Mr. Scott (not his real name) is a seventy year old retired postman who lives at home with his wife. After three years of noticeable cognitive decline, he is now moderately demented. He gets good medical care, and is otherwise healthy. His wife has become knowledgeable about his condition, and she has family members who visit and assist her.



Mr. Scott has not been a major behavioral problem until recently. In the past month, he has had occasional angry outbursts. At these times, he stands up, paces, raises his voice to curse and shout commands or demands, grabs onto someone's arm too tightly, and sometimes raises his

hand menacingly. Usually he ceases after Mrs. Scott starts to cry and begs him to stop. Mrs. Scott is afraid he will injure her or someone else, or provoke others to hit him. She worries more than before, and is becoming somewhat demoralized.

To understand this difficult situation, we must realize that such behavior is not a pure or inevitable result of progressive brain impairment. Rather, it results from certain combinations of (a) brain impairment and (b) environmental stimuli and consequences.

Because of his impaired brain function, Mr. Scott is much less able to make his needs known, to understand accurately social situations, to tell the difference between safe and dangerous situations, and to inhibit his emotional responses. In an ideal environment, these limitations would be no problem, because he would never encounter ambiguous situations or experience unpleasant emotions. In the real world, however, new or unfamiliar social situations are unavoidable, and no caregiver can anticipate a dementia victim's every need.

While dementia predisposes victims to certain unpleasant behaviors, it is often actually the response of caregivers that determines whether the behavior will appear. Angry outbursts often appear to "suddenly come out of nowhere," though, in fact, they usually take from minutes to hours to develop. Early, appropriate intervention by an attentive caregiver can often nip an emerging problem in the bud.

The key is to develop a good sense of which of the victim's needs is going Unmet at the moment.

Based on familiarity with the dementia sufferer, his habits, and his recent schedule, the caregiver can often make a good guess as to which need is being frustrated. Next, the caregiver takes steps to satisfy the unmet need. She should talk reassuringly, gently but firmly separating him from the current situation, and bringing him to wherever the unmet need can be quickly gratified. Surprise and returned anger should be avoided. Armed with this knowledge, Mrs. Scott began to realize that Mr. Scott's "sudden rages" usually occurred during or soon after a visit by a male relative, during which he was excluded from, and unable to understand much of, the conversation. He was therefore bored and lonely. Mr. Scott's impaired thinking allowed him to develop the self-esteem-protecting delusion that this interloper was having an affair with his wife.

Mrs. Scott decided to include her husband more in conversations with visitors. To assure herself the opportunity to have private conversations, she asked visitors to come in pairs. One visitor was therefore always available to chat with Mr. Scott. After each visit, Mrs. Scott took care to show affection to her husband. The result was that his outbursts became very infrequent, and Mrs. Scott's confidence returned.

Example 2

Mrs. Reynolds is a seventy-eight-year-old widow living alone in an apartment building for able-bodied elderly persons. Mild dementia has been present for one year. She is maintaining a good level of social interaction, but recently those around her have noticed her body odor and that she looks unwashed and unkempt. Yet Mrs. Reynolds's appetite, mood, orientation, and other behaviors are not deteriorating.

This is a relatively straightforward example of a behavioral deficit resulting from inadequate environmental input. The staff's optimal approach is to assume that Mrs. Reynolds (a) has not lost the ability to perform personal hygiene activities, but (b) has lost the ability, at least temporarily, to remember on her own to perform them. Intervention consists of building two elements into Mrs. Reynolds's day. First are stimuli that encourage washing, such as prompts, requests, reminders, opportunities, and offers of assistance. Second are positive consequences that reward her for washing, such as praise, compliments, affection, and words of appreciation or admiration.

Example 3

Mrs. Hawthorne is a seventy-year-old, mildly demented female nursing home resident. Though often observed walking around her room, she quickly sits down whenever staff enter her quarters, insists that she can not walk, and demands to be transported in a wheelchair. When staff try to help her to stand or walk, she acts lame, like "dead weight." When the maintenance man came to fix her sink, she slid from the bed to the floor three times, each time pleading with him until he lifted her (again, like "dead weight") back onto her bed.

As was true with Mrs. Reynolds, an explicit program of prompting and rewarding the deficient but desired behavior (walking unassisted) is in order. It is often difficult, however, to find something that is rewarding to people like Mrs. Hawthorne. Though her behavior communicates great dependency, she often seems depressed and claims to have no interest in anything. In such cases, remember the Premeack principle which states that the privilege to engage in preferred activities may be used to reinforce less preferred behaviors. Mrs. Hawthorne very much enjoys her son's weekly visits. With his cooperation, the staff informed her that she could earn additional brief visits by him if she resumed walking to the table at mealtime. This plan was successful, and was extended to walking to activities, and so forth.