Challenging Dementia Behaviors: What They Mean and How to Respond

Behavioral and psychological symptoms are a common part of dementia. Some behavioral changes can appear even before obvious cognitive symptoms.“In one-third of people who develop Alzheimer’s dementia, the behavioral symptoms come before cognitive decline,” wrote University of Calgary researcher Daniella Vellone for Being Patient, describing mild behavioral impairment, or MBI, a syndrome marked by new and persistent behavioral or personality changes that emerge later in life. Its symptoms include decreased motivation, emotional dysregulation, impulse dyscontrol, social inappropriateness, and abnormal perceptions or beliefs. 

In the Cache County Study, a population-based study that followed 408 people with dementia in Utah, 97 percent experienced at least one neuropsychiatric symptom over roughly five years. Depression, apathy and anxiety were the most common.

What causes behavior changes in dementia?

Once dementia develops, behavior can change for many reasons. Neurodegeneration can alter judgment, impulse control, mood, perception, and the ability to interpret what is happening around a person. At the same time, declining memory and communication skills can make it harder for someone to identify or explain pain, loneliness, boredom, fear or other needs.

One useful caregiving approach is to think of behavior as a possible form of communication. Rather than assuming that agitation, resistance, or other difficult behavior is deliberate, caregivers can look for what may be contributing to it — from discomfort or overstimulation to loneliness or a lack of meaningful activity.

In a study published in Psychiatry Research, Jiska Cohen-Mansfield and colleagues assessed 89 nursing home residents with advanced dementia who were experiencing behavioral problems. Among  unmet needs, the most common were boredom or lack of stimulation, loneliness or a need for social interaction, and a need for meaningful activity. Discomfort was associated with more verbal agitation, and the researchers also found evidence that pain and discomfort were frequently missed by caregivers.

For a caregiver, then, the first question may be less “How do I stop this?” than “What might be contributing to this?”

Memory loss

Memory loss is one of the best-known symptoms of dementia and, in Alzheimer’s disease, is often among the earliest. A person may forget a conversation that just happened, repeat the same question or become confused about where they are or what they were doing. As the disease progresses, memory loss can become more severe and affect familiar people, places and routines.

Several strategies can help. Keep routines consistent: regular times for meals, sleep, and familiar activities can make the day more predictable and reduce the need to repeatedly figure out what comes next. Use visible reminders: calendars, whiteboards, notes, and other memory aids can help put important information in view rather than relying on recall. Draw on familiar memories: old photographs, favorite music, and familiar objects can prompt memories from earlier in life, which may remain accessible longer than recent memories for some people with dementia.

Difficulty with communication

Dementia can affect language in many ways, from difficulty finding the right word to losing a train of thought or struggling to understand what someone else is saying. In primary progressive aphasia, or PPA, language problems are among the earliest and most prominent symptoms. In Alzheimer’s and other dementias, communication difficulties may become more pronounced as the disease progresses.

One important distinction, speech pathology professor Deborah Hersh wrote for Being Patient, is that aphasia affects language, not intellect. Hersh points to a phrase coined by Aura Kagan of Canada’s Aphasia Institute that captures the approach: “I know that you know.”

In practice, slowing down and simplifying communication can help: 

• Keep it concise: use shorter sentences and avoid overwhelming the person with too much information at once. 
• Use other forms of communication: gestures, written key words and visual cues can help when speech becomes difficult.
• Be patient: give the person time to respond rather than interrupting or immediately supplying the word for them.

Communication can also continue after spoken language becomes severely limited. Dr. Maggie Ellis, a senior lecturer in psychology at the University of St. Andrews in Scotland, has studied a technique called adaptive interaction, in which caregivers respond to a person’s sounds, movements, and expressions to establish a connection.

“We are not mimicking the person,” Ellis told Being Patient. “What we are doing is behavior matching.”

When the approach works, she said, researchers see “increased eye contact,” as well as smiling, laughing, and people reaching out for physical contact.

Agitation and aggression

Agitation is among the most common behavioral symptoms of Alzheimer’s disease. The Alzheimer’s Association’s 2026 Facts and Figures report estimates that 76 percent of people with Alzheimer’s dementia experience agitation.

Agitation and aggression can have many causes. Noise, crowds, changes in routine, or a task that has become difficult can contribute to frustration, restlessness, or distress. Physical discomfort can also play a role. Because dementia may make it harder for a person to identify or communicate pain, discomfort can sometimes appear as agitation or aggression instead.

Pat Brown, an Admiral Nurse with Dementia UK, told Being Patient that when someone with dementia becomes aggressive, “the person is trying to express what they want or need with their behavior.” Rather than correcting or arguing, she advises caregivers to consider what may have triggered the distress.

Several approaches can help:

• Reduce triggers: keep the environment calm and limit excessive noise, clutter or other sources of overstimulation. 
• Use familiar music: a favorite playlist may help soothe agitation or ease difficult transitions. 
• Provide an outlet for energy: walking, gentle exercise, or even a car ride may help redirect restlessness.

For some people, agitation and confusion become more noticeable later in the day, a pattern often called sundowning. Dr. Smita Patel, a neurologist and sleep specialist, told Being Patient that maintaining a predictable routine can help: “The best thing to do when patients experience sundowners syndrome is to try to keep a regular schedule.”

Wandering

Wandering is common in dementia and can pose a serious safety risk. Six in 10 people living with dementia will wander at least once, and many do so repeatedly.

Wandering often has a purpose. Someone may be trying to fulfill a former obligation, such as going to work, or searching for a place that feels like home — even while already at home. Warning signs can include returning from a regular walk or drive later than usual, becoming restless or pacing, having difficulty finding familiar rooms, and appearing lost in a new or changed environment.

Several strategies may help reduce the risk, including:

• Make the home safer: consider door alarms or other alerts, and place locks out of sight where appropriate. 
• Keep the person engaged: structured, meaningful activities such as folding laundry, sorting objects or getting physical exercise may help reduce anxiety, agitation, and restlessness.
• Maintain a consistent routine: familiar patterns throughout the day can provide structure and reduce confusion.

Retired New York City detective investigator Victor Cabassa, who worked missing-person cases, told Being Patient that searches can sometimes follow familiar patterns: “[People living with] Alzheimer’s usually go in the same direction, so we start that way, like checking the coffee shop two blocks away.” Families can prepare in advance by knowing the person’s usual routes and likely destinations, alerting neighbors and keeping a recent photo available for law enforcement if the person goes missing.

Changes in mood

Dementia can cause changes in mood, including anxiety, depression, irritability, apathy, and agitation. Some of these changes can appear early. Dr. Bruce Miller, a behavioral neurologist at the University of California, San Francisco, told Being Patient that “it is very common to see a patient with early Alzheimer’s disease, sometimes even before they’ve manifested a memory disorder, to be anxious, hyper-reactive, and very concerned about things that are going on around them.”

A sudden change in mood or behavior deserves particular attention. “When there’s a sudden behavior change, take a broad look at your loved one,” Miller said. “Make sure they don’t have an infection.” Infections, dehydration, constipation, pain, medication side effects, and other health problems can contribute to abrupt behavioral changes in someone with dementia, making it important to rule out potentially treatable causes rather than assuming the dementia itself has suddenly progressed.

For day-to-day mood changes, non-drug approaches are generally tried first. These can include identifying and addressing possible triggers, using familiar music or other sensory activities, and helping the person engage in activities that are calming or meaningful. One framework clinicians use is the DICE approach: describe the behavior, investigate possible causes, create a plan, and evaluate whether it works.

Hallucinations and delusions

Hallucinations and delusions can be particularly unsettling for both people with dementia and their families.

“Hallucinations are when somebody is seeing, hearing, smelling, or otherwise sensing something that isn’t really there,” neurologist Dr. Erin Foff told Being Patient. “A delusion is a fixed false belief. It’s when someone is believing something that is not true no matter how much evidence you present to the contrary.”

Dementia is not the only possible cause. Infections, dehydration, pain, medications, and vision or hearing problems can also trigger or contribute to hallucinations, which is why new or persistent symptoms warrant medical evaluation. Hallucinations are also more characteristic of some types of dementia than others. Recurrent visual hallucinations are a core feature of dementia with Lewy bodies, and previous studies have reported them in 32 to 85 percent of autopsy-confirmed cases. Visual hallucinations tend to appear earlier in Lewy body disease than in Alzheimer’s disease.

That distinction can provide an important diagnostic clue. Retired trial lawyer Don Kent was misdiagnosed by six neurologists before receiving a Lewy body dementia diagnosis at Mayo Clinic. He told Being Patient that repeated screenings had focused heavily on memory problems, which he did not have early in his disease.

“The symptoms I recognized first were two things,” Kent said. One was an abrupt change in personality. “I’ve always been a sort of laid-back person, very slow to anger, and relatively cool under pressure.… And all of a sudden, I became this sort of explosive personality.” 

The other was what initially seemed to him like a loss of taste. “Over time I’ve learned that it’s a hallucination, a taste hallucination,” he said. “And of course, with Lewy Body we can have hallucinations with all of our senses.”

When hallucinations occur, the first step is to determine whether the person is distressed or in danger and whether there may be an underlying medical cause. If the person is safe, respond to the emotion rather than arguing about what is real: offer reassurance if they are frightened without reinforcing the hallucination. Redirect attention: moving to another room, taking a walk or turning to a familiar activity may help. And check the environment: shadows, poor lighting, television, or other sensory cues can sometimes be mistaken for something that is not there.

Arguing about what the person sees or hears is unlikely to help. As Chris Schwilk, who lives with Lewy body dementia, told Being Patient, “Sometimes still, I don’t know if what I’m seeing is a hallucination or whether it’s real.” 

For someone experiencing that uncertainty, reassurance and redirection may be more useful than trying to prove that the perception is false.

Behaviors that feel inappropriate

Some of the hardest behaviors for families to navigate are the socially exposing ones: undressing in public, making inappropriate comments, becoming impatient with strangers, or refusing to bathe or change clothes. In dementia, these behaviors can reflect changes in inhibition, judgment, and awareness rather than a deliberate disregard for social rules.

Sometimes there is also a more immediate explanation. A person removing clothing may be too warm, uncomfortable, preparing for bed, or trying to use the bathroom. Resistance to bathing may stem from embarrassment, fear, feeling cold, or discomfort with receiving help during an intimate task. In those moments, moving the person somewhere private, protecting their dignity, and looking for what may be making them uncomfortable can be more useful than correcting the behavior.

The broader approach is to respond calmly, redirect when needed and look for possible causes or triggers before treating the behavior itself as the problem.

The caregiver as detective

One of the hardest parts of responding to dementia-related behavior is recognizing how easily a caregiver’s own reaction can become part of the interaction. Feeling hurt by aggression or defending yourself against an accusation is an understandable response. But arguing or reacting emotionally can sometimes add to the person’s distress, especially when the behavior reflects changes in memory, perception, judgment, or communication rather than an intention to cause harm.

Two habits can help caregivers step back and look for patterns. Ask for help from others: family members, friends and other caregivers may notice triggers or needs that are harder to see from inside the day-to-day routine. Keep a journal: tracking what happened, when it happened and what came immediately before and after can reveal patterns involving time of day, environment, particular activities, or medications.

When possible, non-drug approaches are generally preferred before medication. But medication may be considered when symptoms are severe, dangerous, or significantly interfere with care. In May 2023, the FDA approved brexpiprazole, sold as Rexulti, for agitation associated with dementia due to Alzheimer’s disease — the first drug approved specifically for that indication. Like other atypical antipsychotics, it carries a warning about an increased risk of death in older adults with dementia-related psychosis.

Dr. Dylan Wint of the Cleveland Clinic Lou Ruvo Center for Brain Health told Being Patient that medication decisions require weighing that risk against a potential benefit. “Anytime we use a medication to treat behavioral symptoms, we’re exposing a patient to a risk,” he said. “There has to be some benefit to the patient.”

This article was adapted from the Being Patient guide to challenging behaviors and dementia and draws on Being Patient’s reporting and interviews with clinicians, researchers, and families. It is intended for general information and is not a substitute for medical advice. Sudden behavior changes, persistent hallucinations, and decisions about medication should be discussed with a qualified healthcare professional who knows the person’s full history.