Family caregivers report “irritability” as one of the first behaviors they encounter. It seems like “everything” just pisses off the person living with dementia. I hear caregivers tell me how hard it is to interact with the person living with dementia: “I never know what will set her off.” In this blog, I will explain where the irritability is coming from and what to do about it.
Brain Shrinkage and Irritability
The brain is a lot like a business or company. Every brain cell is a worker and the parts of the brain are the different departments of a company. All of the departments must be staffed properly. In fact, the brain is more like a government bureaucracy—there is definitely overlap and redundancy! Redundancy is how the body protects itself from illness and damage. If one kidney is damaged, the other kidney picks up the slack. The brain is somewhat similar.
Using this example, imagine that the brain is a large government agency with multiple departments. You can pretend the different lobes of the brain are the different departments. The feds decide to trim the budget and eliminate 20 positions. Coincidentally, 20 employees are eligible for retirement, and they decide to leave. Once these 20 people head out the door and move to Florida, work resumes. Nobody feels any impact. The remaining workers easily absorb the functions of the retired workers.
This is sort of what happens when we age. The brain “prunes” away neurons that are not working or haven’t fired in a while. Some neurons simply get old and die off. There are enough neurons to pick up the slack. No biggie.
A year later, and once again, 20 positions are eliminated. The same process happens every year. Some departments lose more positions than others. These departments become the obvious problem children and begin royally screwing up. Other departments run into problems because the problem children are not sending over the correct forms…or are not sending anything over at all!
The office compensates. The better staffed departments share their employees with the departments running with a skeleton crew. Even with these changes, any temporary loss of employees due to sickness or vacation makes it more difficult to function. During these times, there are more arguments, more blaming, more harsh words. Mistakes happen more frequently. A couple of customers notice that things aren’t going as smoothly as possible, and a few comment that it is taking longer to get their orders done. Even though there are glitches, overall the office is meeting expectations.
A couple of months later, 20 more jobs are eliminated. All of the departments are short-staffed. The office has half of its original work force. Work quantity and quality drop. There is daily fighting, hourly disagreements, and continuous arguing. Fewer tasks are being completed correctly. Orders are wrong, projects are abandoned midway. Everything is a mess. Some employees become burned out and simply leave. When a quarter of the original workforce is left, the office is closed because it no longer has enough employees to run the office properly.
What I’ve just described happens in the brains of people with dementia. Sometimes, the loss of nerve cells is sudden, like in a stroke. The majority of times, the loss of brain cells happens quietly over time, just like the gradual layoffs in the example above.
People with Dementia Try to Compensate
People with dementia in the mild stage may start to notice that they have to work a lot harder to get the same things done. They may notice that they cannot tolerate places with a lot of people or noise. This is where family members notice that their loved ones seem to withdraw. They stop wanting to go out. They begin to avoid family functions because they know they will be overwhelmed. They may even withdraw from the caregiver.
It is Not Your Fault
As the brain loses neurons, the brain is unable to pay attention to important things when there is a lot of background noise. The remaining neurons have to work super hard to do the tasks we take for granted. It is exhausting to try to follow a conversation, especially if the person living with dementia is already tired.
Sometimes, the person living with dementia will fuss at the caregiver: “You ask too many questions!” “You talk too much!” The caregiver is obviously hurt and confused, especially if the caregiver is really trying to adjust their communication styles. Here is what you can do:
Pick Your Time
People living with dementia may be at their best first thing in the morning, when there is plenty of “brain juice” swishing around the neurons. If you have an important topic that you need to discuss, this may be the best time. Other good times may be after a rest, like a short nap, or after a pleasant activity. When we engage in pleasant activities, our brains make more happy chemicals that also help reduce irritability.
Talk in a Quiet Place–for Real
Sometimes I call my son while he is working his night shift. I’m an early riser and 4 am is usually quiet, even for highway patrol. I suddenly hear his radio crackle and I immediately stop talking. “Go ahead, it’s fine,” he tells me. Mark can listen to me and filter out his radio because his brain is tuned to specific words and phrases. He has enough neurons to pay attention to our conversation and monitor dispatch.
I’m not that good. I find the radio very distracting. My brain has not been trained about what is important and what is not. I get to feel like a person with dementia because all of the crackles sound the same to me. In fact, if the radio is too busy, I find myself getting irritated and I end the conversation.
You may think you are in a quiet place because the background sounds do not bother you. There is a part of your brain that is hearing the fridge run, the radio play music, and the neighbor mow his grass. But your loved one with dementia is being pulled away by all of these sounds. Their brains are treating these “background” sounds as important messages. They cannot hear you…or they are having trouble focusing. It will help if you are sensitive to these sounds and make sure you and your loved on are in a truly quiet place.
Short, Sweet, Concrete
If you have been reading my blog for any length of time, you are familiar with this phrase. I literally mean: Noun, verb, object. Check out these two sentences, and think about which one is easier to understand:
- Before opening the door, turn on the light.
- Turn on the light and open the door.
#2 is easier, right? It may feel really weird, but that is how to speak with someone who is experiencing mild cognitive impairment and mild dementia. The shrinking brain literally cannot “hold onto” too many ideas at once.
People in the mild stage of dementia start to act irritable because their brains are working harder to stay at baseline. Brains that work harder also get more tired. By changing your approach, you may find that you can have good talks without trigging the irritable behavior. If the irritable behavior shows up, you now know why. It is not your fault.
Dr. Rita Jablonski
Rita Jablonski, PhD, CRNP, FAAN, FGSA is a nurse practitioner, researcher, tenured professor, and former family caregiver. Her research and practice involve all aspects of dementia management; she is best known for non-drug strategies to address dementia-related behaviors.