When Faced With Unwanted Behaviors in Dementia, Try the 4Rs

In my last two posts, we examined the antecedents, behaviors, and consequences (ABC) approach, an excellent way to understand the root cause of behaviors and develop plans to manage unwanted behaviors in dementia. In this post, I will review the 4Rs.

The 4Rs: Reassure, Reconsider, Redirect, and Relax

Using the ABC method is an ideal way to understand and improve behaviors when you have some time to step back and consider each behavior thoughtfully. When you are in the midst of dealing with a situation, however, is not necessarily the best time to start filling in a behavior log. At that time, we suggest the 4Rs: reassure, reconsider, redirect, and relax.

We want to reassure our loved one that everything is all right. We want to reconsider the situation from their point of view. We want to redirect them to activities that they enjoy and are calming. And we want to remember that it is important that we relax so that we do not inadvertently escalate the situation.

Reassure

It is important to understand that your loved one with dementia may have difficulty interacting with the world around them. Because of their memory loss, people and things once familiar may become unfamiliar. Noise, crowds, and activity may be difficult to understand, and they may feel easily overwhelmed. They may be worried or scared when they can’t see you—thinking you’ve been gone for hours even if it’s only been a few minutes. In short, there are many reasons why an individual with dementia may feel more anxious and afraid, even if they have never had trouble with these emotions before.

It can be helpful to remind yourself that if your loved one is yelling or acting agitated, it may be related to their feeling afraid or nervous. Reassure them that everything is all right. Phrases like, “You’re safe”; “Everything is OK”; and “I’m here for you” can provide comfort. You may need to reassure them repeatedly. Reassurance from you can help reduce or stop many problem behaviors.

Reconsider

It is important to consider your loved one’s perspective. Their experience of situations might be very different than you might imagine. For example, perhaps your loved one becomes angry every time the home health aide visits and tries to help him bathe. This behavior may seem mysterious, but reconsidering things from his perspective may help explain it. Because of his memory loss, he may perceive the aide as a complete stranger—even though she has been bathing him for months! He also may not remember that he needs help bathing.

So, from his perspective, a stranger is asking him to take his clothes off so she can bathe him, and he may feel outraged, anxious, or confused. Reconsidering the situation from your loved one’s point of view can improve your ability to empathize with them, help you feel calmer, and provide you with clues about what you might be able to do to manage the problem behavior.

Redirect

Simply telling your loved one to stop a problem behavior rarely works. Redirecting them to something they like often does. When you redirect your loved one, you change the focus and direct them from the upsetting or counterproductive event or environment to something else.

This change may be accomplished by taking your loved one into a different room, starting a fun conversation or activity, pointing out something interesting, or giving your loved one a novel, interesting, comforting, or well-loved object. Use a nurturing touch and tone of voice to redirect your loved one. Using a loud or harsh tone will generally escalate the behavior, which brings us to our last and final R—relax.

Relax

With diminishing abilities, your loved one may increasingly rely on you to help them interpret the world around them. Consciously or unconsciously, they may use your emotions as a way to know how they should be feeling and responding. If you are anxious and upset—whether because of their behavior or something else—your loved one may feed off of your negative feelings and also become anxious and upset. Even if the words you are using are reassuring, if your tone of voice or body language reflects your feeling frustrated or angry, your loved one is likely to pick up on these nonverbal signals. This is why it is so important that you remain calm and relaxed—especially when faced with problem behavior.

Of course, it isn’t always easy to relax your posture, uncross your arms, loosen your hands, and speak calmly and reassuringly. Remaining relaxed in the face of aggressive, agitated, embarrassing, and irritating behaviors is hard for everyone. Practicing good self-care will make it easier for you to remain calm and collected when your loved one is not. Learning deep breathing and relaxation techniques can help you control your emotions. In future blog posts, we will discuss these and other ways that you can take care of yourself, which will help you to be able to remain calm even in the most challenging situations.

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Let’s consider an example to illustrate the 4Rs:

• My father doesn’t want to get out of the car when we arrive at the doctor’s office. I’ve tried pleading with him, talking sternly to him, and even trying to pull him out of the car. Once he started crying, and the last time he tried to hit me. What should I do?

  Your loved one may be anxious about visiting the doctor, which may lead them to resist getting out of the car. When they see you becoming frustrated, angry, and upset, it only makes them more agitated. Remember the 4Rs: reassure, reconsider, redirect, and relax. Reassure them with soothing words. Reconsider things from their point of view: Your loved one doesn’t understand why they need to see the doctor if they don’t feel sick. Redirect them to a pleasing activity such as getting out of the car for a walk, telling them a favorite story or joke, or playing some music they like on your phone. Stay relaxed and calm; it will help them become calm as well.

© Andrew E. Budson, MD, 2022, all rights reserved.