By Holly J. Bean, Ph.D., LCPC, CRC, CTRS
All Behavior is Communication
When we have children we expect the occasional acting out. As a newborn, the infant learns that discomfort that produces crying will bring mother (or another loved one) and relief. With mother comes the end of the discomfort, either by supplying milk, a loving embrace, soothing, or some other technique that helps to calm the behavior.
As adults, we still may act out occasionally to have our needs met. This is the side effect of being human. Older adults, especially when presented with cognitive decline, may return to disturbing behaviors in order to communicate their needs. The concept that all behavior is communication does not have age limits.
When disturbing behaviors take center stage for older adults with cognitive impairment, the result for this vulnerable population can be disastrous. Unfortunately, the first resort is usually medication. Most medications that you or I could tolerate, our elders cannot. Dr. Beer’s created a list of potentially harmful medications for our older adults. In a perfect world, we would have enough resources (caregivers) with available time to utilize psycho-social interventions to increase our elders’ quality of life and safely reduce the disturbing behaviors. Research has determined that psycho-social interventions have an efficacious effect.
Disturbing behaviors may be defined as; symptoms that interfere with functional abilities and quality of life (Colling, 1999 as cited by Buettner & Fitzsimmons, 2009). What are some of the disturbing behaviors that our elders with cognitive decline may display?
Apathetic – a passive outlook, lack of interest or motivation, withdrawal and social isolation.
Psychiatric– symptoms that are diagnosed such as depression*, anxiety, psychosis, paranoia, delusions, or hallucinations. * In an hospital setting, diagnosing dementia cannot take place, as depression can present as dementia. A thorough geriatric assessment is needed.
Physical nonaggressive – motor restlessness (constant fidgeting or movement), repetitive movements, wandering, rummaging or searching hording, hiding things, spitting, pacing, picking, or rubbing.
Verbal nonaggressive – vocalizing (constant calling out), repetitive questioning, complaining, screaming, weeping, crying, or moaning.
Verbal aggressive – arguing, yelling, threatening, exhibiting irritability, cursing, and display of angry outbursts.
Other behaviors – refusing care, medications, foods or liquids; exhibiting socially inappropriate behavior such as disrobing or urinating in public spaces, acting gluttonous, exhibiting pica (eating non-food items) displaying sleep-wake disturbances (up all night and sleeping during the day), sundowning (a temporary change in behavior marked by confusion and fear usually taking place between 3PM and 6PM), sexual inappropriateness, and disinhibition. There may be other behaviors, yet these do make up many (Buettner & Fitzsimmons, 2009).
Research supports that there are treatments, or interventions, that can take place to either limit or reduce the disturbing behavior(s). Being the advocate for the individual with cognitive decline is necessary, as it can help everyone understand why the disturbing behavior occurs and what can be done to help the situation. Evidence based strategies for programming will be discussed in future blogs. This blog, however, will focus on the foundation for understanding the disturbing behavior(s) and the unmet need that the individual may be communicating.
Step 1: Every behavior has meaning. You have the ability to improve the quality of life of another person. To accomplish this, you will need to have taken a thorough assessment that includes background information of the client. Doing this will provide you with a clearer idea of who this person may have been earlier in their life (work, life role, etc.).
Step 2: Examine the environment. Environmental stressors can affect individuals with cognitive decline due to having less coping strategies. Is the environment too stimulating, which would increase anxiety or fear? Or is the environment not stimulating enough, which would increase wandering, feelings of loneliness, etc.? Are there distractions which can increase confusion?
Step 3: Is there assistance in creating quality programming and appropriate rest opportunities for the client? Sometimes, in our exuberance to fill the time, we may forget about rest breaks.
As an example of all behavior as communication, I offer this true account of a gentleman at a nursing home in the dementia unit. The gentleman kept to himself most days. He would wander around the unit aimlessly, yet at a certain time of day he would stop at the locked back door that had a window facing a neighboring field. In the field were cows. Every day, at around the same time, this gentleman would stop at the window, look at the cows, and become very agitated, typically around 3PM or 4PM. No amount of coaxing would help calm him down. The nursing home reached out to family members to learn more about his behavior. What they learned was that this gentleman was a farmer who had cows. Every day the cows needed to be milked at specific times, one of those times was in the afternoon, around 3PM or 4PM. Once the facility learned that this gentleman’s life role was surfacing and creating the need to bring the cows into the barn, they were able to work with the environment to help ease his anxiety. A beautiful covering was put over the window of the door, showing cows inside their barn, being milked, between 3PM and 4PM. A photo album was created of cows, milking stations, and farms. The family members collected photos of his farm and placed them in an album. All of these activities provided relief for the gentleman, the caregivers, and the family. Understanding this gentleman’s life role and the importance of having the cows in the barn for milking time helped provide relief to all involved.
An interesting video made for Veterans’ with cognitive decline, yet for anyone presenting with cognitive impairment, is extremely well done. This video focuses on how to communicate in a respectful and collaborative manner to reduce disturbing behaviors. I highly recommend viewing it: https://www.thechicagoschool.edu/insight/health-care/communicating-and-interacting-with-people-with-dementia/
Next blog we will discuss the various levels of cognitive decline and match those levels with appropriate evidence based programming.
American Geriatrics. (2019). For Older People, Medications are Common; Updated AGS Beers Criteria, Aims to Make Sure They Are Appropriate Too. Retrieved from
Buettner, L. and Fitzsimmons, S. (2009). N.E.S.T. Approach: Dementia Practice Guidelines for
Disturbing Behaviors. PA:Venture Publishing Co.