Repetitive Behaviors

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ASK DR. MINDY

MINDY KIM-MILLER, MD, PhD
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Question:

My dad was diagnosed two years ago with Alzheimer’s disease. A year ago I gave up my career, relocated, and took a lower paying job to move back in with my dad and help him through this disease. My main objective is to keep my dad safe, comfortable and at home as long as we can.

My soon to be 85 year old father has recently become obsessive. Approximately two months ago, he began rubbing and picking at his forearm and elbow. This turned into picking at his skin until it became raw, open and infected. I have treated with Bacitracin and covered the wounds with sterile pads and tape. Having gone through miles of tape, he finds a way to pick at the tape and removes the sterile pad to pick at the wound. Obviously, my fear is an ulcerated wound and/or staph infection. We have been to his physician twice to monitor the wounds.

While I believe I have found a tape with good staying power, my dad continues to pick at the gauze and tape until he has it removed. For two weeks now, my dad is up at between 1:00 a.m. – 2:30 a.m. searching the medicine cabinet for something for his wounds. When I get up and discover he has bloody hands and fingernails, I use the antiseptic wash on his wounds and get my ‘big girl tape’ out to redress the wounds.
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He insists the gauze ‘falls off.’ I know better than to argue with dad. The disease prevents him from understanding he has pulled the gauze off himself. Given we both have a good sense of humor, I ask if the Leprechauns visit him at night!!

Last November I had a private meeting with my dad’s neurologist. He has put my dad on 25 mg of Seroquel to help with some of the anxiety my dad feels.

I have provided rosary beads (Roman Catholic), worry beads, and other similar items to help with the fidgeting. None of these items have been of use to ease whatever stress my dad may be feeling.

Do you have any suggestions to help me to help my dad?  Thank you!

–Margaret, New York

Answer:

You offer a very insightful story about compulsive or repetitive behaviors among those with Alzheimer’s disease.

Compulsive or repetitive behaviors are quite common in the later stages of Alzheimer’s disease. Studies suggest that progressive damage to a combination of several parts of the brain (the frontal lobe, caudate nucleus, and globus pallidus) may account for repetitive behaviors. Repetitive or agitated behaviors may be a sign that your loved one is depressed, anxious, stressed, or in pain and does not know how to express it in words. Repetitive behaviors may be a way for the person to find comfort, familiarity and a sense of control. If they are harmless, they can often be ignored. But if they are harmful, as in your father’s case, there are some strategies you can try to decrease or prevent the behaviors.

Drug therapy:
Anti-anxiety and anti-depressant medications can help reduce compulsive or repetitive behaviors. You should work with a physician to find the medications and the dosages that work best for your loved one. If your family member is depressed, anxious, or in pain, a healthcare professional should evaluate and treat it as soon as possible.

Behavioral Approaches:
Certain stressors can trigger repetitive or agitation behaviors. Caregivers should try to figure out whether there is a trigger for the behavior, such as the TV or a particular TV program, excessive noise or activity, visitors, or lack of stimulation in the environment. Then modify the environment to reduce any known stressors, such as reducing noise, shadowy lighting, or mirrors.

Because individuals with dementia like routines and consistency, try to avoid changes in the environment, routines, and caregivers. Organization on your part can help isolate and control some repetitive behaviors. As the caregiver, you have to use all of your senses to understand the environment and your loved one’s behaviors.

Watch for signs of fatigue, as it can increase sensitivity to stress and anxiety. Try to avoid fatiguing activities, especially in the later part of the day when people are more prone to fatigue.

On the other hand, it is important to provide safe, meaningful activities that occupy and satisfy your loved one throughout the day. Providing meaningful activities to do depends upon your knowledge of the person’s history, interests, and personal preferences. Look for activities that reflect your loved one’s previous interests or career. Consider setting aside an occupational space with safe activities and tools that the person can enjoy.

Look for any signs that tension and anxiety are increasing, such as pacing or incoherent vocalizations, and try to provide a distraction before the repetitive/compulsive behavior begins or soon after it starts. Studies have found that the only thing that interrupts ongoing behavior is the introduction of a distractive auditory, visual or tactile stimulus. Distractions are more effective if they are interesting and meaningful to the individual.

Music is one of the most effective ways to calm repetitive and agitated behaviors. Indeed a person’s favorite music from the past has greater beneficial impact on behavior than non-individualized music. So offer a couple of musical choices that the person likes and have them ready to play at the first sign of restlessness or distress. Other distractions include exercise (such as going for a walk), playing games or cards, offering a snack, going through old photos, or any enjoyable activity that interests the person.

To reduce undesirable, repetitive behaviors with the hands, try offering activities that keep the hands occupied. There are a variety of simple hand puzzles, squeezable stress relief toys, and activities that require hand-held tools or equipment that you can offer. In fact, you can offer an activity that makes your loved one feel useful; for instance, folding laundry or napkins, organizing a drawer, or sorting things, such as coins. In your case, your loved one fidgets with tape and picks at skin. Try offering a safer substitute that he can pick at. For example, try wrapping a small gift or healthy treat in a box covered with tape and have your loved one pick off the tape to find the pleasant surprise. You can also try offering a spongy/foam toy wrapped in tape as a substitute when your loved one feels the urge to pick at his skin.

Human interactions are important to everyone. Try arranging for visits with familiar people with whom your loved one can reminisce. But try to avoid large gatherings that might be distressful. It may also help to give your loved one a hug and assure her/him that everything is fine.

Caregivers and families should avoid placing excessive demands upon their loved ones with dementia, as this can be stressful as well as futile. They must accept that their loved ones have lost mental functions that cannot be recovered with extra quizzing, reality orientation, brain exercises, or retraining, and avoid pushing too hard or setting unrealistic goals for performance. Caregivers should encourage independence, provide positive support and understanding, and offer assistance only when necessary. Also, continue to provide the loving care that you are already doing.

 Dr. Mindy Kim-Miller is a trained medical physician who provides useful, but general answers to questions provided by online visitors. While Dr. Mindy can not provide specific medical advice or services, we hope you find her responses useful in your personal education. All information is provided for informational and educational purposes only and is not meant to be a substitute for professional medical advice, diagnosis or treatment. If you suspect you have an illness or disease, or a health related condition of any kind, seek professional medical care with an appropriate health care professional immediately. Do not postpone or delay seeking treatment or disregard professional advice based upon the general answers provided by Dr. Mindy. Dr. Mindy’s advice is not intended to substitute for a visit to your personal physician or other qualified health provider. Any specific medical concerns or questions you may have should be directed to your personal physician or other qualified health provider.

References

Ames D, Cummings JL, Wirshing WC, Quinn B, Mahler M. (1994). Repetitive and compulsive behavior in frontal lobe degenerations. J Neuropsychiatry Clin Neurosci; 6:100-13.
Behaviors: What causes dementia-related behavior like aggression, and how to respond. (2005) Alzheimer’s Association. Retrieved January 28, 2009 from http://www.alz.org/national/documents/brochure_behaviors.pdf.
Cohen-Mansfield J. (2001). Nonpharmacologic Interventions for Inappropriate Behaviors in Dementia. A Review, Summary, and Critique. Am J Geriatr Psychiatry; 9:361-81.

O’Boyle R. (2000). Managing Agitation Behavior in Alzheimer’s Patients. HealingWell.com. Retrieved January 28, 2009 from http://www.healingwell.com/LIBRARY/alzheimers/oboyle1.asp.

 

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