Alzheimer’s Symptoms and How to Manage Them

The Alzheimer's Handbook for Caregivers

Depression and Alzheimer’s Disease

Depression is a common cause of “reversible” dementia in older adults. Depression is four times more likely to strike those over age 65 than younger individuals. It is found in 20 percent of persons with Alzheimer’s disease, in up to 50 percent of Alzheimer caregivers and in 15 percent of adults over age 65. Sadly, most people never get help for this treatable illness.

Those with Alzheimer’s disease commonly exhibit symptoms of depression in the early stages of the disease, while they are still aware. Because depression and dementia share common symptoms, the two are sometimes confused, with the result that depression often goes untreated in persons with Alzheimer’s disease. Alzheimer symptoms, however, are more progressive than the symptoms of depression and include profound memory loss. While their depression can be treated through medications, the cognitive abilities of persons with dementia will continue to decline.

Symptoms of Depression in Alzheimer’s Patients

Persons with depression may lose interest or pleasure in activities that were once fulfilling, have difficulty concentrating or experience feelings of hopelessness and worthlessness. They may exhibit such physical symptoms as changes in appetite, weight, energy and sleeping patterns.

The presence of at least four of the following symptoms over a two-week period may indicate depression:

  • Depressed or irritable mood
  • Feelings of worthlessness or excessive guilt
  • Suicidal thinking or attempts
  • Motor retardation or agitation
  • Disturbed sleep
  • Fatigue and loss of energy
  • Loss of interest or pleasure in usual activities
  • Difficulty thinking or concentrating
  • Changes in appetite and weight

Source: American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders

How Do You Treat Depression in Alzheimer’s Patients?

If symptoms of depression are present, it is important for you to obtain a complete medical evaluation to rule out any other physical causes. Medications or an unrecognized disorder may cause depression. If there are no other underlying causes, consult a psychiatrist to obtain a diagnosis. Geriatric psychiatrists specialize in recognizing and treating depression in older adults.

There is no one test to identify depression. The diagnosis involves an assessment of medical history, interviews with the person with Alzheimer’s and family members and a mental status examination. Treatment for depression can include some combination of medicine, therapy, psychosocial support and activities.

Agitation in Alzheimer’s Patients

The term agitation is used to describe a large group of behaviors associated with Alzheimer’s disease. As the disease progresses, most people with Alzheimer’s experience agitation in addition to memory loss and other thinking symptoms.

Agitated Behaviors

In the early stages of the disease, people with Alzheimer’s may experience personality changes such as irritability, anxiety or depression. As the disease progresses, other symptoms may occur, including sleep disturbances, delusions (firmly held belief in things that are not real), hallucinations (seeing, hearing or feeling things that are not there), pacing, constant movement or restlessness, checking and rechecking door locks or appliances, tearing tissues, general emotional distress and uncharacteristic cursing or threatening language.

What Causes Agitation in Alzheimer’s?

Agitation may be caused by a number of different medical conditions and drug interactions or by any circumstances that worsen the person’s ability to think. Situations that may lead to agitated behavior include moving to a new residence or nursing home, other changes in the environment or caregiver arrangements, misperceived threats, or fear and fatigue resulting from trying to make sense out of a confusing world.

Treating Agitation

A person exhibiting agitated behavior should receive a thorough medical evaluation, especially when agitation comes on suddenly. The treatment of agitation depends on a careful diagnosis, determination of the possible causes and the types of agitated behavior the person is experiencing. With proper treatment and intervention, significant reduction or stabilization of the symptoms can often be achieved.

There are two distinct types of treatments for agitation: behavioral interventions and prescription medications. Behavioral treatments should be tried first. In general, steps to managing agitation include (1) identifying the behavior, (2) understanding its cause and (3) adapting the caregiving environment to remedy the situation.

Preventing Agitation

General caregiving strategies to prevent or reduce agitated behaviors include the following:

  • Create a calm environment: remove stressors, triggers or danger; move person to a safer or quieter place; offer rest or privacy; limit caffeine use; provide opportunity for exercise; develop soothing rituals; and use gentle reminders.
  • Avoid environmental triggers: noise, glare, insecure space and too much background distraction, including television.
  • Monitor personal comfort: check for pain, hunger, thirst, constipation, full bladder, fatigue, infections and skin irritation; ensure a comfortable temperature; be sensitive to fears, misperceived threats and frustration with expressing what is wanted.
  • Simplify tasks and routines.
  • Allow adequate rest between stimulating events.
  • Use lighting to reduce confusion and restlessness at night.

Identifying Agitation Triggers

Correctly identifying what has triggered agitated behavior can often help in selecting the best behavioral intervention. Often the trigger is some sort of change in the person’s environment:

  • Change in caregiver
  • Change in living arrangements
  • Travel
  • Hospitalization
  • Presence of houseguests
  • Bathing or changing clothes

During an Episode of Agitation

  • Do: Redirect the person’s attention, back off and ask permission, use calm positive statements, reassure, slow down, use visual or verbal cues, add light, offer guided choices between two options, focus on pleasant events, offer simple exercise options or limit stimulation.
  • Do not: Raise voice, take offense, corner, crowd, restrain, rush, criticize, ignore, confront, argue, reason, shame, demand, condescend, force, explain, teach, show alarm or make sudden movements out of the person’s view.
  • Say: May I help you? Do you have time to help me? You’re safe here. Everything is under control. I apologize. I’m sorry that you are upset. I know it’s hard. I will stay until you feel better.

Safety Measures

  • Equip doors and gates with safety locks.
  • Remove guns and knives from the person’s environment.

Combativeness in Alzheimer’s Patients

When individuals with dementia are frustrated, scared or unable to communicate, they may become aggressive and even combative.

What Causes Combative Behavior in Alzheimer’s?

Combativeness can be caused by many factors including physical discomfort, environmental factors and poor communication. If the person you are caring for is exhibiting combativeness, consider the following:

Physical Discomfort

  • Is the person tired because of inadequate rest or sleep?
  • Are medications causing side effects?
  • Is the person unable to let you know he or she is experiencing pain?

Environmental Factors

  • Is the person over stimulated by loud noises, an overactive environment or physical clutter?
  • Does the person feel lost or abandoned?

Poor Communication

  • Are you asking too many questions or making too many statements at once?
  • Are your instructions simple and easy to understand?
  • Is the person picking up on your own stress and irritability?
  • Are you being negative or critical?

Caregiving Tips

  • Identify signs of frustration. Look for early signs of frustration during activities such as bathing, dressing or eating. Respond in a calm and reassuring tone.
  • Don’t take the behavior personally. The person isn’t necessarily angry with you. He or she may have misunderstood the situation or be frustrated with lost abilities caused by the disease.
  • Avoid teaching. Avoid elaborate explanations and arguments. Be encouraging and don’t expect the person to do more than he or she can.
  • Use distractions. If the person is frustrated because he or she can’t unbutton a shirt, distract the person with another activity. After some time has passed you can return to helping the person unbutton the clothing item.
  • Communicate directly with the person. Avoid expressing anger or impatience in your voice or physical action. Instead use positive, accepting expressions, such as “don’t worry” or “thank you.” Also use touch to reassure and comfort the person. For example, put your arm around the person or give him or her a kiss.
  • Decrease level of danger. Assess the level of danger — for yourself and the person with Alzheimer’s. You can often avoid harm by simply stepping back and standing away from the person. If the person is headed out of the house and onto the street, be more assertive.
  • Avoid using restraint or force. Unless the situation is serious, avoid physically holding or restraining the person. He or she may become more frustrated and cause personal harm.

Hallucinations and Delusions in Alzheimer’s

A hallucination is a false perception of objects or events involving the senses. When individuals Alzheimer’s disease have a hallucination, they see, hear, smell, taste or feel something that isn’t there. The person may see the face of a former friend in a curtain or may hear people talking.

If the hallucination doesn’t cause problems for you, the person or other family members, you may want to ignore it. However, if they happen continuously, consult a physician to determine if there is an underlying physical cause. Also, have the person’s eyesight and hearing checked, and make sure the person wears his or her glasses and hearing aids on a regular basis.

Offer Reassurance

  • Respond in a calm, supportive manner.
  • A gentle tap on the shoulder may turn the person’s attention toward you.
  • Look for the feelings behind the hallucinations. You might want to say, “It sounds as if you’re worried” or “I know this is frightening for you.”
  • Avoid arguing with the person about what he or she sees.

Modify the Environment

  • Check for noises that might be misinterpreted, such as noise from a television or an air conditioner. Look for lighting that casts shadows, reflections or distortions on the surfaces of floors, walls and furniture.
  • Cover mirrors with a cloth or remove them if the person thinks that he or she is looking at a stranger.

Use Distractions

  • Suggest that you take a walk or sit in another room. Frightening hallucinations often subside in well-lit areas where other people are present.
  • Try to turn the person’s attention to music, conversation or activities you enjoy together.

Incontinence and Alzheimer’s

Incontinence, a loss of bladder or bowel control, often occurs in people who have Alzheimer’s. Incontinence can be caused by:

  • Medical conditions. The person may have a urinary tract infection, constipation or a prostate problem. Other illnesses, such as diabetes and stroke, and medication side effects may also trigger incontinence.
  • Fear. The person may fear that an embarrassing accident may occur. This fear may cause him or her to visit the bathroom more times than necessary.
  • Abrupt movement. Urine release may be caused by a sneeze, laugh or cough. Weak pelvic muscles in women can also cause uncontrollable loss of urine.
  • Dehydration. Withholding fluids when a person starts to lose bladder control may compound the problem. Dehydration can create urinary tract infections that lead to incontinence.
  • Diuretics. Certain beverages, such as coffee, cola and tea, may contribute to incontinence.
  • Environment. The person may be having trouble finding the bathroom or getting to it in time because it is too far away.
  • Clothing. Zippers and buttons on clothing could be making it difficult for the person to undress.

Ways to Help

  • Providing visual cues. Signs may assist an individual in finding the bathroom. Placing colored rugs on the bathroom floor and lid covers on the toilet may help the bathroom stand out.
  • Avoiding having items nearby that can be mistaken for a toilet, such as a trash can.
  • Monitoring incontinence. Identify when accidents occur and plan accordingly. For example, if they happen every two hours, get the person to the bathroom before that time. To help control incontinence at night, limit the intake of liquids after dinner and in the evening.
  • Removing obstacles. Make sure clothing is easy for the individual to remove. Clothing with Velcro™ may be easier for the person to remove than clothing with buttons.
  • Providing reminders. Because the person with Alzheimer’s may forget to use the bathroom, you may need to remind him or her periodically. Also watch for visible cues such as restlessness or facial expressions that may indicate the person needs to use the bathroom.

Being supportive. Help the person with Alzheimer’s retain a sense of dignity despite incontinence problems. A reassuring attitude will help lessen feelings of embarrassment.

Sleeplessness and Sundowning in Alzheimer’s Patients

Sleeping problems experienced by individuals with Alzheimer’s and caregiver exhaustion are two of the most common reasons people with Alzheimer’s are eventually placed in nursing homes. Some studies indicate that as many as 20 percent of persons with Alzheimer’s will, at some point, experience periods of increased confusion, anxiety, agitation and disorientation beginning at dusk and continuing throughout the night.

While experts are not certain how or why these behaviors occur, many attribute them to late-day confusion, or “sundowning,” caused by the following factors:

  • End-of-day exhaustion (mental and physical)
  • An upset in the “internal body clock,” causing a biological mix-up between day and night
  • Reduced lighting and increased shadows
  • Disorientation due to the inability to separate dreams from reality when sleeping
  • Less need for sleep, which is common among older adults

To learn more about sundowning, read Caring for Alzheimer’s Patients with Sundowning Symptoms.

Tips for reducing evening agitation and nighttime sleeplessness

  • Plan more active days. A person who rests most of the day is likely to be awake at night. Discourage afternoon napping and plan activities, such as taking a walk, throughout the day.
  • Monitor diet. Restrict sweets and caffeine consumption to the morning hours. Serve dinner early, and offer only a light meal before bedtime.
  • Seek medical advice. Physical ailments, such as bladder or incontinence problems, could be making it difficult to sleep. Your doctor may also be able to prescribe medication to help the person relax at night.
  • Change sleeping arrangements. Allow the person to sleep in a different bedroom, in a favorite chair or wherever it’s most comfortable. Also, keep the room partially lit to reduce agitation that occurs when surroundings are dark or unfamiliar.

Nighttime restlessness doesn’t last forever. It typically peaks in the middle stages, then diminishes as the disease progresses. In the meantime, caregivers should make sure their home is safe and secure, especially if the person with Alzheimer’s wanders. Restrict access to certain rooms or levels by closing and locking doors, and install tall safety gates between rooms. Door sensors and motion detectors can be used to alert family members when a person is wandering.

Once the person is awake and upset, experts suggest that caregivers:

  • Approach their loved one in a calm manner
  • Find out if there is something he or she needs
  • Gently remind him or her of the time
  • Avoid arguing or asking for explanations
  • Offer reassurance that everything is all right and everyone is safe

Dealing with Unpredictable Situations

People with Alzheimer’s disease can act in different and unpredictable ways. It is important to remember that the person is not acting this way on purpose. Whatever the behavior, try to identify the cause and possible solution.

Bold Behavior

Individuals with Alzheimer’s disease may forget that they are married and begin to flirt or make inappropriate advances toward others. When there is unusual, inappropriate behavior, try to distract the person with another activity or lead him or her into a private place. Avoid getting angry or laughing at the person.

Inappropriate Dressing

The person may forget how to dress or take clothes off at inappropriate times and in unusual settings. For example, a woman may remove a blouse or skirt simply because it is too tight or uncomfortable. Help the person dress by laying out clothes in the order they need to be put on. Choose clothing that is simple and comfortable.


The person with Alzheimer’s may not understand or remember that merchandise must be paid for. He or she may casually walk out of the store without paying — unaware of any wrongdoing. Have your loved one carry a wallet-size card that states that he or she is memory-impaired. This may prevent the person with Alzheimer’s disease from feeling embarrassed.


The person may become easily jealous and suspicious. For example, a man may think his wife has a boyfriend if he sees her with their son. A person with Alzheimer’s may also misinterpret an unfamiliar face as someone who is a thief. If the person makes accusations or becomes extremely suspicious, don’t waste time arguing. Try to distract the person with another activity or reassure him or her with a hug or touch.

Managing Wandering Patients With Dementia

An individual with Alzheimer’s disease or a related dementia is likely to become disoriented and wander at some point. Up to 67 percent of those with dementia will wander. Identifying the cause of the behavior can help eliminate or reduce its occurrence. Awareness of the problem can result in reduced injury and death.

What Is Wandering in Dementia?

Persons with dementia have varied movement patterns and trying to identify what qualifies as wandering can be difficult for a caregiver as well as for professionals. Many people with dementia do not fit the textbook definition of wandering, “To move about without a definite destination or purpose.” In fact, persons with dementia may have a definite purpose for their actions.

The working definition that best describes wandering is, “aimless or purposeful motor activity that causes a social problem such as getting lost, leaving a safe environment or intruding in inappropriate places.”

Is Someone I Know at Risk? Warning Signs for Wandering

  1. Returns from a regular walk or drive later than usual
  2. Tries to fulfill former obligations, such as going to work
  3. Tries or wants to “go home” even when at home
  4. Is restless, paces or makes repetitive movements
  5. Has difficulty locating familiar places like the bathroom, bedroom or dining room
  6. Checks the whereabouts of familiar people
  7. Acts as if doing a hobby or chore, but nothing gets done (e.g. moves around pots and dirt without actually planting anything)
  8. Appears lost in a new or changed environment
senior woman using a walker

What Causes Wandering in Dementia Patients?

  • Medication side effects
  • Stress
  • Confusion related to time
  • Restlessness
  • Agitation
  • Anxiety
  • Inability to recognize familiar people, places and objects
  • Fear arising from the misinterpretation of sights and sounds
  • Desire to fulfill former obligations, such as going to work or looking after a child

Tips for Reducing Wandering Behavior

  • Encourage movement and exercise to reduce anxiety, agitation and restlessness
  • Involve the person in productive daily activities, such as folding laundry or preparing dinner
  • Place color-matching cloth/paint over doorknobs
  • Redirect pacing or restless behavior
  • Place a mirror near doorways
  • Reassure the person if he or she feels lost, abandoned or disoriented

Tips for Protecting a Loved One from Wandering

  • Enroll the person in the Alzheimer’s Association’s Safe Return®, a nationwide identification system designed to assist in the safe return of people who become lost when wandering
  • Inform your neighbors and local emergency responders of the person’s condition and keep a list of their names and telephone numbers
  • Keep your home safe and secure by installing deadbolt or slide-bolt locks on exterior doors and limiting access to potentially dangerous areas
  • Be aware that the person may not only wander by foot but also by car or by other modes of transportation

Tips for Preparing for Emergencies

  • Keep a list of emergency phone numbers of the local police and fire departments, hospitals, and poison control as well as the Safe Return 24/7 incident line 1-800-572-1122
  • Keep a list of physicians phone numbers and current medications (with dosages)
  • Keep copies of legal documents (living will, power of attorney, etc.)
  • Check fire extinguishers and smoke alarms, and conduct fire drills regularly