Vocally Disruptive Behaviour

Vocally Disruptive Behaviour (VDB) covers a range of vocalisation (both verbal and non-verbal) that may cause distress to others (Ahmed et al., 2021).

Some examples of VDB are (Dementia Collaborative Research Centre, 2012):

• Noises that seem purposeless and preservative
• Noises as a response to surroundings
• Noises intended to provoke a response from others

VDB tends to become more prevalent as dementia progresses (McMinn & Draper, 2005).  

There are various factors that can contribute to VDB. These factors can be interconnected with different triggers and various time periods. (McMinn & Draper, 2005):

Brain Changes and Language Deficits 

The stage of dementia is likely to be a significant factor. Psychosis, physical dependency, sleep disturbances, depression, and confusion, which are associated with the severity of dementia, may contribute to the complexity of VDB (Ahmed et al., 2021).

Certain changes in the brain may contribute to VDB as well. For example, damage to areas involve in understanding consequences, making decisions, and controlling behaviour may make it harder for a person to regulate their actions. (Von Gunten et al., 2008)

According to a study by Matteau et al. (2003), significant impairment in language skills in persons living with dementia is linked to a higher frequency of VDB and a wider variety of these behaviours, suggesting that VDB may happen because of communication challenges.

Expression of Discomfort or Suffering 

A person with late-stage dementia may experience reduced verbal communication, which can impact their ability to express physical discomfort that stems from pain, thirst, hunger, or uncomfortable room temperature (Khan et al., 2021). VDB is thus their way to express discomfort, which may go unnoticed or ignored. VDB could also be a response to mental or physical stimuli which are unsuitable or perceived as a threat by a person living with dementia (Matteau et al., 2003; Von Guten et al., 2008).  

Sensory Over- or Under-stimulation

Both over- and under-stimulation can contribute to VDB in persons living with dementia. Physiological changes resulting in sensory impairments, such as hearing or vision loss, make it challenging for social engagement such as karaoke and group conversations. Reduced opportunities for meaningful social interaction may result in under-stimulation and social isolation, leading to unmet needs for connection and engagement, which may then be expressed through VDB.

On the other hand, changes in the perception of sensory stimulation in persons living with dementia make them more sensitive to environmental stimuli, resulting in over-stimulation, thus VDB becomes a channel to express their discomfort (Ahmed et al., 2022). Busy or noisy environments can become overwhelming and lead to over-stimulation. For example, eating in a crowded and noisy restaurant may cause a person with dementia to feel distressed or uncomfortable. As cognitive changes may affect their ability to recognise or communicate these feelings, they may express their distress through VDB.

Persons Living with Dementia

Adverse consequences of VDB on persons living with dementia include increased anxiety and overwhelming distress. These can lead to social isolation and an over-reliance on medication if their caregivers are overwhelmed (Nwogbunyama et al., 2020), resulting in a reduced quality of life in social interactions and physical health.

Caregivers

Caregivers often feel helpless when faced with VDB as it disrupts their routines and increases emotional stress (Roberto et al., 2024). High caregiving stress and persistent VDB often then lead to caregiver burnout and institutionalisation of the persons living with dementia (Sefcik et al., 2018).

There are various ways to identify these behaviours. Below are some examples of assessment tools used to identify the presence of VDB in dementia (Dementia Collaborative Research Centre, 2012):

Revised Neuropsychiatric Inventory- Clinician (NPI-C) includes a subscale with eight items that quantify vocalisation behaviour, such as:

• Screaming – loud, high‑pitched vocal outbursts
• Shouting – forceful loud speech, often to gain attention
• Crying or yelling for help
• Moaning – prolonged low vocal sounds
• Groaning – deep, non‑verbal vocal sounds
• Repetitive calling out / verbal repetition
• Cursing or use of abusive language

Other disruptive vocalisations (non‑verbal or verbal sounds judged clinically disruptive)

• Typology of Vocalisations (TOV) scale
  • The TOV scale uses a five-point rating system to assess the frequency and characteristics of these behaviours: Verbal (e.g. singing or shouting) or non-verbal (e.g. groaning or howling)
  • The possible meaning or reason behind the behaviour (e.g. physical discomfort, hallucinations, or requests related to daily activities) Timing (constant, random, apparent pattern)
  • Level of disruptiveness

Non-pharmacological management is a practice that focuses on fulfilling unmet needs of persons living with dementia to reduce behaviour of concerns and to ensure that persons living with dementia have comfort and dignity (Ahmed et al., 2021).

Multi-sensory Environment

Multi-sensory environments can be beneficial in managing VDB. These environments can be stimulated either at the natural setting of the person or bringing them to a designated area or room that is separate from the rest of the house. If persons living with dementia presents with VDB in their natural setting and sensory activities (such as playing soft calming music or dimming the lights) do not reduce the behaviour, introducing dividers or partitions to reduce environmental sound or light stimulation could be considered as a potential solution (Lorusso & Bosch, 2017).

When in a multi-sensory environment, persons living with dementia should experience reduced VDB, and caregivers can follow their lead in activities. It is usually non-directive, for example enjoying music with eyes closed or tapping along to the rhythm of music. Activities should also focus on their senses rather than cognitive demands to support relaxation.

Namaste Care

Another method is Namaste Care, which is named after the Hindu greeting of ‘honouring the spirit within’. It aims to enhance the quality of life of persons with late-stage dementia. In addressing their emotional and psychosocial needs, sensory-based activities can reduce vocally disruptive behaviours.

Ideally, Namaste Care should be done twice a day, seven days a week (Salvi et al., 2025).

The two principles defining Namaste Care are (DementiaHub.SG, 2024):

1. Comfortable environment
2. Loving touch

Namaste Care is usually conducted in a small group setting and in line with Tom Kitwood’s psychological needs of persons with dementia:

• Establishing Routines

Personalised routines provide persons living with dementia a sense of predictability and familiarity. Starting the day with physical activities such as going for walks or joining exercise groups with family members or friends is highly recommended. These activities can provide a sense of achievement and fulfilment for persons living with dementia despite their cognitive changes (Telenius et al., 2022).

Even in the moderate to late stage of dementia, it is important to routinely include persons living with dementia in daily activities at home. The person-centred care principle, such as knowing their preferences is important in setting routines. However, being adaptable according to the mood and ability of the person also increases success of maintaining routines (Randall & Clissett, 2015).

Some activities that can be included are (Andersen et al., 2019):

• Food preparation: Washing vegetables before lunch or dinner time.
• Simple cleaning: Wiping table or washing cutlery after meals.
• Laundry: Folding and organising laundry.
• Listening to radio or music: Playing energetic music in the morning to signify the start of the day, and soothing music before bedtime to ease into sleep routine.
• Mealtimes: Having fixed mealtimes at the dining table with family members.

The inability for persons living with dementia to express their unmet needs and decreased engagement in activity can make it challenging for caregivers to understand the meaning behind VDB. Therefore, managing VDB often requires caregivers and professionals to work together to identify possible triggers of the behaviour. Such collaboration can help caregivers adapt and refine management strategies as their loved one’s dementia progresses.

Presenting Issues

Mdm Cynthia is 90 years old. Throughout the day, she repeatedly requests to go to the toilet. Her daughter tries to accommodate her requests and brings her to the toilet each time. However, shortly after returning, Mdm Cynthia asks to go again. Although her daughter has reminded her that she is wearing diapers, Mdm Cynthia continues to insist on using the toilet.

Enriched Model  

As mentioned above, Vocally Disruptive Behaviour or VDB is likely a form of communication especially when needs are unmet. Using Tom Kitwood’s Psychological Needs Model, we have identified the following unmet needs of Mdm Cynthia and the strategies to meet her needs.  

This case study shows that Vocally Disruptive Behaviour (VDB) is often a form of communication rather than simply a behaviour to stop. Mdm Cynthia’s repeated requests reflected a combination of physical discomfort, anxiety, memory changes, and unmet psychosocial needs. By taking a person-centred approach and understanding the meaning behind the behaviour, caregivers can better identify unmet needs and tailor strategies that promote comfort, engagement and overall wellbeing.