Verbal outbursts in dementia caregiving

When people living with dementia have verbal outbursts, it can be inconvenient for dementia caregivers, embarrassing, or hurtful. Although inappropriate, verbal outbursts are not intentional. Even if the words used are articulate, they may not express the speaker’s true feelings if dementia is involved.

One of my clients experienced this recently and I thought I would share this with you, since verbal outbursts are a common symptom of dementia. David was visiting his mom, Patsy, in the assisted living community where she lived. While having lunch in the cafeteria, Patsy pointed out one of the aides as she passed by their table. Loud enough for the aide to hear, Patsy said, “Just look at that aide. Somebody ought to tell her those leggings how how big her butt is.”

Mortified, David shrunk down in his chair. “Mom!” His whisper was not really a whisper at all. “Don’t be so mean! She might have heard you!”

Different from before, different for that person

Dementia has a way of showing up with behaviors that seem nothing like what is typical for that person, based on his or her past. Patsy was more reserved in her pre-dementia days. She would not have even commented on the aide’s leggings, let alone criticize or speak loudly enough to be heard by anyone not seated at their table.

In this case, Patsy displays the lack of empathy, loss of inhibition, and/or loss of self-control that has developed as dementia’s progression affects the frontal lobe, where executive thinking and empathy skills are located. The use of naughty words usually also signals that a person with dementia has limited access to his or her “good words” any more. Vocabulary is stored in the left temporal lobe, and this area of the brain is frequently one of the first to be changed by dementia.

Left temporal lobe loses skill quickly. Right temporal lobe retains skill much longer.

Mean, lewd, or profane words are stored in the right temporal lobe, though, and skills in this part of the brain are usually retained a great deal longer in the progression of dementia. Verbal outbursts such as Patsy’s are thought to be a combination of damage to linguistic skills and executive functioning.

Unfortunately for David, his correction only made the situation worse. Patsy, using a louder voice, started to explain why she was right. Soon the people at nearby tables were staring. David felt embarrassed for himself and his mother. He also had no idea how to end the escalation or undo the harm she may have caused.

Was Patsy uncomfortable or in pain? Could her bad manners have been caused by a physical trigger? Or was Patsy just trying to start a conversation, but lacked the proper words to do so, or perhaps did not have the short term recall to bring up a current topic? It’s also possible she was responding to an emotional trigger, by attempting to satisfy a need to belong, or to feel relevant.

Having explained the changes in Patsy’s brain that may have been responsible for her outburst, I worked with David to craft some alternate responses to verbal outbursts.

There will be many opportunities for a “do-over” in dementia caregiving

Dementia’s symptom-related behaviors seem to escalate in phases – these escalations come in multiples over the course of several weeks or months. That may not be good news for dementia caregivers, but there is a silver lining. Caregivers will have multiple chances to learn how to meet these escalations with confidence and competence J

The next time a verbal outburst occurs, David will first assess the underlying trigger. These triggers may be physical (such as pain, discomfort, hunger), environmental (the room is too cold, the noise is too loud, there is not enough mental stimulation, etc), or emotional (negative feelings such as isolation, hopelessness, fear, and more).

Once he has identified the trigger, he will address that and resolve it. Usually, when unmet needs are fulfilled, a person with dementia will de-escalate rather quickly.

Unmet physical and environmental needs are fairly easy to address because they are tangible and measured by objective means. Emotional triggers can be more complex, as they are intangible, and measured subjectively.

A page from Maya Angelou

In a scenario where Patsy does feel lonely and if she doesn’t belong, while having difficulty carrying on a conversation as she once did, David might try to bring up memories of Patsy’s past, and get her to talk about feelings (rather than facts – feelings seem to remain while facts become blurry…remember what Maya Angelou said?) associated with old memories. Patsy may not have a grasp of current events, but she is still a subject matter expert on her past.

When asking about Patsy’s past, I learned from David that she used to love to watch Bonanza on television. So, David might ask her about that. “Mom, when Bonanza was on TV, did you ever have a crush on any of the Cartwright boys?”

Notice that this question is about emotions, not facts. Also, it is a yes-or-no question, which may be easier for Patsy to answer than an open-ended one. David can move the conversation along by supplying the facts of some Bonanza episodes, or the actors, and then ask Patsy emotion-oriented questions related to those facts. Engaging Patsy in conversation about topics she is familiar with will help her feel less isolated in her dementia and help her continue to feel that she belongs in her family and in her community. David will work on developing a list of fruitful topics for general engagement, and also some quick questions he can pose to distract Patsy when external scenarios may trigger outbursts…because the aide in the leggings will inevitably pass by their lunch table in the future.