"Problem Behaviors" in Alzheimer's Patients Are Actually Expressions of Need
MaisuZenwaveWhen an Alzheimer's patient repeatedly slaps a table, insists on going outside, or even lashes out verbally at a caregiver, most people's first reaction is, "They're confused again." However, a growing body of clinical research and caregiving practice points to a very different explanation: these actions, labeled "problem behaviors," are actually the patient's remaining way of voicing needs they can no longer express in words.
Misread "Problem Behaviors"
A patient with moderate Alzheimer's may ask "Where is my mother?" over and over from morning to night. Family members often become exhausted by the questioning and may even lose their temper. But from the patient's perspective, he is experiencing a profound sense of loss. Behavioral changes are often "a form of communication," possibly stemming from the patient "feeling a certain emotion (such as fear, anxiety, confusion, or distress)," or because "they need something but cannot tell anyone."
Alzheimer's disease causes changes in the brain, which can alter the way people behave. The National Institute on Aging (NIA) further notes that beyond brain changes themselves, other factors can influence a patient's behavior, including emotions such as sadness, fear, stress, confusion, or anxiety, as well as health-related issues such as illness, pain, new medications, and lack of sleep[1]. In other words, behavior is the "effect"—the need is the "cause."
Understanding Behavior Through the Lens of Needs
Pain, hunger, thirst, constipation, the urge to urinate—these most basic physical needs are precisely what Alzheimer's patients have the hardest time expressing on their own. The NIA's caregiving guidance clearly states that when evaluating behavioral changes, one must consider physical problems such as "infection, constipation, hunger, or thirst"[1].
Patients may also be using behavior to tell us: "I'm scared," "I'm lonely," "I'm too tired," "It's too loud." Common triggers include "too much noise or confusion, or too many people in the room," "being rushed by others to do something," and "feeling lonely, without enough human contact." The American Psychiatric Association's special report also notes that behavioral problems may stem from "physical illness, infection, untreated pain," "too much stimulation, lack of routine, or changes in routine," and "caregiver stress," among other factors[2].
A Concrete Example: Late-Afternoon "Acting Out"
Many families are familiar with "sundowning": as evening approaches, the patient becomes restless, slaps the table, and insists on going home. Sundowning is not a disease; it is a group of symptoms that appear at a specific time of day. Factors that may worsen late-day confusion include fatigue, dim lighting, disruption of the body's "internal clock," hunger or thirst, and infection.
Behavior is the "symptom"; the need is the "cause." The patient may not be "acting out for no reason" but rather saying, "I'm tired," "I'm afraid of the dark," or "My body doesn't feel right."
How to Respond to the Needs Behind Behavior
When behavior is understood as an expression of need, caregiving strategies undergo a fundamental shift. The first step is always to rule out physical discomfort. If you don't know what is causing the problem, call a doctor and consult a medical professional.
The second step is to accept the feeling rather than correct the facts. Focus on his or her feelings rather than the words, for example by saying, "You seem worried," while also "not arguing with the patient or trying to reason with them." Emotion-oriented interventions (including validation therapy, reminiscence therapy, and others) can significantly improve cognition, depressive symptoms, and health-related quality of life in dementia patients.
Environmental adjustments are equally critical. Maintain a regular daily routine, reduce noise and clutter, play calming music, and introduce natural light during the day. Keep fixed times for going to bed, waking up, eating, and activities; schedule daytime activities and exposure to light; limit daytime naps; keep a night light on in the evening; and minimize background noise and stimulating activities at night.
The Caregiver's Role: From "Managing Behavior" to "Understanding Needs"
Non-pharmacological interventions are recommended by clinical guidelines in multiple countries as the first-line treatment for behavioral symptoms of dementia. A 2024 umbrella review published in the International Journal of Nursing Studies clearly states that "non-pharmacological interventions are considered the first-line treatment for managing behavioral and psychological symptoms of dementia"[3]. A 2024 practice recommendations article published in Psychogeriatrics emphasizes that the causes of behavioral and psychological symptoms are "primarily neurobiological (so-called 'primary' symptoms) or primarily environmental and functional ('secondary' symptoms)," and this distinction drives the choice of treatment strategy[4]. The American Psychiatric Association further notes in its 2024 special report that "non-pharmacological approaches are recommended as first-line treatment for behavioral symptoms of dementia," and emphasizes that "behavioral changes and concerns should be viewed as signals of distress and clues that need investigation, not merely behaviors to be suppressed. Focusing on the person, not just the symptoms, is what matters"[2].
Person-centered care means the caregiver's task is not to "eliminate" behavior but to "translate" it—treating it as an encrypted message from the patient and patiently decoding it. When caregivers stop viewing "problem behaviors" as a challenge or torment directed at them and instead see them as the patient's only "native language," the caregiving relationship itself can undergo a qualitative transformation.
Alzheimer's disease robs patients of the ability to express themselves clearly, but it does not rob them of the ability to feel needs. Those so-called "problem" behaviors are, in the end, one person's effort—as cognition gradually recedes—to tell the world: "I am still here, and I still need something." Understanding that sentence is the true starting point of care.
[1] National Institute on Aging. Managing Personality and Behavior Changes in Alzheimer‘s.
[2] American Psychiatric Association. More Than Memory Loss: How Dementia Affects Mood and Behavior. Psychiatry.org. 2026.
https://www.psychiatry.org/news-room/apa-blogs/how-dementia-affects-mood-and-behavior
[3] Cho E, et al. Symptom-specific non-pharmacological interventions for behavioral and psychological symptoms of dementia: An umbrella review. Int J Nurs Stud. 2024;159:104866.
https://pubmed.ncbi.nlm.nih.gov/39163681/#1
[4]Mercier C, et al. The treatment of behavioural and psychological symptoms in dementia: pragmatic recommendations. Psychogeriatrics. 2024;24(4):968-982.
