Addressing Startling Behaviors in Long-Term Care


Gregg Warshaw, MD

Medical Editor


Currently, more than 16 million adults in the United States, the majority of who are older, are living with some form of cognitive impairment. This condition has numerous etiologies, from head trauma, to stroke, to progressive dementias, such as Alzheimer’s disease. In addition, adverse effects from various medications may result in cognitive impairment in older adults. The manifestations of cognitive impairment are as varied as its etiologies, making it a challenging condition to manage, particularly when startling behaviors are encountered. In long-term care (LTC) facilities, where cognitive impairment tends to be more severe, these behaviors may be wrongly attributed to the underlying cognitive impairment; however, in some cases, they may have an independent  cause. In this issue of Annals of Long-Term Care: Clinical Care and Aging® (ALTC), we include several articles that examine undesirable behaviors and symptoms in cognitively impaired persons residing in LTC facilities. In two of these articles, the undesirable behavior was not a manifestation of the cognitive impairment, demonstrating the importance of considering a variety of other triggers when encountering such scenarios.

In “There’s a Monster Under My Bed: Hearing Aids and Dementia in Long-Term Care Settings”, the authors demonstrate that sensory deficits in patients with dementia can cause startling behavior. The authors provide a case report of a patient who was legally blind, deaf in one ear, and severely hearing impaired in the other, necessitating use of a hearing aid. The patient started to become agitated and confused at night, tugging at her urinary catheter and screaming that she had been assaulted. After a thorough physical examination that included a hearing assessment, it was determined that her hearing aid battery had been depleted. Once it was replaced and her hearing restored, these events stopped until her battery became depleted again. After this incident, her care plan was improved to ensure regular hearing screenings and hearing aid battery changes, and no other events occurred. This Clinical Experience report underscores the importance of considering and addressing sensory deficits in patients with dementia.

In “Borderline Personality Disorder in Residential Care Facilities”, the authors report the case of two patients with cognitive impairment not otherwise specified who demonstrated disturbing behavioral issues, with one resident consistently antagonizing staff and thwarting care attempts, and the other threatening staff with a butcher knife. Upon psychiatric evaluations, it was determined that both patients had borderline personality disorders (BPD), a condition that has received little attention in the literature with regard to older adults. Instead of using a pharmacological approach to manage these patients’ BPD, the authors focused on nonpharmacological interventions, specifically validation therapy with limit-setting. Although this intervention did not completely eliminate the problems associated with the patients’ BPD, such as splitting, it did make them manageable.

Finally, we include a Practical Research report by a group of Finnish investigators, which outlines their experience with using a cholinesterase inhibitor, memantine, or a combination of these agents to manage symptoms of Alzheimer’s disease, such as cognitive decline, depression, social engagement, and inappropriate behavior, in a group of nursing home residents. The authors found that combination therapy with a cholinesterase inhibitor and memantine was associated with favorable outcomes, with patients receiving combination therapy having less deterioration in cognition and communication skills and requiring fewer restrictions. In addition, more study participants receiving dementia medication were able to discontinue using antipsychotics. To put their study findings in context, the authors provide a brief review of the literature. Clearly, more research is needed in this area.

We hope you enjoy this issue of ALTC and we welcome your feedback on any of the articles. You can send your comments to our assistant editor, Allison Musante, at

Thank you for reading!

‹ Previous articleNext article ›