Dementia, a progressive condition affecting cognitive functions, is often accompanied by behavioural changes that affect both persons living with dementia and those around them. These changes in behaviour can be challenging to understand and manage, especially when they seem to emerge unexpectedly.
This is especially the case for disinhibited behaviours, which are characterised by actions that disregard social norms or boundaries and can range from inappropriate comments to physical aggression. Unlike other behavioural changes, disinhibition may be an uncomfortable topic for some due to the societal taboos surrounding it.
While potentially challenging to address, understanding the underlying causes and employing person-centred strategies can help persons living with dementia and caregivers like yourself navigate these difficulties with compassion and effectiveness.
Continue reading to find out more about disinhibited behaviours, uncover potential causes and triggers, and discover effective strategies for management. We hope these insights will empower you further in your caregiving journey.
Understanding Disinhibited Behaviours
Disinhibition is closely associated with the deterioration of brain regions responsible for decision-making, impulse control, and social appropriateness. These behaviours are especially evident when, the frontal lobe, which plays a key role in these functions, undergoes degeneration.
Loss of inhibitions is more common in certain types of dementia, such as frontotemporal dementia
Disinhibited behaviours in persons living with dementia manifest in various forms and can be verbal, physical or emotional in nature.
Types of Disinhibited Behaviours
1. Inappropriate social interactions or comments
(i.e. making rude remarks about someone’s appearance, asking intrusive questions, or engaging in inappropriate flirting.)
2. Undressing at inappropriate times or places.
3. Touching themselves (i.e. genital areas) in public spaces.
4. Impulsiveness, including reckless driving, cutting in line, or indiscriminately sharing personal information.
5. Verbal and physical outbursts which may involve shouting, cursing, or even physical confrontations with others.
Possible Causes and Triggers
Unmet Needs
Unmet needs, including physical discomfort, hunger, or the desire for social interaction, often play a significant role in prompting disinhibited behaviours. This is especially so amongst those who have trouble communicating their needs.
For instance, if they are feeling hot and uncomfortable, persons living with dementia may remove their clothing to cool down and address their physical discomfort. Alternatively, they may start touching their genitals or shout out loudly when they are feeling uncomfortable due to a wet or soiled diaper.
Other than physical needs, persons living with dementia also have psychological needs that should be addressed in order to care for their wellbeing. For example, some persons living with dementia may express their desire for intimacy and love by saying sexual comments or make sexual propositions, towards strangers. Read more about psychological needs in our article about Person-Centred Care.
Memory Loss
Memory loss is a hallmark feature of dementia, amongst others. The person living with dementia may lose the ability to recognise people and places, or forget how to perform familiar tasks such as bathing, putting on and removing clothes, and using the toilet. This may lead to inappropriate behaviours such as disrobing or urinating in public. There may be confusion regarding the people around them, such as misidentifying the domestic helper as one's wife, resulting in inappropriate sexual expressions towards the helper.
Medication Side Effects
Medications prescribed to manage symptoms of dementia may come with side effects that can impact cognitive function, mood, and physical well-being of persons living with dementia. For instance, a person experiencing insomnia as a side effect of Donepezil may find it challenging to maintain appropriate social boundaries due to fatigue and increased irritability. This could result in impulsive actions, such as making inappropriate comments or invading personal space.
Environmental Factors
Specific environmental factors can trigger or exacerbate disinhibited behaviours. For instance, crowded, bright and noisy environments such as busy shopping centres or social gatherings can be overwhelming for persons living with dementia. To cope, they may respond by covering their ears, yelling, or displaying physical agitation.
Responding to Disinhibited Behaviours
Responding to disinhibited behaviours involve addressing the specific incident as it occurs, focusing on the immediate needs and concerns of your loved one. The goal is to ensure safety, comfort, and emotional well-being in that particular moment.
Here are some key principles to keep in mind in your approach:
Stay calm and composed as much as possible. Avoid reacting with frustration or anger, as this can escalate the situation further. It is important to remember that, in moments like this, your loved one’s behaviour is a result of their condition and not a personal attack.
Take a moment to assess the immediate environment and identify any potential triggers that may be contributing to the behaviour. Look for factors such as noise, changes in routine, or unmet needs that could be causing distress.
Once you have identified the trigger, take immediate steps to address it. For example, if loud noises are causing agitation, move your loved one to a quieter area or reduce the noise level in their environment. Alternatively, if your loved one begins undressing in public, assess whether they may be experiencing discomfort due to clothing or environmental factors.
Prioritise safety for both the person living with dementia and those around them. If the behaviour poses a risk of harm, take steps to remove any immediate threats and ensure a safe environment.
If the behaviour poses no immediate harm to your loved one, ensure the safety and dignity of others involved. For instance, if your loved one is making inappropriate advances towards someone in the space, discreetly guide them to a private area to address the situation. Where feasible, you should clearly communicate boundaries in a firm yet respectful manner, and let them know that their behaviour is not acceptable. You might say ” Please stop. You should not touch others without their consent.”
Practice active listening and validation techniques to diffuse tense situations. Instead of arguing with your loved one, acknowledge their feelings even if their behaviour seems unusual to you or is inappropriate.
For instance, if your loved one becomes agitated and starts shouting during a family gathering because they are overwhelmed by the noise and activity, you might say “I know it is very noisy here, let me bring you to another room where it is quiet.”
If necessary, use gentle redirection techniques to shift your loved one’s focus away from the triggering stimulus or situation. Offer alternative activities or distractions that are calming and engaging such as listening to music, craft activities, or looking at family photo albums.
However, if the behaviour persists, especially if it is of a sexual nature such as masturbation, gently the person to a more private area. This allows for a discreet and respectful approach whilst still maintaining your loved one’s privacy and dignity.
Managing Disinhibited Behaviours
Identify triggers and patterns
Observing and identifying triggers that may potentially cause disinhibited behaviours is key. These triggers could be related to specific activities, changes in routine, unmet needs, or sensory stimuli. Understanding these triggers can help you anticipate and prevent potential escalations.
For instance, if your loved one has repeatedly tried to remove their clothing in public, it might be worth checking your loved one’s clothes. Are their clothes too tight or uncomfortable? Are they too hot for the weather outside? Once you have identified the problem, you can try different clothing solutions such as pants without zippers.
You could also consider keeping a physical journal or noting these down on your phone. Regularly recording such instances and responses can help you better understand patterns and implement strategies to mitigate such behaviours effectively. A sample entry could look like this:
Date and Time: January 15, 2024, 10:30 AM
Description of Behaviour: Raised voice, was verbally aggressive and became agitated during breakfast.
Location: Dining room.
Activity/Situation Before the Behaviour: Serving breakfast; asked to sit down at the table.
Triggers (if known): Change in routine, feeling rushed.
Response: Offered reassurance, provided gentle reminders about breakfast routine.
Outcome: Calmed down; finished breakfast without further incident.
Maintain Structure and Routine
Your loved one with dementia may feel disoriented and anxious when faced with sudden changes in their daily routine.
Establish a consistent daily routine that includes regular meals, medication times, and activities. Use visual cues such as calendars and clocks to help orient your loved one to the time of day and upcoming events.
By maintaining consistency and structure in their daily activities, you can help provide a sense of stability and security.
Encourage Meaningful Engagement
Engaging your loved one in activities that align with their interests, preferences, and abilities can foster a sense of purpose and connection. Research suggest that these activities help enhance their quality of life, foster a sense of identity, reduce frustration and promote feelings of accomplishment and belonging.
Find out more about meaningful activities here.
Create a Conducive and Supportive Environment
Create a calm and supportive environment by minimising noise, distractions, and environmental stressors.
This might involve turning down the volume on the television or radio, closing curtains to reduce outside stimuli, or dimming lights to create a more relaxing atmosphere. Keep a close eye on your loved one’s response to the changes you have made. Be prepared to make additional adjustments if needed and continue to provide support and reassurance as they navigate their environment.
If these behaviours tend to occur in the shower, you could consider making several physical enhancements to the bathroom. Find out how you can do so here. If the behaviours are sexual in nature, you could arrange for a care professional or someone else in the family of the same gender to help with the showering or bathing.
Coupled with these enhancements, communication is also an effective way of creating a calm and supportive environment for your loved one. It is best to communicate clearly with empathy, patience, and understanding. Find out how to effectively communicate with your loved one here.
Seek Help
If disinhibited behaviours persist or become challenging to manage, consider seeking guidance from healthcare professionals. They can offer additional support and intervention strategies tailored to your loved one’s needs.
Apart from professional help, it is also important to reach out to other family members and friends for support and assistance. Speaking with them about the nature of disinhibited behaviours and encouraging open communication can help create a supportive environment for both you and your loved one with dementia. This open dialogue fosters understanding and empathy, enhancing the overall well-being of everyone involved.
To find out more about how to get support, contact a Community Intervention Team (COMIT) or call Dementia Singapore’s helpline at 6377 0700.
Practise Self-Care
Caring for your loved one with dementia can take a toll on your emotional and physical well-being. Remember to prioritise self-care and seek support from family, friends, or support groups. Take breaks when needed and engage in hobbies or activities that promote your own well-being. Maintaining a balance and managing caregiver stress is essential for providing sustained care.
Tell us how we can improve?
- Disinhibited behaviours | Dementia Australia
- Managing Disinhibited Behaviour in Dementia.pdf (ntfgh.com.sg)
- Roland, K. P., & Chappell, N. L. (2015). Meaningful activity for persons with dementia. American Journal of Alzheimer’s Disease & Other Dementiasr, 30(6), 559–568. https://doi.org/10.1177/1533317515576389