Responding to Behavioural Changes Archives - DementiaHub.SG

Managing Anxiety

shekinah — Wed, 11 Jun 2025 00:57:24 +0000

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Anxiety is common in persons living with dementia and can make daily life challenging. This article explores the causes and symptoms of anxiety in persons living with dementia and provides practical tips for caregivers to support their loved ones.

For persons living with dementia, anxiety often intensifies, making daily tasks and interactions harder. Anxiety is more commonly experienced by persons with Vascular Dementia or Frontotemporal Dementia (FTD) Understanding how anxiety affects them and learning how to manage it can greatly improve quality of life for both the caregiver and the person living with dementia.

Causes of Anxiety

Sometimes, persons living with dementia may display anxiety due to neurological and psychological factors. Some common causes of anxiety are listed below:

Neurological Factors

Damage to parts of the brain that involve emotion regulation:

As dementia progresses, it can affect areas of the brain that are responsible for processing emotions.

Cognitive decline:

Difficulty with memory, and spatial orientation may create fear and anxiety.

Psychological Factors

Fear of the future:

In the early stages of dementia, individuals may become anxious about their future.

Confusion and disorientation:

In later stages of dementia, anxiety may stem from feeling lost or an inability to recognise familiar faces.

Other Contributing Factors

Pain or Discomfort such as physical ailments or hunger:

Physical ailments or even hunger can trigger anxiety in persons living with dementia.

Medications:

Certain medications used for persons with dementia can have side effects that increase anxiety.

Trauma or Past Mental Health Issues:

A history of trauma, abuse, or pre-existing anxiety disorders can make individuals more vulnerable to anxiety.³

Anxiety in persons living with dementia can look different depending on the stage of the condition. In the early stages, anxiety can be due to concerns about the future and the fear of how the condition may worsen. However, in later stages of dementia, anxiety is typically rooted in confusion about the present, such as an inability to recognize one’s surroundings.

Symptoms of Anxiety

It is important to recognise signs of anxiety in persons living with dementia. These symptoms vary based on the individual’s stage of dementia and overall health.

Common symptoms may include:

Restlessness or fidgeting
Irritability or frustration
Rapid heart rate or trembling
Insomnia
Increased confusion
Feeling constantly ‘on edge’

Supporting Your Loved Ones with Anxiety

Establish a Calm and Predictable Environment

A consistent routine can reduce uncertainty and anxiety. Try to keep daily activities, such as mealtimes, dressing and bathing times predictable and minimise any major changes in the environment. If changes are needed, introduce them gradually. This can help your loved one feel safe, which can reduce anxiety.

Reassurance and Validation

When your loved ones with dementia expresses anxiety, do acknowledge their feelings without judgment.

Gently acknowledge their anxiety: “We understand you’re worried, and we’re here to help.”
Keep your tone calm.
Redirect their attention by using activities they enjoy, like arts or games, to reduce anxious emotions.

Physical Exercises

Accompany your loved ones for regular physical activities, such as walking or gardening to reduce feelings of anxiousness. Encourage them to take part in group sessions, such as dancing or singing.

Relaxation Exercises

Consider guiding your loved ones to participate in relaxation activities, such as arts and crafts or music. Include mindfulness activities in their routines to reduce anxious emotions.

Watch this short mindfulness video to learn simple breathing techniques that can help ease anxiety.

Mindfulness Exercise for Stroke Survivors and Caregivers [English Version]

Source: Agency for Integrated Care

This video demonstrates a 10-step mindfulness exercise customised for stroke survivors, but is also suitable for anyone with affected mobility to manage stress. It takes only 15 minutes to complete all the practices in the video.

Seek Professional Help

If anxiety becomes unmanageable, consult a healthcare provider to adjust care plans or explore medication options.

It is important to note that these strategies may generally be more effective for persons living with early to middle stages of dementia. Your loved one may also want to try complementary and alternative therapies. This can include aromatherapy, acupuncture, or massage therapy.

Do consult a doctor first before participating in any of these therapies.

Adapted from Alzheimer’s Society and DementiaUK.

Conclusion

Managing anxiety in loved ones can be challenging but with patience and the right strategies, you can help reduce anxiety and improve the quality of life for you and your loved ones.

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Alzheimer’s Society (2025). Anxiety and Dementia. https://www.alzheimers.org.uk/about-dementia/symptoms-and-diagnosis/anxiety-dementia.
Barrell, A. (2020). Stress vs. anxiety: How to tell the difference. Medical News Today. https://www.medicalnewstoday.com/articles/stress-vs-anxiety
Dementia UK. (October, 2022). Managing anxiety and depression in a person living with dementia. https://www.dementiauk.org/information-and-support/health-advice/managing-anxiety-and-depression-in-a-person-living-with-dementia/

What is Person-Centred Care?

Admin — Fri, 06 Sep 2024 01:23:22 +0000

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Person-centred dementia care aims to enhance the wellbeing of persons living with dementia by meeting their psychological needs, which maintains personhood.

An Introduction to Person-Centred Care

Source: Agency for Integrated Care

This video covers the five psychological needs which person-centred care aims to meet and shows scenarios of ways in which person-centred care can be applied.

Seeing each person living with dementia as a person who
- Is valuable
- Has their unique history, routines, personal preferences, and needs
- Experiences the world in their own way
- Sees the social relationships that the person has as important for their wellbeing
Improving and taking care of the person’s level of wellbeing by taking care of these things.

This is different from the medical model of care, which:

Sees the person living with dementia as only a medical patient who requires treatment from healthcare professionals;
Focuses on keeping the person clean and safe from injury and harm;
Does not consider the person’s unique history, routines, personal preferences;
Ignores the psychological needs of the person.

What is the goal of PCC?

To maintain personhood in the face of a person’s declining mental powers.

How is this goal achieved?

By meeting the 5 areas of psychological need that each person experiences.

Tom Kitwood’s Flower of Psychological Needs shows the needs that each person, including persons living with dementia, has. These needs are: Comfort, Attachment, Inclusion, Occupation, Identity, and Love.

While caring for persons living with dementia, we can aim to meet these needs.

What happens as these needs are met?

The person feels loved.
The person’s entire sense of self-worth will be enhanced.
The person will be more likely to experience a sense of personal control and empowerment.
There will be an improvement in the physical and psychological wellbeing of the person.

10 Key Principles of PCC according to Tom Kitwood

A non-judgemental acceptance of the uniqueness of each person.
Respect for the past experiences and learning of each person.
Recognising the whole person as having emotional, social, physical and spiritual needs.
Staying in communication requires flexibility, lateral thinking, and acceptance of other viewpoints.
Nourishing attachments means ensuring people feel welcome and included.
Creating a feeling of community gives us a sense of belonging, of where we fit in and what is expected of us.
Maximising freedom for people to contribute to their care and eliminating unnecessary controls.
Allowing ourselves to receive from others and valuing what they give (in other words, allowing the person with dementia to contribute in some way to the care environment, as far as they are able).
Building and maintaining an environment of trust – protect from bullying, exploitation and other abuses of power.
Focusing on positives – on people’s abilities and what they can do.

Person-Centred Care in Dementia by Alzheimer’s WA

Find out how to apply the person-centred care approach in everyday life with persons living with dementia.

Through this online course, you will learn about dementia and gain insights into its impact on individuals and caregivers, and how adopting a person-centred dementia care approach can enhance the wellbeing of persons living with dementia by meeting their psychological needs.

You can conveniently access the course from any device, including mobile phones and tablets, allowing you to learn at your own pace, anytime and anywhere.

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Tips for Managing Disinhibited Behaviours

aleene.chow — Wed, 10 Apr 2024 16:08:32 +0000

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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:

Remain Calm

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.

Assess the situation

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.

Ensure Safety

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.”

Acknowledge and Validate Feelings

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.”

Distract and Redirect

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 move 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.

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When to Consider Moving into a Nursing Home

aleene.chow — Mon, 11 Mar 2024 00:17:03 +0000

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Caregivers want their loved ones to live in the environment most comfortable to them, which is usually home. However, circumstances might call for a person living with dementia to move into a nursing home if their needs cannot be met at home. Find out more about when you might need to consider having your loved one move, and how you can support them throughout the process.

If the primary caregiver can no longer provide care that the person needs to live well
If the person with dementia lives alone, but requires additional care that is too costly or difficult to access from home because they are wheelchair or bed-bound
If community services are unable to meet their needs adequately
Safety concerns when the caregiver is unable to cope with severe behavioural and psychological symptoms of dementia (BPSDs) or sundowning experienced by the person living with dementia

Allied healthcare professionals may advise a change of living arrangement with the following considerations, in order of priority:

1. Medical health of the person living with dementia
2. Psychoemotional needs of the caregiver (whether the caregiver’s ability to cope with stress, maintain personal relationships and quality of life is impacted by the current caregiving arrangement)
3. Functional status (ability to carry out activities of daily living) and the safety of the person living with dementia
4. Socio-economic considerations

Sudden changes in the person with dementia or the caregiver’s health may require the person living with dementia to change living arrangements. It is hence best to prepare for these situations ahead of time and select the best nursing home for your loved one’s needs by discussing their long-term care plans with them while they still retain mental capacity.

Who makes the decision to move?

The decision should always be left to the person living with dementia, as long as they have been assessed to retain mental capacity. This means that they are judged to still be capable of making important decisions. They must be able to understand information and weigh options, as well as communicate their decision. However, if the person living with dementia has lost the mental capacity required to make this decision, the Lasting Power of Attorney (LPA) donee can make this decision on their behalf. If the person living with dementia has not appointed anyone as their LPA donee, health and social service professionals can advise their next-of-kin on this decision. If a person living with dementia no longer has mental capacity and has lost contact with their next-of-kin, then a professional body may be appointed as the donee. They are then referred to as a public trustee.

For more information about the Mental Capacity Act, please refer to the Code of Practice.

Code Of Practice – Mental Capacity Act
Source: Office of the Public Guardian

The code of practice elaborates on the Mental Capacity Act, especially in how it is applied to actual situations. It helps professionals, paid caregivers, informal caregivers, family and friends of the person understand their roles and responsibilities under the act to safeguard the interests of the person lacking mental capacity.

It is common for caregivers to feel worried about the changes that living with a loved one with dementia may bring. Many also feel guilt over the decision to move their loved one into a nursing home, even when it is in their loved one’s best interests.

How should the move to a nursing home be carried out?

Your loved one will go through a period of adjustment when they enter the nursing home. Nursing Home Respite Care is a service which offers short-term care for persons living with dementia, and can range in duration from several days up to a maximum duration of one month. Although this is mainly meant to provide respite for caregivers when they are temporarily unable to provide care, it may be a good way to see how your loved one responds to the care environment in a nursing home and for families to ease into the change. To be eligible for respite care options, your loved one must meet some minimum criteria:

- Has moderate to high nursing care needs
- Must have a discharge care plan after the end of the respite care period (they must have a permanent place of stay they can return to)
- Application requires medical records

Often, the application to a nursing home is done through communication with a social worker. As part of the application, a needs assessment will be conducted to assess your loved one’s fit for respite or nursing home programmes, as well as a family conference to hear the opinion of everyone involved. You can find out more about the application criteria here.

You or any authorised caregiver also needs to provide your loved one’s recent (dated no earlier than six months from submission of the application) medical report, which must include the following:

Diagnosis

Clinical History

Current functional status

Required nursing procedures

Drug allergy history (including list of currently prescribed medications)

Cognitive and behavioural symptoms (if applicable)

Results from a chest X-Ray (negative for infectious disease)

COVID-19 vaccination information (full vaccination status required)

You can also use your loved one’s hospital discharge summary if they were discharged within the past six months of application. All of these documents can be provided by your loved one’s primary physician.

Nursing homes will prioritise applications based on your loved one’s fit for criteria. Some nursing homes have specialised dementia wards for those who are mobile but may have behaviours that make them unsuitable for general wards. Priority is usually given to wheelchair- or bed-bound seniors for public nursing homes. For private nursing homes, anyone can apply.

You can speak to a care consultant at AIC Links to find more information about making the change in living arrangement. Alternatively, you can speak to a medical social worker at a polyclinic during your loved one’s scheduled doctor’s visits.

Addressing your loved one's needs during the move

Your loved one will be quite limited in the number of personal possessions they are able to bring into the nursing home when admitted. Often, they are only allotted one wardrobe, or even simply a drawer for personal clothing. They are also not able to bring pets with them, which is another consideration if your loved one is very attached to a family pet. Wherever possible, you should also consider whether the faith and language preferences of your loved one match the nursing home you are applying to. There are several nursing homes affiliated with faith-based organisations.

After the move, speak to the person living with dementia to find out how they feel about the move as early as possible. Many seniors experience relocation stress when moving into a nursing home, although the adjustment period is different for everyone. Some nursing homes also have support groups for family and friends of the home’s residents, which may help if you are feeling anxious over the decision. Talk to the care home nurses/staff about your loved one’s life history and interests. You can still remain actively involved in your loved one’s care even after they move into a nursing home.

Moving from the Nursing Home back to home
You or any authorised caregiver also needs to provide your loved one’s recent (dated no earlier than six months from submission of the application) medical report, which must include the following:It is uncommon for persons living with dementia to transfer from the nursing home back to the home setting. In the case that occurs, the caregiver/guardian should have a conversation with the care team at the nursing home as part of discharge care planning. You may also arrange for an occupational therapist to make a home visit and recommend necessary changes to make the home safer for your loved one. If you are considering moving your loved one back home, you may apply for home leave from the nursing home so they can adapt to the change. Under home leave, residents from a nursing home are temporarily discharged to stay at home.

For more information on the support services available, contact a Community Outreach Team (CREST).

Financial support for application to nursing homes

Nursing homes can be very expensive. Before subsidies, the average cost per month is $4,000 for public nursing homes. Singaporean citizens and Permanent Residents are eligible for between 10-75% subsidy for nursing homes depending on monthly household income per person. A table of subsidy levels can be found on the Ministry of Health’s website.

Other Financial Support

- Moderate/mild disability: Pioneer Generation Disability Scheme
- Severe disability: Interim Disability Assistance Programme for the Elderly/ElderFund, MediSave Care, Pioneer Generation Disability Scheme

You can find a more detailed list of financial schemes here.

Other options

It is always best for persons living with dementia to age in place whenever possible. If your loved one does not require nursing care but have high care needs, there are several services that can offer the support they need for daily activities of living, including:

If they have difficulty with a few ADLs, You can apply for an Integrated Home and Day Care (IHDC) package, which combines different home-based and centre-based care services suited to your loved one’s needs. If you provide care for your loved one at home with the aid of a domestic worker, you are also eligible for the Home Caregiving Grant and Migrant Domestic Worker (MDW) Levy Concession in addition to the schemes listed under Other Financial Support above.

You may also consider assisted living facilities, such as St. Bernadette’s Lifestyle Village or Red Crowns Assisted Living. These facilities are communal living spaces that offer the services mentioned above including housekeeping. It is intended for those who require assistance with ADLs but not nursing or medical care, and can offer residents more independence and privacy compared to a nursing home.

If your loved one is living alone and prefers to continue to do so, you can arrange for befriending services or for a community nurse to make regular visits. You can also get your loved one connected to a Community Case Management Service (CCMS) team for care coordination. The CCMS provider depends on the region of your loved one’s residence, so you can speak to an AIC care consultant to find out more or get a referral from your loved one’s GP.

You can also apply for the Home Monitoring System (HoME+) by the Singapore Red Cross, which is a non-invasive system that uses motion sensors and a panic button to monitor your loved one’s safety and assist them in cases of emergency. However, this service requires you to have a Wi-Fi network set up in your home. Wait time from the point of application for HoME+ can take up to six months.

Singapore Red Cross HoME+

HoME+ helps seniors living on their own, through a helpline and a monitoring, alert and response system for home safety. It offers 100% privacy (no CCTV), and empowers the elderly with greater freedom and security in their own homes. The system features 2 motion sensors, 1 door sensor, 1 gateway and 1 duress button, entirely supported by a call center, community responders and Red Cross’ ambulance services.

Additional Resources

FINDING A NURSING HOME | Connecting Caregiver Tips

For those caring for persons living with dementia, choosing a nursing home may become an eventual necessity.

Patsy Chia was a caregiver to her mother for more than 10 years. She narrows down the factors in finding a nursing home for your loved one, and how families can provide care and concern even if their loved one is not living at home.

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Why Do Behavioural Changes Happen?

Admin — Tue, 25 Oct 2022 10:04:41 +0000

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Dementia is accompanied by behavioural changes, which affect your loved one living with dementia and all of you around him/her. Behavioural changes can be one of the aspects of dementia that are most difficult to address. Persons living with dementia who experience behavioural changes are often described as having a “completely different personality” from their “old self”. Different behaviour changes occur at different points in mild and moderate stages of dementia, and vary between people and across different types of dementia.

These are some common behaviours exhibited by persons in the mild, moderate, and advanced stages of dementia that vary from person to person:

Mild Dementia

⇒ Forgetting things

⇒ Occasionally repeating themselves

⇒ Isolating themselves from others

⇒ Feeling tired all the time

⇒ Being easily irritated

Moderate Dementia

⇒ Getting lost in familiar places

⇒ Repeating things said

⇒ Problems with communication

⇒ Neglecting personal hygiene and self-care

⇒ Losing track of time & events

⇒ Misplacing items more frequently

⇒ Behavioural disturbances

⇒ Forgetting the names of common objects and familiar people

⇒ Forgetting important events, e.g. birthdays of their children

⇒ Being confused about timings and places

⇒ Poor or decreased judgement

⇒ Problems with abstract thinking

⇒ Swallowing problems

Advanced Dementia

⇒ Losing mobility and ability to perform daily tasks

⇒ Losing ability to communicate

⇒ Food refusal

⇒ Swallowing problems

Sometimes, behavioural changes during mild and moderate stages of dementia can cause concern. Some examples of behaviours of concern that are commonly seen include:

Aggression

Agitation

Being easily upset

Being easily irritable

Being prone to argue

Inappropriate screaming or crying

Refusal to shower or be groomed

Running away from home

Disinhibition

Sexually inappropriate behaviour

Socially inappropriate behaviour

Hoarding

Irregular Night-time Activity (Sundowning)

Getting up at night

Repetitive Behaviours

Sundowning

Anxiety or excessive worry

Apathy or indifference

Delusions and/or hallucinations

Depression

Misidentifying familiar people

Personal Stories

What My Grandmother Was Trying To Say

In this video, Dr. Chen Shiling, who cared for her late grandmother living with dementia, tells us how she has learnt to understand what her grandmother was trying to communicate through many trying episodes and her grandmother’s behavioural changes, which included her making wrongful accusations, wandering behaviour, and depression.

Dr. Chen Shiling is a Resident Physician at Khoo Teck Puat hospital. She was raised by her grandmother who had dementia.

Source: ForgetUsNot Initiative by LIEN Foundation, Khoo Teck Puat Hospital, & Dementia Singapore

Where Is My Money?

Episodes involving accusations, arguments, and tension are trying and stressful for family members. Unfortunately, these situations are common in households with persons living with dementia. In this video, Lily tells us her secret to always being able to ‘find’ missing money that has been misplaced by her mother-in-law.

Lily Phang is a caregiver and co-founder of Homage, a caregiving service. She helps her family to cope with the symptoms and behavioural changes that her mother-in-law, Tan Mui Hua faces.

Source: ForgetUsNot Initiative by LIEN Foundation, Khoo Teck Puat Hospital, & Dementia Singapore

Causes of Behaviour Changes

Every individual has needs that need to be met. However, as dementia affects the brain which controls all mental functions and voluntary behaviours including thoughts, emotions, and speech, the progression of dementia may cause your loved one to be increasingly less able to recognise their needs, know how to meet them, or communicate them. In addition to this, behaviour changes also occur due to changes in the brain. The type of behaviour change exhibited depends on the areas of the brain affected by the condition causing the person’s dementia as well.

It is also crucial to understand these behaviours from the perspective of your loved one living with dementia. They may present with these behaviours as a result of their needs not being met, their attempt to meet a need, or an attempt to communicate to individuals around them.

Unmet needs underlying behaviour changes can be generally categorised into the following four factors:

1. Physical Needs: Your loved one living with dementia may be experiencing pain or discomfort, and may be suffering from other illnesses at the same time.

2. Psychological/Cognitive Needs: Your loved one may be depressed or may have other mental health issues. They could also be feeling confused or threatened in an environment that does not seem right or familiar.

3. Social Needs: Your loved one may be feeling lonely, isolated, or bored.

4. Environmental/External Needs: Your loved one may be in an overstimulating environment (e.g., with loud noises or busy environment), or experiencing a different and unfamiliar routine.

Management of Behaviour Changes

When managing your loved one’s behaviours, it is important for you, as a caregiver, to ascertain some factors that may cause certain behaviours to happen. For example:

• What triggers the behaviour: Consider commonly unmet needs, such as constipation, pain, and toileting needs, or environmental triggers such as sounds, smells, and temperature.

• Whether the behaviour is causing distress to the person: If so, prompt treatment may be necessary.

• Whether the safety of the person is compromised: If so, some modifications to the home setting may need to be made to ensure that the environment is safe.

For every behaviour change, it is always good to share the above information you have collected and consult the doctor (geriatrician or psycho-geriatrician) who is seeing your loved one with dementia to rule out any physical health problems (for example, infections, medication side effects) that may be causing it. After ruling these problems out, non-pharmacological approaches should be first attempted to meet your loved one’s unmet needs and minimise or prevent their behaviour changes, before considering pharmacological management.

It is often the daily, non-pharmacological methods and techniques that turn out to be effective in the long-term. Non-pharmacological measures such as psychosocial interventions (e.g., music therapy, art therapy) are usually the first-line approach before medication treatment is considered. Below are some examples of simple, non-pharmacological techniques to consider as well:

1. Revise your approach. The task on hand may be too difficult that it needs to be simplified, or your loved one living with dementia may need some help with it. Help them to focus on their abilities, rather than on their inabilities.

2. Validate your loved one feels. Acknowledge your loved one’s feelings and experience, and patiently communicate this acknowledgement to them by your words and actions. Do not confront or argue – it is not necessary to always correct the person when they are in the wrong.

3. Direct their attention elsewhere. Identify the cause behind the behaviour and address it through engaging your loved one in meaningful activities.

Sometimes, a combination of both non-pharmacological and pharmacological managements may offer better outcomes too. Read further about the Pharmacological Management of dementia and behaviour changes.

Some Tips to Manage Behaviour Changes

In the fifth episode of a 6-part series “All About Dementia – Ask the Experts”, Dr Ng Wai Chong explains why persons living with dementia have changes in their behaviours. He also answers questions related to strategies in managing these behaviour changes, such as wandering behaviour, repetitive behaviour, refusal to take medications, and refusal to eat.

Source: Agency for Integrated Care

The Alzheimer’s Society from the United Kingdom provides general tips to family caregivers on ways to support persons living with dementia to meet their needs and reduce their behaviour changes using a non-pharmacological approach. It also lists a five-step strategy to manage behaviour changes. Read further about Alzheimer’s Society’s tips and strategies.

Finally, it is not easy managing the behaviour change(s) your loved one living with dementia is exhibiting. It is thus equally important that you take good care of yourself by seeking support from family, friends, counsellors or support groups, in order to better cope with your caregiving journey. Learn more about tips and resources on how to look after yourself.

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Additional Resources for Other Behaviour Changes

Admin — Thu, 08 Sep 2022 07:02:47 +0000

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1. Talking Point | CNA Insider

Looking after a loved one living with dementia can be frustrating. In this episode of Talking Point, it provides you with some tips on what to do when you face the following 3 scenarios – when your loved one living with dementia:

Refuses to bathe
Forgets that he/ she has eaten and keeps demanding for food
Accuses you or others of stealing

Source: CNA Insider

2. UCLA Alzheimer’s and Dementia Care Video series

The Multicampus Programs in Geriatric Medicine and Gerontology (MPGMG) at the David Geffen School of Medicine at UCLA created a series of videos on understanding and managing behaviours associated with dementia.

Every video scenario shows:

The common response that family caregivers give in order to manage the behaviour change exhibited by their loved ones living with dementia;
An expert’s explanation about the behaviour change, with tips to identify and minimise the triggers and suggestions for redirection; and
The recommended response (incorporating the tips) that family caregivers can show instead to better manage the behaviour change.

This site also provides a Take Action worksheet that allows caregivers and care professionals to record what they can do to minimise the triggers of the behaviour changes.

Watch the UCLA Alzheimer’s and Dementia Care Video series now.

3. Fact Sheets Developed by Overseas Dementia Associations

There are other behaviour changes that a person living with dementia may exhibit. For each of the following list of behaviour changes, there are overseas resources which:

Define each behaviour change;
Detail their possible causes and underlying unmet needs; and
Suggest some plausible strategies to manage them at the time and when the behaviours have passed (to prevent the behaviours in future).

Please note that this is not an exhaustive list of resources. Click on the logos to access the fact sheets and websites for further reading.

Anxious Behaviours

Restlessness

Refer to Pg. 8

Refer to Pg. 94-105

Apathy

Refer to Pg. 6

Refer to Pg. 106-117

Depression

Refer to Pg. 7

Disinhibited Behaviours

Hallucinations & Delusions

Ooi, Yoon, How & Poon, 2018

Hallucinations

Delusions

Hallucinations

Accusing

Paranoid Thoughts

Hoarding

Repetitive Behaviours

Repetitive Behaviour

Trailing, Following & Checking

Repetitive Behaviour

Repetitive Phone Calls

Repetitive Questions

Ooi, Yoon, How & Poon, 2018

Resistance to Activities of Daily Living (ADLs)

Refusal to Bathe

Refusal to Take Medications

Sleep Disturbances

Ooi, Yoon, How & Poon, 2018

Vocally Disruptive Behaviours

Refer to Pg. 8

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Managing Wandering Behaviour

Admin — Thu, 08 Sep 2022 07:02:37 +0000

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Many persons living with dementia feel the urge to walk about and in some cases leave their homes. Though it is sometimes termed as “wandering”, it is rarely ever aimless. Persons living with dementia may simply not remember where they had set out to go, or what they had intended to do.

It is all right for persons living with dementia to walk around in a secure environment (for e.g., in their own homes or at day care centres), with supervision from others. However, wandering becomes a cause of concern when persons living with dementia meet with dangerous situations while wandering outside, about the neighbourhood alone. For example, they often experience problems with orientation, which causes difficulties in finding their way back home (getting lost). When the person living with dementia is away from home for an unusually long time, or when the caregiver is unable to locate him/her, then wandering becomes a problem.

Moreover, there is a significant number of older persons living with dementia, whose primary caregivers are seniors (for e.g., their spouse) as well. These seniors are more prone to falling and more susceptible to sustain fall-related injuries.

Your loved one may set off to a place and forget where he/she is going or why. Sometimes your loved one may tend to wander and forget how he/she got into that room in the first place. This can happen a lot more often in persons living with dementia. Your loved one may be trying to ‘retrace’ their steps. Likewise, if they do not remember an area, they may wander off until they find something familiar.

Confusing night with day

Your loved one may suffer from sleep problems, or wake in the early hours and become disoriented. He/she may think it is daytime and decide to go for a walk.

Looking for familiar persons / items / places

Your loved one may wander off in search of someone, something, or a place relating to their past when he/she becomes confused. Wandering may occur because they suddenly decide they need to find an old friend they have not seen for a long time. They could also be wondering where they parked their car, even if they have not driven for quite some time. Confusion about time and place is one of the symptoms of dementia.

Continuing with a habit or routine.

If your loved one had a very specific routine or habit that they used to follow, they may want to carry on with it. Your loved one who is used to walking long distances may simply wish to continue doing so. They may also head out to attempt to go shopping or back to their old workplaces if this was something they used to do in the past.

An attempt to get away from something

If the situation or place they are currently in is stressful or unpleasant in any way, they may simply walk off to get away. Likewise, if the environment is noisy, they may walk off to find somewhere more quiet and peaceful.

Change of environment

Your loved one may feel uncertain and/or disoriented in a new environment such as a new home environment or daycare centre.

Physical discomfort or pain

Your loved one may walk to ease discomfort that is caused by uncomfortable clothes, excessive heat or the need to go to the toilet.

Night Wandering

Always be aware that wandering can happen at any time, including the middle of the night. If a person who lives with dementia gets easily confused with what time of the day it is, you may find them wandering at 2 a.m. because they think they have to be somewhere and do not understand that they are supposed to be asleep.

Some Ways to Manage Wandering Behaviours

The tendency to wander is common amongst persons living with dementia. Depending on your loved one’s personality, how well they can cope, their reason(s) for wandering and the safety of the surrounding environment, you may use the following strategies to manage your loved one’s wandering behaviour:

Carry out daily activities

Having a routine can provide structure. Try to create a daily routine for your loved one with dementia.

Install locks out of the line of sight

Install either high or low exterior doors and consider placing slide bolts at the top or bottom.

Identify the most likely times of day or situations that wandering may occur

Identify your loved one’s wandering behaviour patterns by keeping records or a diary. Plan activities at that time. Activities and exercise can reduce anxiety, agitation and restlessness.

Use devices that signal when a door or window is opened

Use devices that signal when doors or windows are opened. For example, doors can be placed over bells, and electronic home alarms can be used.

Reassure the person if they feel lost, abandoned or disoriented

If your loved one wants to leave to “go home” or “go to work”, use communication focused on exploration and validation, and refrain from correcting them.

Provide supervision

Do not leave someone living with dementia unsupervised in new or changed surroundings. Never lock them at home or leave them in a car alone.

Keep car keys out of sight

If the person is no longer driving, remove access to car keys — a person living with dementia may try to drive. If the person is still able to drive, consider using a GPS device to guide them if they get lost.

Redirect attention elsewhere with activities

Engage your loved one through a simple and quiet activity that is familiar to them from their earlier days.

Ensure all basic needs are met, and that your loved one is not experiencing any illness, pain or discomfort

Has your loved one gone to the bathroom? Is he or she thirsty or hungry? Go for his/her regular physical check-ups, which help to identify the presence of any illness, pain or discomfort.

Avoid busy places that are confusing and can cause disorientation

Shopping malls, grocery stores or other busy venues.

Remove objects that may encourage wandering

Objects that may prompt wandering, such as handbags or keys, can be removed from sight.

Remove any obstacles to allow your loved one to wander about safely – ensure supervision is available and he/she has steady gait at all times.

Carry identification

Have your loved one carry identification such as the CARA Membership Card (which replaces the Safe Return Card). This can be helpful when he/she is found by others or the police. Find out more about the CARA Membership Programme.

ForgetUsNot Initiative: Don’t Go Missing

Source: LIEN Foundation, Khoo Teck Puat Hospital, & Dementia Singapore

Hear what care specialist Lily Teh from Homage has to say about helping the community and persons living with dementia find their way home.

When Your Loved One Goes Missing, You Should:

Remain calm.
Make a thorough search of the house and familiar places.
Try to remember what he/she was wearing.
Walk or drive around the vicinity and/or to any places he/she may visit regularly. Have someone stay at home in case he/she returns home, or to answer any phone calls.
Contact the police if immediate searches yield no result. Tell them the person has dementia and any concerns you have for their safety.

For CARA members, use the CARA app to notify members of the public to keep an eye out for your loved one living with dementia who is lost.
If your loved one lives in the Sembawang-Woodlands community, you may reach out to the Dementia Search Activation Network (DSAN). DSAN is a Telegram channel run by AWWA Community Outreach Team (CREST) for persons living with dementia and caregivers within the area. The Telegram channel will be activated upon receiving information about lost seniors within Woodlands and Sembawang from national apps such as CARA. Upon activation, the channel’s chat function will be activated for 48 hours to allow participants to share critical information to help locate the lost individual. Those interested to join the channel can click here.

When your loved one returns home:

Notify the police immediately.
Do not scold them or show anxiety as this may confuse or frighten them.
Provide reassurance and get back into their regular routines as quickly as possible.

William’s Story

CNA Insider: My Grandpa Has Dementia

Source: Channel News Asia

At first, William’s dementia symptoms included forgetfulness and confusion, but then the wandering and getting lost began. William’s dementia makes him sneak out in the middle of the night. He even found a way out after the family padlocked the gate.

Watch how Bethany and her mother, Geraldine (William’s daughter and main caregiver), coped until they finally realised they needed help.

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Changi General Hospital. (2020, October 5). Managing agitation and aggression in dementia. HealthHub. https://www.healthhub.sg/live-healthy/843/managing-agitaton-and-aggression-in-dementia

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Managing Sundowning

Admin — Thu, 08 Sep 2022 07:02:22 +0000

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Changes in the physical brain may affect the sleep cycle and cause wakefulness in the evening and at night.
Your loved one may have previously been occupied and busy at a particular time of the day.
Little or disturbed sleep that may cause restlessness or napping during the day time.
Side effects of medication that can cause confusion, agitation or wear off during the evening time.
Environments that cause discomfort may precipitate sundowning, for e.g., shadows that occur around evening time.

Some Ways to Manage Sundowning

Sundowning may cause some distress to caregivers. Here are some tips which may be helpful in reducing sundowning symptoms in your loved one.

Implement a daily schedule.
Occupy your loved one with a familiar activity that will bring them comfort, such as listening to their favourite music and looking at old photographs.
Reduce sources of discomfort from the environment such as loud noises and bright lights.

Content adapted from Alzheimer’s Society.

How Exercise Helped My Wife with Sleep

John Chin explains to us how evening walks have helped to prevent sundowning in his wife by keeping her engaged.

John Chin used to live in Miami with his wife Kwan. With the help of Kwan’s family, he now shuttles between the US and Singapore to take care of his wife who now lives here.

Source: ForgetUsNot Initiative by LIEN Foundation, Khoo Teck Puat Hospital, & Dementia Singapore

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Mealtime Behaviours

Admin — Thu, 08 Sep 2022 07:02:08 +0000

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Persons living with dementia may sometimes refuse to eat. They may become angry, agitated, or challenging to feed during mealtimes. This can happen for a variety of reasons:

Disliking the food
Feeling rushed
Feeling uncomfortable with people or the environment
Feeling frustrated with the difficulties they are having

It can be challenging to identify what the actual problem is, particularly if they have difficulties communicating. It is important to remember that these reactions are not deliberate.

Try not to rush your loved one or pressure them to eat and drink quickly. Instead, look for non-verbal cues such as body language and eye contact as a means of communication. Wait until they are calm and less anxious before proceeding with the meal.

What You May Observe & Suggested Strategies to Prevent This

Refusing feeding attempts, spitting out food

• Check their mouths for ulcers or poor dental health as these can be painful
• Encourage independence when eating or drinking; gently place your hand over theirs to guide the cutlery to their mouth if they are unable to self-feed
• Offer familiar or favourite food and drinks
• Make the food look and smell appealing — prepare food with different tastes, colours and aromas
• Use familiar utensils
• Ensure that the temperature of the food served is appropriate

Eating very quickly

• Supervise the meal and use verbal and non-verbal prompts, e.g. prompt them to chew before swallowing
• Gently place your hand over theirs to control their feeding rate
• Cut up their food into smaller pieces to reduce the risk of choking

Distracted during mealtimes/ not attentive to eating

• Have a minimalistic table set-up
• Ensure that there are minimal distractions, e.g. quiet and calm environment, or fewer people
• Play calm and soothing music in the background during mealtimes
• Ensure appropriate and adequate lighting

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Responding to Behavioural Changes Archives - DementiaHub.SG

Managing Anxiety

In this Article

What is Anxiety

Causes of Anxiety

Neurological Factors

Damage to parts of the brain that involve emotion regulation:

Cognitive decline:

Psychological Factors

Fear of the future:

Confusion and disorientation:

Other Contributing Factors

Pain or Discomfort such as physical ailments or hunger:

Medications:

Trauma or Past Mental Health Issues:

Symptoms of Anxiety

Supporting Your Loved Ones with Anxiety

Establish a Calm and Predictable Environment

Reassurance and Validation

Physical Exercises

Relaxation Exercises

Seek Professional Help

Conclusion

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What is Person-Centred Care?

In this Article

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Tips for Managing Disinhibited Behaviours

In this Article

Understanding Disinhibited Behaviours

Types of Disinhibited Behaviours

1. Inappropriate social interactions or comments

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

Memory Loss

Medication Side Effects

Environmental Factors

Responding to Disinhibited Behaviours

Managing Disinhibited Behaviours

Identify triggers and patterns

Maintain Structure and Routine

Encourage Meaningful Engagement

Create a Conducive and Supportive Environment

Seek Help

Practise Self-Care

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When to Consider Moving into a Nursing Home

In this Article

Why move into a nursing home?

Who makes the decision to move?

Code Of Practice – Mental Capacity Act Source: Office of the Public Guardian

How should the move to a nursing home be carried out?

Addressing your loved one's needs during the move

Financial support for application to nursing homes

Other options

Additional Resources

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Code Of Practice – Mental Capacity Act
Source: Office of the Public Guardian