Dementia and paradoxical behaviors


By Micha Shalev

More than 50 percent of people with dementia experience behavioral and psychological symptoms of dementia (BPSD). BPSD are distressing for individuals and their caregivers, and are often the reason for placement into residential care. The development of BPSD is associated with a more rapid rate of cognitive decline, greater impairment in activities of daily living, and diminished quality of life (QOL). Evaluation of BPSD includes a thorough diagnostic investigation, consideration of the etiology of the dementia, and the exclusion of other causes, such as drug-induced delirium, pain or infection. Care of individuals with BPSD involves psychosocial treatments for both the patient and family. BPSD may respond to those environmental and psychosocial interventions, however, drug therapy is often required for more severe presentations.

Some of the most difficult behaviors involve those which cause the caregiver to question just how disabled the individual really is. Caregivers are sometimes tempted to believe that the individual may be more capable than he really is because he appears to be able to do a task one day and not the next. It can be especially irritating when it involves some of the more unpleasant and difficult caregiving tasks such as managing incontinence. If the individual is a particularly hostile individual, the caregiver’s feelings of anger, resentment, frustration or helplessness may be intensified, influencing even the quality of care rendered.


The individual can dress himself one day and then seems unable or unwilling to dress himself the next.

The individual has been incontinent for weeks and suddenly is able to go to the bathroom alone and take complete care of bladder and bowel needs.


To become sensitive to the individual who seems to continually change in his ability and to plan caregiving strategies based on what the individual can do at a given time.

Suggested approach:

Do not assume that the individual’s behavior or ability will be predictable. Provide support and assistance based on what the person appears to need at a particular point. He may need help putting on his shoes and lacing them up one day but not the next. Watch for changes and provide assistance when needed.

Make good use of those periods of improved functioning. Support and encourage the person, converse with him.

He/she may be able to tell you things that are important to him which he/she may not be able to express otherwise.

Do not become angry or frustrated when the person is not able to sustain the level of improvement.

Do not assume that the individual willfully chooses their behaviors out of laziness or a desire to manipulate you.

Another very difficult topic for many caregiver is the issue of sexual behavior in public.

For example, when the individual is trying to masturbate in public, try to distract them. Do not raise your voice or act in anger. It is the disease that controls the action and not the individual as you knew him prior to the diagnosis. Take the individual for a walk, and remove from him the public area and big crowd, offer a favorite treat, or provide a simple task he may agree to do. At the same time it is very important to protect the person’s dignity by providing privacy. Take them to their room and close the door. When the person cannot be distracted and the behavior occurs often, his physician should be contacted and may suggest medications to help lessen the problem.

Micha Shalev MHA CDP CDCM CADDCT is the owner of Dodge Park Rest Home and The Adult Day Club at Dodge Park located at 101 Randolph Road in Worcester as well as the new state of the art Oasis at Dodge Park which is scheduled to open fall 2015. He is a graduate of the National Council of Certified Dementia Practitioners program, and well-known speaker covering Alzheimer’s and dementia training topics. The programs at Dodge Park Rest Home specialize in providing care for individuals with dementia and Alzheimer’s disease. The facility is holding a FREE monthly support group meeting on the second Tuesday of each month for spouses and children of individuals with dementia and/or Alzheimer’s disease. He can be reached at 508-853-8180 or by email at or view more information online at Archives of articles from previous issues can be read at