How to manage difficult behaviours in the elderly

As we journey along life, we inevitably also watch the people around us age. Our loved ones may start to display changes in their everyday behaviour, and we may find them to act like a completely different person - sometimes, even in a manner we find difficult to manage.

As frustrating as it may be, there are usually causes for the change in behaviour. Moreover, we may find that it's not just one behaviour which has changed - but a few behaviours.

What are some difficult behaviours in the elderly, some possible causes, and how can we effectively manage them?

Causes of behaviours

The reasons for behavioural changes are usually linked to changes in situations or circumstances. Here are some reasons: 

• Difficulties from medical conditions: Developing conditions such as Alzheimer's, or dementia, leads to difficulties with memory and cognitive function. This results in behavioural changes in the elderly as the condition progresses.
• Also, some elderly may suffer from the side effects of conditions like stroke, such as aphasia. This may make communication challenging for these elderly, and they are unable to perhaps get their needs met, such as hunger, thirst, or help to reduce their pain. This may result in increased frustrations and outbursts.
• Stresses from daily life: Your loved one may face financial stresses from having less income and yet having to foot higher medical expenses. Not having enough money in their MediSave to fray the cost of medical encounters could lead to tensions between seniors and carers as they discuss money matters. Other possible stresses include loneliness and fear of declining function as they get older. 
• Dealing with grief and loss: The loss of a loved one or a friend could lead to depression in the elderly if not well managed. 

Different types of challenging behaviour in the elderly and what to do about them

Now that we know the possible causes of challenging behaviours, let's look at some types of behaviours and tips to deal with them. 

1. Aggressive behaviours 

It comes as a shock to some carers and families when the sweetest old person suddenly turns into a snarling, nasty monster who hurls insults or curses.

Using profanities, offensive language, or saying inappropriate things are some aggressive behaviours which the elderly may suddenly engage in. If left unchecked, it could escalate into abuse of the caregiver, as the people closest to the senior tend to be the ones who receive the brunt of the aggression. 

How to deal with aggressive behaviours: 

• Know possible causes behind the aggressive behaviours: If the aggressive behaviour is not typical of the elderly and it gradually gets worse, the culprit is likely Alzheimer's or dementia. If the behaviour is sudden, it could be due to urinary tract infections. Urinary tract infections can cause the elderly to have changes in behaviour, like agitation. In some cases, these behaviours may stem from a mental illness, such as narcissistic personality disorder (NPD) or borderline personality disorder (BPD).  
• Set ground rules with the elderly person: Sometimes, clear boundaries have to be set up. Let the person you're caring for know that you will not tolerate such behaviour from them. You could help them to see how their behaviour is detrimental by trying to give a different perspective, like helping them imagine how a loved one or a partner would feel if they were to have to hear this from him/her.
• Use distraction: Try to divert your elderly's attention away from the outburst. Talking about the past may be a helpful distraction as elderly enjoy reminiscing about the past. If distraction does not work, sometimes you will just have to wait it out, and remember it's not about you.

2. Emotional outbursts of anger and hostility 

Age and illness can cause certain personality traits to become more pronounced in unpleasant ways. If an elderly person was already irritable prior to their condition, they may get angry more frequently, or become impossible to please.

Sometimes, the elderly may become upset if external help is offered, and they may lash out in anger at the mention of external help. Some may even be hostile to the external help, ignoring them completely when they come over. 

How to deal with emotional outbursts:

• Identify the cause of their outburst: Is it a medical condition like dementia? Is it because of the inevitable but natural process of ageing? This may help you empathise and try to hold back a bit more.
• Identify who they may have outbursts with: Some elderly folks will only show their worst behaviour to those who are closest to them, like their families. To counter this, if home help services are a possible option, do consider inviting them to help while you take some respite as the caregiver. 

3. Attention-seeking behaviour

When a family member becomes a caregiver for their loved one, in some instances, the care recipient may demand complete attention and time from their caregivers. This may not be reasonable as caregivers have their own lives to live and other commitments as well.

Seniors who are still capable of doing things for themselves can easily become completely dependent on a caregiver for all their physical and emotional needs, and this causes frustration for the caregiver to be at the care recipient's beck and call. Some elderly even go as far as to block their caregivers from having other plans of their own, and to focus only on caring for them. 

How to deal with attention-seeking behaviour:

• Set boundaries: Make the point clear to your care recipient that while he or she is important to you, you must live your life as well. Have them interact more with others outside by bringing them to senior centres, book clubs, adult daycare and so on - so that they get to socialise and mingle with others beyond yourself. This helps them to focus on something other than your attention and eases the dependency on you.
• Consider engaging external help: Consider hiring a home-based caregiver to provide company for your loved one.

4. Paranoia, suspicions, or delusions

Mental health issues in the elderly can cause them to be paranoid and hallucinate falsely about events. The elderly may accuse someone of theft or abuse when in reality it has not happened. They may also see things which aren't there, and believe that someone is out to harm them. This can be difficult for caregivers to watch and attempt to remedy. 

How to handle mental health issues in the elderly: 

• Consider possible conditions: Having hallucinations and delusions could be a sign of physical or mental problems. Discuss with your doctor if you are not sure what is happening with your elderly. Urinary Tract Infections could cause such hallucinations or could be a side effect of a certain medication. Dementia could also be a cause.
• Validate what your elderly is feeling: Help your elderly cope by acknowledging what they see and experience, all the while reassuring them that they are safe and you are there to help them. Do not try to convince him/her that what they are seeing is not real, as this could result in more frustration. 

5. Sleep or bathing issues

Refusing to bathe and maintain good personal hygiene is a common issue among the elderly. Also, insufficient sleep may pose an issue as age creeps up. Some elderly, especially those with dementia, may suffer from what is called Sundown Syndrome. This refers to certain behaviours which happen at a certain time of the day, usually in the late afternoon. The elderly may present as being confused, agitated, and restless. Its cause is believed to be the lack of sleep in such individuals. 

How to handle issues related to sleep and bathing:

• Have a sleep routine and schedule: Ensure your loved one has a consistent sleep routine and schedule. Make the room conducive for sleep, and set the same bedtime for your elderly every night.
• Give them more independence: Elderly who are able to control when they shower, and how they dress, are more likely to take a shower themselves. If we nag them to take a shower, we may create the opposite effect instead. 

6. Obsessive-compulsive behaviours

Obsessions and compulsive behaviours are sometimes related to an addictive personality or having a history of obsessive-compulsive disorder (OCD).

The elderly may engage in behaviours like constantly picking at their skin, keeping excessive numbers of tissue packets, or worrying constantly if it's time to take their medication. These can disrupt the daily lives of seniors and their caregivers.

How to handle obsessive-compulsive behaviours: 

• Discuss with your elderly's doctor: Discuss your senior's symptoms with their doctor, especially if OCD is interfering with their quality of life and daily routines. Therapy and/or medication may help your elderly. 
• Understand the triggers behind OCD: Watch out for the things that trigger your senior's OCD. If it is related to a certain event, avoid it. If you helped in their rituals in the past, cease immediately and do not encourage them to continue. Find ways to minimise triggers as much as possible. For example, if dry skin triggers a fit of picking off skin for your elderly, try to keep their skin moist and hydrated. Trying to distract and redirect them can also be helpful. 

7. Poor financial management (overspending or excessive frugality) 

Some seniors veer to either ends of the extreme by overspending excessively, or being excessively frugal. They may conjure heavy debts from gambling, shopping, or sending money to scammers. On the other end of the spectrum, some may refuse to spend a single penny on necessities even, such as medication, food, or long-term care. 

How to handle poor financial management: 

• Bring in a third party to mediate: Having an independent person who is not a carer or related to the family may be helpful. They may be able to present the truth more objectively to the elderly, and they may be more willing to listen. 
• Print it out in black and white for them: Print out their expenses in black and white, so that they can see the effects and accumulation of their spending. This may help to sober up the overspender. Some elderly have been brought up in times where there wasn't much, and hence they excessively save as a result, not wishing to burden their family members with financial hardships. Showing them the out-of-pocket costs you are paying for may help them to see that you can financially help with their condition as well. 
• Monitor your elderly's cognitive state: Mismanaging money could be one of the first signs of dementia. Ensure there is a durable power of attorney for finances document available in the event your elderly is unable to manage his finances for himself anymore. 

8. Hoarding 

Seniors who hoard may be feeling overwhelmed by the uncertainty ahead with ageing. They may keep items they deem useful or to have potential future use in excess, having them pile up all around the house. Also, they may obsessively save money in case of a rainy day.

When a senior hoards (acquires and fails to throw out a large number of items), the onset of Alzheimer's or dementia could be to blame. Also, this may be a way of keeping their memories with them, as some elderly do fear losing their memories if something tangible gets thrown out. 

How to handle hoarding: 

• Reason with your loved one: Discuss items to throw out or give away, and make a special memory box or organisational system to keep their 'special things' inside. This could help to reduce the hoarding. 
• Bring in a specialist: If the hoarding is extreme, consider behavioural intervention therapies and family counselling services. This is especially so when the elderly's behaviour has led to unsanitary or unsafe living conditions e.g. things piled up all around the flat. 

ALSO READ: China’s elderly want to enjoy their golden years, not raise next generation unless they get paid for it

This article was first published in Homage.