In a previous post, I spoke about behavior management problems in dementia (also known as ‘behavioral and psychological symptoms of dementia,’ or BPSD for short) and talked about both the underlying causes of behavior management issues, and the problems posed by relying on medication management. I also said that I would spend some time in my next installment talking a bit more specifically about different approaches that may work to manage BPSD and that work for both paid and unpaid (family or informal) caregivers.

Sick Brain Versus Unmet Needs

The traditional model of BPSD (and one that almost no one informed about the subject subscribes to today) is that behavior problems in dementia are simply the result of a sick brain. Much like an infected wound oozes discharge, the thinking goes, a dementia brain emits behavior problems, and so therefore, it’s the job of medicine to offer (medical) treatments that directly address the cause. This means almost exclusively medication treatments, such as antidepressants, or worse, so-called minor and major tranquilizers, with all of their attendant side effects. Why do anything else?

Of course, the paradigm now is that BPSD is caused by unmet needs of dementia patients. Problem behaviors occur as meaningful responses to interpersonal or environmental causes, or triggers – and nursing staff are taught to look for these when a demented resident is distressed, agitated, wandering, etc., so they can try and modify these triggers.

Depression as Trigger for Behavioral Problems

The problem is, because our residents often have trouble with expressing their needs (because a common symptom of dementia is impaired communication), nurses have to make educated guesses about the needs of residents; they need to basically become detectives. I plan on talking a bit later about the best way to start doing that detective work – but let’s just imagine something for a second. Let’s focus on just one possible (but in my view, fairly endemic) unmet need of people who have dementia. What if the issue that is driving your loved one or care recipient with dementia to act out is, well, they’re depressed?

So let’s take a moment to talk about depression. What is clinical depression? According to the so-called “psychiatric bible” (the DSM-V being the current version), clinical depression consists of several criteria, most of which need to be present for most of the time over at least the past couple of weeks. Aside from feelings of subjective depression (feeling sad) most of the day, nearly every day, patients also have problems with so-called vegetative symptoms (e.g., eating or sleeping less or more than usual), feeling “keyed up” or anxious (or conversely, slowed down), trouble concentrating, and also, potentially feeling suicidal.

Finally, there is the issue of anhedonia, which is defined as an inability to feel pleasure, or lack of reactivity to pleasant events. In fact, many authors and thinkers consider this a central issue or distinguishing feature of clinical depression – once the so-called “first-factor variance” common to all psychiatric disorders is removed (call it “general distress” or “demoralization”), this – the anhedonia – is what makes clinical depression a distinct psychiatric disorder from all the others.

Now let’s think about how depression is typically diagnosed.

In normal, cognitively intact people, while diagnosing depression can at times be tricky (and in older adults, even trickier, as issues such as so-called pseudodementia and “depression without sadness” can come into play), it’s made a bit more straightforward, relatively speaking, by virtue of the fact that cognitively intact people can give relatively straightforward and accurate self-report of their symptoms, are reliable personal historians, and have no trouble with communicating. In other words, they can go to their doctor and state “I’m sad!”

People with dementia, however, are typically unable to verbalize directly that they’re depressed. They may cry out. They may stop eating, they may eat more. They may be combative. They may be withdrawn and stare at a wall. They are easily labeled as having “agitation” or worse, as being “problem patients.” In fact, I would say that any number of people with dementia who are acting out may in fact be having chronic problems with depression and anxiety and that this acting out is the only way they can express it!

Like intact older adults or younger adults with depression, a number of approaches that have been found to work well with them have also been found to be effective as interventions for BPSD. For one, antidepressants in the Selective Serotonergic Re-uptake Inhibitor (SSRI) class (think Prozac), which are the first-line medication treatment for depression in cognitively intact patients, have also been found to be effective in managing behavior problems in dementia (as I mentioned in my first article). Moreover, there are at least a couple of psychotherapeutic approaches for treating depression that are based principally on systematically increasing patients’ pleasant activities. Most well-known of these techniques are Lewinsohn’s Pleasant Events Therapy and its current, “third-generation” outgrowth, Behavioral Activation.

It should be of no surprise, then, that in approaches such as the STAR program and others, systematically engaging care recipients who exhibit BPSD with personally meaningful pleasant activities yields powerful benefits.

The Pleasant Events Approach to Behavior Management

The approach of systematically offering a resident or care recipient pleasant events as a way to combat behavior problems in dementia is one that has received a great deal of support in the geropsychology and nursing literature. In fact, it forms a foundational piece of at least a couple of major approaches to managing mood and behavior problems in dementia, such as Suzanne Meeks’ BE-ACTIV approach and Linda Teri’s STAR program. Even in the cases where other intervention emphases, such as modifications to how staff approach and communicate with their patients, or offering caregivers emotional and practical support – may take center stage (such as Burgio & Stevens’ “Program for Managing Behavioral Disturbances in Nursing Home Residents” and also the REACH program), offering care recipients pleasant activities as a way to manage behavioral issues is still suggested as an effective, non-pharmacological approach for managing behavior problems.

If you care for a patient with dementia, and they’ve got some problematic behaviors you’d like to address – it never hurts to try and offer them pleasant activities, and may even help to reduce the frequency and severity of the issues you’re faced with (and can certainly be offered in conjunction with whatever medical or medication treatments are being used as well).

Some things to remember:

• A pleasant event doesn’t have to be something involved, like taking your care recipient to a movie or a concert. It can be as simple as a five-minute conversation where you talk to them about what they did for a living (pleasant reminiscence), or complimenting them on how nice they look, or offering (and sharing) a meal or a snack with them.
• Pleasant events should be personally meaningful to a care recipient in order for them to be most effective. For example, would you offer a lifelong introvert the activity of attending a group activity? Would you play country music to a care recipient who loves classical music (you might – but you better make sure!)?
• Pleasant events are not just to be used as a reward for good behavior. It’s OK to offer a care recipient a pleasant activity, even if they are currently in the throes of acting out, say, as a distraction or diversion. Moreover, withholding pleasant activities from a person with dementia as a condition for “being good” may backfire – particularly if it’s seen as a way to motivate a person to “think before they act.” Obviously, people with dementia don’t have this capacity, and denial of pleasant activities may just make things worse.
• “Four pleasant events a day keeps the blues away” – this was a statement of an old supervisor of mine (and apparently is backed up by research!). Try and make pleasant activities a regular, daily event with your care recipient or loved one. Greater benefits can result if it’s something done regularly!
• Find something fun to do with your care recipient or loved one that you also enjoy. Caregiving for people with dementia is a high-stress job and for family caregivers, leads to increased risk of developing mood disorders of their own (such as clinical depression). If you can’t take a break from caregiving, try and take a break while Take a walk together. Play a card game with your care recipient. Listen to music you both enjoy.

Take care of yourselves!