to person and varies depending on the type of dementia, we nevertheless associate certain symptoms and behaviors with these stages. The type of dementia, along with a person’s general health, co-morbid conditions ,* and family support can affect how fast and how far the dementia progresses.
*Co-morbid conditions: the presence of two or more medical conditions.
3.1 Symptoms and Behaviors Associated with Each Stage
Symptoms and behaviors are related but different. A symptom is a change in the body or the mind. Loss of memory is a symptom of dementia. Changes in judgment and logical thinking are also symptoms of dementia. Behaviors are actions—for example, biting, screaming, pacing, or hugging.
Depending on the type of dementia and underlying medical issues, symptoms and behaviors can gradually worsen over time. Behaviors can change gradually or suddenly, depending on the type of dementia, environmental factors, caregiver competence, medical issues, and the overall quality of care.
3.1.1 Symptoms and Behaviors in Mild Dementia
Mild cognitive changes, which have likely been developing for several years, affect memory, decision-making, and planning. Although a person living with mild dementia experiences forgetfulness, they can still perform all or most activities of daily (ADLs) and independent activities of daily living (IADLs). Shopping, cooking, yard work, dressing, bathing, and reading may be independent, or nearly so. These people may even continue to work but will likely begin to need help with complicated tasks such as balancing a checkbook and planning for the future.
In the early or mild stage of dementia, particularly Alzheimer’s dementia, forgetfulness and mild emotional changes are the most common symptoms. Although less obvious, logical thinking and judgment are also mildly affected.
At this stage, you will notice a little confusion with multi-step tasks, increased frustration, and a loss of interest in usual activities. People living with mild dementia understandably try to hide their confusion from friends, coworkers, and family. A person may begin to repeat questions over and over due to short term memory loss.
Even when symptoms are mild, behaviors can begin to change—especially with Alzheimer’s disease. People living with mild dementia know something is wrong. They may begin to feel stress and anxiety and worry about the future. Depression can become an issue as they struggle with changes in their thinking.
People living with mild dementia can occasionally become angry or aggressive. They often have increased difficulty making decisions. They will ask for help more often. They still might be able to work, drive, and live independently, but they will begin to need more help from family or coworkers.
3.1.2 Symptoms and Behaviors in Moderate Dementia
As Alzheimer’s disease progresses from the mild to moderate stage, plaques and tangles spread to the areas of the brain involved with language, judgment, and learning. Work and social life become more tiring and challenging. Speaking and understanding speech; the sense of where your body is in space; executive functions such as planning, logical thinking, safety awareness; and ethical thinking are affected. Many people are first diagnosed with Alzheimer’s disease in this stage.
In the moderate stage of dementia, behavioral changes are more obvious to family members and caregivers. Increased forgetfulness and confusion, difficulty with communication, and impaired (weakened) judgment and reduced logical thinking are common symptoms. Cursing, arguing, yelling, or hitting can develop at this stage, often due to unmet needs. Some people may repeat questions over and over, call out, or continually demand attention. Sleep problems, anxiety, agitation, and suspicion can develop.
Because the part of the brain that controls movement is not damaged, some people living with moderate dementia might wander. More direct monitoring (watching) is needed than during the early stage of dementia and people at this stage may no longer be safe on their own. Caregiver responsibilities increase, causing stress, anxiety, and worry among family members and caregivers.
3.1.3 Symptoms and Behaviors in Severe Dementia
My mom is a 96-year-old and has pretty severe dementia. She lives at home with 24/7 care. She would hate being in a nursing home and probably wouldn’t survive there for long. Loud noises, too many people around, people who don’t know her needs and habits, boredom, loneliness—all those things would drive her crazy. She likes to walk and I’m sure she’d wander, and probably swear, hit, or cry. At home she doesn’t do any of these things very often, but we work pretty hard to keep things quiet, warm, and consistent for her.
Family Caregiver, Miami, Florida
In the late or severe stage, damage is spread throughout the brain. Because so many areas of the brain are affected, individuals may lose their ability to communicate clearly, to recognize family and loved ones, and to care for themselves.
People with severe dementia can lose all memory of recent events although they often still remember events from the past. They tire easily, are unable to make decisions, are easily confused, and cannot think logically. Speech, communication, and judgment may be severely affected. Sleep disturbances and emotional outbursts are very common.
All sorts of challenging behaviors occur at this stage. Screaming, swearing, crying, shouting, loud demands for attention, negative remarks to others, and self-talk are common. These types of behaviors are often triggered by boredom, loneliness, depression, cold or heat, loud noises, or pain, and should not be shrugged off by caregivers.
Behaviors seen in the moderate stage will likely persist and worsen in the severe stage of dementia—especially if caregivers fail to determine the cause of the unwanted behavior. Wandering, rummaging, and hoarding are common behavioral issues. Some people, particularly those with Lewy body dementia, may become paranoid or experience delusions or hallucinations.
3.1.4 Symptoms and Behaviors at End of Life
Although you will use many of the same communications techniques you have already learned, a person living with dementia nearing the end of their life will probably be more challenging. Nonverbal communication skills are critical—especially if the person’s dementia is severe. This means you need good nonverbal communication skills but must also be able to understand and interpret your client’s nonverbal cues. All the things we take for granted and all the things we do to keep ourselves comfortable depend on the skill and compassion of caregivers.
To complicate things, some people living with dementia may refuse to take medications. Some may have problems swallowing a pill. Symptoms can change from day to day and a treatment that worked one day may not work the next day.
As a person living with severe dementia nears the end of their life, they may be nonresponsive or experience significantly reduced mobility. Caregivers and healthcare providers must closely monitor nonverbal cues that indicate pain or discomfort.
At the end of life, a person living with dementia may experience agitation, psychosis,* delirium ,** restlessness, and depression. Because of hearing and visual deficits, they can be startled by loud noises and quick movements. Communication may be entirely nonverbal: moaning, calling out, hitting, biting, and grabbing.
* Psychosis : loss of contact with reality.
** Delirium : a sudden, acute, and severe confusion that can be caused by infections, a reaction to medications, surgery, or illness.
3.2 The Problem-Solving Approach
The problem-solving approach encourages caregivers and family members to understand and address challenging behaviors by looking for the root cause of a behavior and treating it—usually by changing the environment, managing medication, and further caregiver training. The problem-solving approach identifies critical points for intervention based on observing the antecedent , behavior , and consequence (A, B, C) of a challenging behavior.
A ntecedent—what caused the behavior?
B ehavior—what is the behavior?
C onsequence—what are the consequences (outcomes) of the behavior?
The ABC approach is very effective when successful strategies are shared by staff, caregivers, and family members. It helps caregivers understand when, and how often, a behavior occurs and offers the opportunity for discussion and planning.
The problem-solving approach is also valuable for examining your own behaviors and responses to dementia. How you react and interact with a person living with dementia can have a profound effect on that person’s behavior. Understanding your own biases (personal viewpoints), frustrations, and triggers (what makes you behave in a certain way) will help you approach a person struggling with dementia with patience and compassion. When examining the cause of a difficult behavior, consider the following:
Does the behavior last all day?
Has the person’s behavior recently changed?
Has there been success dealing with the behavior in the past?
Is the person experiencing something that is treatable?
May the treatment or intervention affect the person’s functioning?
Is a treatment done for the convenience of the caregivers?
3.3 Strategies and Techniques for Addressing Challenging Behaviors
Caring for a person having cognitive and sensory changes due to dementia requires strategies and techniques that need to evolve as a person’s dementia changes. Family caregivers may not understand (or want to understand) that dementia is progressive (gets worse with time), and strategies and techniques that work with mild dementia may not work as the dementia progresses. Healthcare providers and care workers may fall into the same trap and must learn strategies and techniques that are effective for each person’s level of dementia.
There are certain strategies and techniques that are useful, no matter the type or stage of dementia. A problem-solving approach is useful because it encourages care providers to try to understand the root cause of an unwanted behavior while also considering how their own behaviors and responses might be affecting the person they are caring for. There are some behaviors that are commonly seen in people living with dementia, although they are certainly not universal or inevitable.
3.3.1 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. Instead, these reactions should be viewed as an expressive communication of a possible unmet need.
Teepa Snow, STOP Treating Behaviors with Restraining Medications
teepasnow.com
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 is a restless behavior that is excessive, inappropriate, and repetitive. It includes a wide range of behaviors. Aggression involves physically or verbally threatening behaviors.
Agitated and aggressive behaviors can include:
insulting caregivers
shouting, screaming, and loudly demanding
hitting, punching, kicking, pushing
throwing objects or using objects to hit or lash out
engaging in inappropriate sexual advances or obscene language
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.
Behavioral interventions, including searching for behavioral triggers (what touches off the behavior), remain the preferred management strategy for dealing with agitation and aggression (AGS, 2023). Psychosocial and environmental interventions can reduce or even end agitated or aggressive behaviors.
The use of antipsychotic medications should be a last resort and used only in collaboration with shared decision-making with older adults and their care partners. The 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults stresses the need to avoid medications for behavioral problems associated with dementia and delirium because their use is frequently associated with harm (AGS, 2023).
3.3.2 Dementia-Related Psychosis
Psychosis is surprisingly common in Alzheimer’s disease and can emerge as part of the disease process during the mild cognitive impairment (loss or weakness) stage or even earlier (Ismail et al., 2022). Dementia-related psychosis can include delusions, paranoia, and hallucinations.
A delusion is a false belief about reality. Paranoia is a type of delusion in which a person may believe 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.
Hallucinations occur when a person hears, tastes, smells, sees, or feels something that is not there. A person living with dementia might see or hear something they believe is real that exists only in their mind. For example, they may see someone outside their window, bugs crawling on the wall, or images of threatening people or things. One caregiver reported that her father saw the Wells Fargo wagon with horses on the wall opposite his bed!
Visual hallucinations sometimes occur in the moderate to severe stages of dementia and are particularly common in people living with Lewy body dementia. In 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 carefully reviewed.
Acute health issues such as urinary tract infections (UTIs) or environmental factors such as poor lighting or sensory overload can cause delusions and hallucinations. Changes in the brain also 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 an acute medical cause. Observing a person’s behavior and listening to what they have to say can help caregivers address the cause of the delusion or hallucination.
When communicating with someone who is experiencing paranoia or delusions, know that even if their complaint is not true, it is very real for that person . Do not argue; simply explaining the truth of the situation does not work. Do not buy into the paranoia or delusion; instead, try to respond to the person’s emotion. For hallucinations, it is often helpful to decrease auditory and visual stimuli, as well as to evaluate for visual or hearing impairment.
There may be times when caregivers and healthcare providers attribute a person’s complaints or anxiety to paranoia or delusion. But the claims by the person living with dementia may be real. For example, in a Florida nursing home, complaints of strangers entering several resident rooms and stealing items were attributed to dementia and psychosis by staff (including nurses and physicians). When the complaints increased, the facility installed cameras in the alley next to the facility. Several of the rooms facing the alley had malfunctioning locks on their sliding glass doors and the cameras showed that people were entering resident rooms at night and rummaging through residents’ drawers and closets. Theves really were entering the bedrooms of the residents and stealing items!
3.3.3 Wandering
Wandering and exploring are activities that almost everyone enjoys. But because a person living with dementia might be at risk of falls or injury, providers and caregivers often see wandering as a problem. For a variety of reasons, caregivers may want to control or prevent wandering. 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 behaviors vary depending on the person and the type and stage of dementia. It can involve repeatedly moving to a specific location, lapping or circling along a path, or pacing back and forth. 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 people living with dementia 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.
This person may not be able to find “home.” (Source: NIA, public domain).
3.3.4 Rummaging and Hoarding
A person who rummages and hoards gathers, hides, or puts away items in a secretive and guarded manner. These actions are considered a type of obsessive-compulsive behavior (OCD). Rummaging and hoarding are not necessarily dangerous or unsafe, but they can be frustrating for caregivers and other residents.
Memory loss, poor judgment, and confusion can contribute to rummaging and hoarding. People may rummage because they are bored or to find something they think has been misplaced. They may have a fear of being robbed or feel a need to protect their possessions. Rummaging through familiar items can create a sense of safety and security.
To address rummaging and hoarding behaviors, try to determine what triggers (touches off) the behavior. Look at the after-effects, 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.
Rummaging through another person’s belongings can be prevented by installing locks on drawers and closets. Caregivers who create a rummaging room, or a bag or drawer of items that the person can pick through, may find it useful. Restricting all rummaging and hoarding can be frustrating for a person who enjoys these activities.
In a home setting, 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 observe carefully to learn a person’s preferred hiding places.
Other recommendations:
Remove or lock up poisonous items such as caustic liquids and poisonous plants.
Label cabinets, doors, and closets with words or pictures.
Reduce clutter.
3.3.5 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).
When treating sleep disturbances, look for potentially treatable causes, such as pain, hunger and thirst, the need to urinate, infections, adverse drug reactions, and even noise. Non-drug treatments shown to improve sleep include:
light therapy
exposure to natural light
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
3.4 Alternatives to 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
A physical restraint is any manual, physical or mechanical device, material, or equipment attached to or next to a person’s body that the individual cannot remove easily, and which restricts the person’s freedom to move or reach their own body.
Chemical restraint is the use of medications (antipsychotic, antianxiety, antidepressant, or sedative) for the purpose of controlling or restricting a person’s behavior or movement. Unfortunately, decreasing the use of physical restraints has been linked to the increased use of chemical restraints (Cain et al., 2023).
Restraints affect a person’s sense of well-being. They cause feelings of low self-worth, depression, withdrawal, humiliation, and anger. They can also increase agitation and confusion, and cause deconditioning (failure to thrive), pressure ulcers, strangulation, and even death.
According to Florida law, patients must be free from physical or chemical restraints that are not required to treat a medical symptom. A restraint cannot be used for discipline or convenience. If a restraint is used, it must be the least restrictive alternative, for the least amount of time, and be regularly re-evaluated (FL Statutes, 2024).
Staff must complete a formal assessment on the risk of using a restraint to determine if a less restrictive method is safer. Medical problems such as temperature elevations, hypoxia (low levels of oxygen), hypoglycemia (low blood sugar), electrolyte imbalances, drug interactions, and drug side effects must be carefully considered. These issues can cause confusion, agitation, and aggressive behaviors (FL Statutes, 2024). They should be considered before resorting to restraints.
Restraints are not only limited to physical devices or chemical substances. They can include using (or threatening) force; also, restricting a person’s movements— even if they do not resist (Nuffield Council on Bioethics, 2009 latest available). Forced isolation (such as locking a person in their bedroom) is also a type of restraint.
Behavioral interventions are preferred for treatment of difficult behaviors associated with dementia. The decision to use or not use a physical or chemical restraint should always be made while including the patient and family members (AGS, 2023).
3.4.1 Types of Physical and Chemical Restraints
Physical restraints can include:
belts
mittens
soft wrist and ankle restraints
vest and jacket restraints
bedrails
geriatric chairs and recliners
wheelchair safety bars
lapboards
Physical restraints should not be considered a routine part of a falls-prevention program. There is no evidence that the use of physical restraint (including raised side rails) will prevent or reduce falls. Additionally, falls that occur while a person is physically restrained often result in more severe injuries. In fact, in some instances, reducing the use of physical restraints decreases the risk of falling (CMS.gov, 2024).
The use of chemical restraints is limited to prescribed dosages of medications authorized by a physician and must be consistent with the person’s diagnosis. Clients who are receiving medications that can serve as chemical restraints must be evaluated by a physician at least annually to assess (FL Statutes, 2024):
1. The continued need for the medication.
2. The level of the medication in the resident’s blood.
3. The need for adjustments in the prescription.
A provider may choose to prescribe an antipsychotic medication when symptoms are severe, dangerous, or cause undue distress to the patient. These medications may be effective in some cases. However, the provider must disclose to the patient 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 patient 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.
3.4.2 Alternatives to Restraints
There are many alternatives to the use of physical and chemical restraints. Some alternatives enhance safety and comfort for all residents, 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 person’s ability to move about safely, adjusting care and caregiver assignments to a client’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, prevents dashes to the bathroom that increase the risk of falls. Regular exercise, a comfortable place to rest, and a schedule for napping may 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 environment can reduce the need for physical restraints. Hallways, common areas, and client rooms 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.