Have you ever been told that your heart rate is slow, or maybe too slow?

This is called bradycardia, and it’s fairly common in older adults. Whereas in younger adults, a slow heart rate is often due to being in good cardiovascular shape, with aging, a slower heart rate often reflects changes in the heart’s electrical system. (Medications are another common cause.)

This can be an issue because a slower heart rate can cause symptoms such as fatigue, dizziness, falls, or trouble keeping up with usual activities.

Fortunately, in certain situations, a pacemaker can be an effective treatment that helps older adults feel substantially better.

To help older adults learn more about bradycardia and when to consider a pacemaker, I interviewed cardiologist Cara Pellegrini, MD, who specializes in cardiac electrophysiology. Here’s what’s most important to know, based on our conversation.

What Is a Pacemaker and How Does It Help a Slow Heart Rate?

A pacemaker is a small electronic device that monitors the heart’s electrical activity and can stimulate the heart to produce a heartbeat when needed.

Pacemakers are generally used when the heart is beating too slowly.

A pacemaker has three basic components:

1. A battery, which powers the device
2. A computer, which monitors the heart and determines when pacing is needed
3. A connection to the heart, either through traditional wires called leads or through electrodes built into a leadless pacemaker

The pacemaker continually monitors what the heart is doing.

If enough time passes without an appropriate heartbeat, the device delivers a small electrical stimulus that causes the heart to beat.

People generally do not feel the electrical stimulation from an ordinary pacemaker.

For many older adults with symptomatic bradycardia, a pacemaker is used primarily to improve symptoms and quality of life. With certain types of heart block, however, a pacemaker can also be life-saving.

To understand when a pacemaker is needed, it helps to first understand what doctors mean by a slow heart rate.

What Is Bradycardia, or a Slow Heart Rate?

Bradycardia is the medical term for a slow heart rate.

It is usually defined as a heart rate below 60 beats per minute.

But a heart rate below 60 does not automatically mean something is wrong.

For example, younger athletic adults commonly have resting heart rates in the 40s or 50s without having a medical problem. Some older adults may also have a relatively slow resting heart rate and feel perfectly well.

So the heart-rate number by itself does not determine whether treatment is needed.

What matters more is whether the heart is beating fast enough for the body’s needs, and whether the heart is able to increase the heart rate enough with physical activity.

How the heart’s electrical system works

The heart is a pump, but it also has its own electrical system.

Normally, each heartbeat begins in the sinus node, also called the sinoatrial or SA node. You can think of the sinus node as the heart’s natural pacemaker.

The sinus node generates an electrical signal. That signal travels through the upper chambers of the heart, called the atria, and then reaches the atrioventricular, or AV, node.

From there, the signal travels into the heart’s lower pumping chambers, the ventricles.

This allows the different parts of the heart to contract in a coordinated way.

Problems with either generating this electrical signal or transmitting it through the heart can cause the heart rate to become too slow.

What Heart Rate Is Too Low for an Older Adult?

There is no single heart-rate number that is too low for every older adult.

A very low heart rate, such as one in the 20s or 30s, is clearly concerning.

In an older person, a resting heart rate in the 40s may also warrant further evaluation, especially if the person is having symptoms such as dizziness, fatigue, fainting, or difficulty with exertion.

But doctors also need to consider what happens to the heart rate during physical activity.

Some people have a resting heart rate in the 50s or 60s and feel fine while sitting. But when they walk, climb stairs, or otherwise exert themselves, their heart rate cannot increase enough to meet their body’s increased demand for blood flow.

This is called chronotropic incompetence.

Chronotropic incompetence can be one of the earliest signs of sinus node dysfunction, a common cause of bradycardia in older adults.

So when deciding whether a heart rate is “too low,” doctors consider both:

• How low the heart rate is at rest
• Whether the heart rate increases appropriately with activity
• Whether the slow heart rate is causing symptoms

What Are the Symptoms of Bradycardia in Older Adults?

When the heart is beating too slowly to provide the blood flow the body needs, symptoms of bradycardia can include:

• Fatigue or low energy
• Dizziness or lightheadedness
• Shortness of breath
• Becoming unusually short-winded with activity
• Reduced ability to exercise or perform usual activities
• Mental clouding or confusion
• Feeling as though you might pass out, known as presyncope
• Fainting, known medically as syncope

Can a slow heart rate cause fatigue?

Yes. Fatigue and reduced exercise tolerance are common symptoms when the heart rate is too slow for the body’s needs.

Some people notice that activities they previously managed easily become much more tiring.

Can bradycardia cause dizziness or falls?

Bradycardia can cause dizziness, near-fainting, and fainting.

In geriatrics, falls can sometimes be part of the picture as well.

For instance, if an older person suddenly falls and cannot clearly explain what happened, it can be worth considering whether they briefly became lightheaded or lost consciousness.

That said, fatigue, dizziness, shortness of breath, confusion, and falls can all have many possible causes in older adults.

So simply finding a slow heart rate does not prove that bradycardia is causing the symptoms.

The important detective work is determining whether the symptoms and the slow heart rate are actually occurring together.

Why Do Slow Heart Rates Become More Common With Aging?

One of the most common reasons older adults develop an abnormally slow heart rate is age-related changes in the heart’s electrical system.

Over time, scar-like tissue can develop in areas involved in generating and transmitting electrical signals.

Eventually, these changes can interfere with the heart’s ability to maintain an appropriate heart rate.

Cardiovascular risk factors such as high blood pressure may contribute to this process.

But aging is not the only possible cause of bradycardia.

Other contributors can include:

• Certain medications, including
  • Cardiovascular medications such as beta-blockers and calcium channel blockers
  • Medications for irregular heartbeats (e.g. atrial fibrillation) such as amiodarone
  • Alzheimer’s medications such as donepezil
• Thyroid problems
• Electrolyte abnormalities
• Certain infections
• Inflammatory illnesses
• Heart surgery or valve procedures that affect electrical conduction

This is important because some causes of a slow heart rate can be reversed without placing a pacemaker.

Sinus Node Dysfunction vs. AV Block: Two Important Causes of Bradycardia

When evaluating bradycardia, doctors try to determine where the problem is occurring in the heart’s electrical system.

Two particularly important causes are sinus node dysfunction and AV block, sometimes called heart block.

What is sinus node dysfunction?

The sinus node is the heart’s natural pacemaker.

When it begins generating electrical signals too slowly, or is unable to increase the heart rate enough when the body needs it, this is called sinus node dysfunction.

You may also hear the older term “sick sinus syndrome.”

Sinus node dysfunction often develops gradually with aging.

Possible symptoms include:

• Low energy
• Fatigue
• Reduced exercise tolerance
• Dizziness
• Falls
• Mental clouding

It is one of the common reasons older adults eventually receive pacemakers.

What is AV block or heart block?

AV block is different.

With AV block, the sinus node may be generating electrical signals normally, but those signals have difficulty reaching the heart’s lower chambers.

In other words, the problem is not necessarily that the electrical signal isn’t being created. Instead, the signal is being blocked as it travels through the heart.

Certain types of AV block can develop more suddenly and can be much more serious than typical sinus node dysfunction.

They may cause:

• Very slow heart rates
• Fainting
• Falls
• Sudden loss of consciousness

Some forms of AV block can be life-threatening and generally require a pacemaker.

How Is Bradycardia Diagnosed?

The tests used to diagnose bradycardia depend on what symptoms are happening and when they occur.

Checking the resting heart rate

A slow heart rate is often first noticed during a routine medical visit.

A pulse oximeter, blood pressure monitor, smartwatch, or other device may also reveal an unusually low heart rate.

If a person’s heart rate used to be higher and has recently become persistently slower, that can be useful information for the healthcare team.

Electrocardiogram or ECG

A standard 12-lead electrocardiogram, also called an ECG or EKG, records the electrical activity of the heart.

An ECG can help doctors determine both how fast the heart is beating and whether the electrical signals are moving through the heart normally.

The limitation is that an ECG only provides a brief snapshot.

If bradycardia or pauses happen intermittently, they might not occur during the few seconds being recorded.

Wearable heart monitors

If symptoms come and go, doctors may recommend wearing a heart rhythm monitor or patch.

These devices can record heart rhythm over several days or weeks.

One of the main goals is to determine what the heart was doing at the time symptoms occurred.

For example, if someone becomes dizzy while walking, doctors can review the recording to determine whether the heart rate became unusually slow at that time.

Exercise or treadmill testing

When symptoms mainly occur with physical activity, exercise testing can be particularly useful.

The person may walk on a treadmill while the heart rate and rhythm are monitored.

This allows doctors to see whether the heart rate rises appropriately during exertion.

If it does not, this may help identify chronotropic incompetence.

Can Medications Cause a Slow Heart Rate?

Yes. Medications are an important and potentially reversible cause of bradycardia, especially in older adults.

Several commonly used heart medications can slow the heart rate.

These include:

• Beta-blockers, such as metoprolol
• Calcium-channel blockers, such as diltiazem
• Digoxin
• Amiodarone and certain other anti-arrhythmic medications

These medications may be prescribed for important reasons, such as atrial fibrillation, heart failure, high blood pressure, or another heart condition.

There are also non-cardiac medications that can cause a slower heart rate in some people, such as donepezil, which is often prescribed for Alzheimer’s and other forms of dementia.

So the answer is not necessarily to stop them.

Instead, the healthcare team should determine whether a medication could be contributing to the slow heart rate and whether the dose or treatment plan can safely be changed.

It is also important to review all medications, not just pills.

For example, beta-blockers are sometimes used as eye drops for glaucoma. Enough of the medication can occasionally be absorbed into the body to slow the heart rate.

So when investigating bradycardia, make sure the healthcare team knows about:

• Prescription medications
• Over-the-counter medications
• Eye drops
• Herbs
• Supplements

What Other Reversible Causes of Bradycardia Should Be Checked?

Before recommending a pacemaker for chronic bradycardia, doctors should consider whether there is a reversible cause.

Depending on the situation, this may include:

• Reviewing and adjusting medications
• Checking thyroid function
• Checking electrolytes
• Looking for certain infections
• Considering inflammatory illnesses
• Considering whether a recent heart procedure temporarily affected the electrical system

If one of these underlying problems can be corrected, the heart rate may improve without requiring a pacemaker.

For chronic sinus node dysfunction, however, there generally isn’t a long-term oral medication that reliably fixes the underlying problem.

When Is a Pacemaker Needed for Bradycardia?

For sinus node dysfunction, pacemaker placement is usually not an emergency.

The key question is:

How likely is the slow heart rate to be causing this person’s symptoms, and how likely is a pacemaker to help?

Doctors may consider questions such as:

• Is fatigue being caused by the low heart rate?
• Is dizziness occurring during episodes of bradycardia?
• Is poor exercise tolerance related to chronotropic incompetence?
• Is the person fainting or nearly fainting because the heart rate is too low?
• Would increasing the heart rate likely improve function or quality of life?

Sometimes the connection between symptoms and bradycardia is clear.

Other times, longer-term monitoring or exercise testing can provide more confidence before a pacemaker is recommended.

When symptomatic bradycardia is due to chronic sinus node dysfunction and reversible causes have been addressed, a pacemaker is generally the main treatment.

Certain forms of AV block are different.

Because serious AV block can be dangerous or life-threatening, a pacemaker may be recommended primarily for safety rather than symptom relief.

Standard vs. Leadless Pacemakers in Older Adults

There are now several ways to provide cardiac pacing.

The right pacemaker depends on the type of electrical problem, the heart’s overall function, and the person’s individual circumstances.

Standard pacemakers

A traditional or transvenous pacemaker generally consists of a small device placed under the skin near the shoulder.

One or more wires, called leads, travel through blood vessels from the device into the heart.

Depending on a person’s needs, the pacemaker may have one or more leads.

A single-chamber pacemaker uses one lead.

A dual-chamber pacemaker generally uses two.

Doctors usually try to choose the simplest device that will adequately meet the person’s needs.

What is a leadless pacemaker?

A leadless pacemaker is a small, self-contained pacemaker placed directly inside the heart.

Rather than making an incision near the shoulder, the device is inserted through a catheter placed into a large vein, usually through the groin.

There is no traditional wire connecting a pacemaker near the shoulder to the heart.

One of the major advantages is a faster and simpler recovery because there are no shoulder-related lead restrictions.

This may be especially useful for older adults who rely heavily on their arms to:

• Push themselves up from a chair
• Use a walker
• Transfer in and out of bed
• Perform other everyday activities

Is a leadless pacemaker better for older adults?

A leadless pacemaker can be a very good option for some older adults, particularly when basic pacing is all that is needed and avoiding shoulder restrictions would make recovery easier.

But it is not automatically better for everyone.

Leadless pacemakers do not provide all the monitoring or pacing capabilities of standard systems, and they cannot always be upgraded in the same way if other heart problems develop later.

The choice should therefore be based on the person’s particular pacing needs and overall health.

What Are Biventricular Pacemakers?

Another type of device is a biventricular pacemaker, also called cardiac resynchronization therapy, or CRT.

This device is generally used for certain people with heart failure.

Rather than simply preventing a slow heart rate, it helps different areas of the heart contract in a more coordinated way.

This can improve the heart’s pumping efficiency in appropriately selected people.

A biventricular pacemaker is therefore different from the standard pacemaker commonly used to treat age-related sinus node dysfunction.

What Is an Implantable Cardioverter Defibrillator?

An implantable cardioverter defibrillator, or ICD, is another implanted heart device that people sometimes confuse with a pacemaker.

An ICD can generally perform pacemaker functions, but it also monitors for certain dangerous fast heart rhythms.

If it detects a life-threatening rhythm, the ICD may first try to stop it using rapid pacing.

If that doesn’t work, it can deliver a much stronger electrical shock to reset the heart’s rhythm.

Unlike ordinary pacemaker stimulation, an ICD shock can be felt.

ICDs may be recommended for people with conditions such as:

• Certain forms of severe heart failure
• Previous ventricular tachycardia
• Previous sudden cardiac arrest requiring resuscitation

Someone who simply has age-related sinus node dysfunction generally does not need an ICD.

What Is Pacemaker Implantation Like?

Pacemaker implantation is generally a relatively short procedure.

Many people can go home the same day, although some spend one night in the hospital.

The procedure itself often takes approximately one to two hours.

A standard pacemaker generally involves a small incision near the shoulder.

A leadless pacemaker is placed through a large vein using a catheter.

Does pacemaker surgery require general anesthesia?

Usually not.

The amount of sedation is individualized, but many people receive conscious sedation or monitored anesthesia care.

This means they continue breathing on their own but receive medication to reduce anxiety, discomfort, and awareness of the procedure.

Is pacemaker implantation painful?

Experiences vary, but most people require relatively little pain medication afterward.

Some need none.

Others may take a few doses of acetaminophen.

It is unusual to need narcotic pain medication after a routine pacemaker procedure, and discomfort usually improves within several days to about a week.

How Long Does It Take to Recover From a Pacemaker?

Recovery depends partly on whether someone receives a standard or leadless pacemaker.

Recovery after a standard pacemaker

After a traditional pacemaker is placed near the shoulder, people are often advised for about six weeks to avoid:

• Raising the arm on the pacemaker side high above the head
• Lifting more than about 10–15 pounds with that arm

The goal is to reduce the risk of pulling one of the newly placed leads out of position.

But this does not mean keeping the arm completely still.

Gentle use is important, especially in older adults, because prolonged lack of shoulder movement can contribute to stiffness or frozen shoulder.

After the initial healing period, most people can return to their usual physical activities.

Recovery after a leadless pacemaker

Recovery after a leadless pacemaker is generally faster.

There are no prolonged arm restrictions because there are no leads running from the shoulder into the heart.

Heavy lifting may still be restricted for about five to seven days while the catheter insertion site heals.

For some older adults, this easier recovery is an important advantage.

What Is It Like to Live With a Pacemaker?

For most people, the goal of a pacemaker is to allow them to return to ordinary life with relatively few restrictions.

How pacemakers are monitored

Most modern pacemakers can be monitored remotely.

People may receive a small device that communicates with the pacemaker and sends information to their healthcare team.

Some systems can also use a smartphone app.

Remote monitoring can provide information about:

• Heart-rate patterns
• How often the pacemaker is pacing
• Certain abnormal rhythms
• Battery status
• How well the device is functioning

Changing the pacemaker’s settings generally requires an in-person visit.

How long does a pacemaker battery last?

Pacemaker batteries often last roughly 7–10 years, although this varies depending on the device and how much pacing is required.

The battery is monitored over time, so replacement can generally be planned well before it runs out.

For a standard pacemaker, replacement often involves reopening the small area near the shoulder, disconnecting the old generator from the existing leads, and connecting a new device.

If the leads do not need to be changed, recovery is usually easier than after the original implantation.

For leadless pacemakers, the options may include removing and replacing the device or placing a new device alongside it, depending on the particular system.

Can You Travel, Have an MRI, and Use Household Devices With a Pacemaker?

After the initial recovery period, most people with pacemakers can return to ordinary activities.

People are usually given an identification card listing the pacemaker model and other important information.

It is useful to keep this card available when traveling or receiving medical care.

Ordinary household appliances generally do not pose a problem.

Many newer pacemakers also allow MRI scanning under specified conditions.

However, anyone with a pacemaker should always tell the healthcare team about the device before having an MRI or another medical procedure so that the specific model and precautions can be checked.

Can Someone in Their 90s Get a Pacemaker?

Yes. Advanced age by itself does not automatically rule out a pacemaker.

A more useful question is whether the pacemaker is likely to provide meaningful benefit for that particular person.

For an older adult with symptomatic sinus node dysfunction, improving the heart rate may help with:

• Fatigue
• Dizziness
• Falls
• Reduced mobility
• Poor exercise tolerance
• Mental clouding

In some very old adults, correcting significant bradycardia can noticeably improve function and quality of life.

The decision should be based on overall health, expected benefit, procedural burden, and the person’s preferences — not simply chronological age.

Should Someone With Dementia Get a Pacemaker?

Having Alzheimer’s disease or another form of dementia does not automatically mean a pacemaker is inappropriate.

The important question remains:

What benefit are we hoping the pacemaker will provide, and how likely is it to provide that benefit?

In someone with memory problems, it can be harder to determine whether symptoms such as fatigue, reduced activity, or mental clouding are actually being caused by bradycardia.

That can make the decision less certain.

Still, if there is good reason to believe the slow heart rate is causing significant symptoms, a pacemaker may improve function or quality of life.

The decision should consider:

• How likely bradycardia is to be causing symptoms
• What improvement can realistically be expected
• The risks and burdens of the procedure
• The person’s frailty and other health conditions
• How difficult recovery would be
• The person’s goals and preferences

For some frail older adults or people with memory problems, the shorter recovery associated with a leadless pacemaker may also be worth discussing.

Does a Pacemaker Extend Life?

The answer depends on why the pacemaker is needed.

For typical sinus node dysfunction, the main benefit is often improved symptoms, function, and quality of life.

Sinus node dysfunction is generally not immediately life-threatening.

Certain forms of AV block are different.

If electrical signals can no longer reliably reach the ventricles, a pacemaker can potentially be life-saving.

Some people are also pacemaker-dependent, meaning they rely heavily on the device to maintain an adequate heartbeat.

But most people with pacemakers are not completely pacemaker-dependent.

What Happens to a Pacemaker at the End of Life?

Pacemakers can be turned off, but this is not routinely necessary for most people approaching the end of life.

One reason is that most people are not fully pacemaker-dependent.

Another is that a pacemaker can continue to support comfort and function without necessarily preventing the natural dying process.

A pacemaker does not mean that a person cannot die naturally when the rest of the body is shutting down.

The situation is somewhat different with an ICD.

Because an ICD can deliver a strong electrical shock in response to certain dangerous fast heart rhythms, people approaching the end of life sometimes choose to have the shock function turned off.

If the ICD is also providing necessary pacing, the pacing function can remain active while the shock function is deactivated.

These decisions should reflect the person’s goals, values, and overall plan of care.

Questions to Ask Your Healthcare Provider About Bradycardia and Pacemakers

If you or an older person you care about has been diagnosed with bradycardia or has been advised to consider a pacemaker, here are some useful questions to ask:

1. Could there be a reversible cause of the slow heart rate?
2. Could any medications be contributing?
   Be sure to review prescription medications, over-the-counter drugs, eye drops, herbs, and supplements.
3. How sure are we that my symptoms are being caused by bradycardia?
4. Would additional heart monitoring or exercise testing help?
5. Is this sinus node dysfunction, AV block, or another electrical problem?
6. What benefit do you expect a pacemaker to provide in my situation?
7. What type of pacemaker would be most appropriate?
8. Would a leadless pacemaker be an option?
9. Do I need an echocardiogram to assess my heart function before choosing a device?
10. What will recovery involve given my mobility, frailty, and other health conditions?

The Bottom Line on Slow Heart Rates and Pacemakers in Older Adults

A slow heart rate becomes increasingly common with aging, but not every heart rate below 60 requires treatment.

What matters most is whether the heart is beating fast enough to meet the body’s needs.

Bradycardia can cause fatigue, dizziness, shortness of breath, reduced exercise tolerance, confusion, near-fainting, fainting, and sometimes falls.

Doctors may use an ECG, longer-term heart monitoring, or exercise testing to determine whether the slow heart rate is actually responsible for a person’s symptoms. They should also look for potentially reversible causes, especially medications, thyroid problems, electrolyte abnormalities, and certain illnesses.

When persistent bradycardia is due to sinus node dysfunction and is causing symptoms, a pacemaker can be a very effective treatment.

Pacemaker implantation is generally a relatively straightforward procedure, and newer leadless pacemakers may offer an easier recovery for some older adults.

For someone who is very old, frail, or living with dementia, the decision should ultimately come back to one of the most important principles in geriatrics:

Is this treatment likely to help this person feel better, function better, and receive care that is consistent with what matters most to them?

(This article is by my colleague Paula Spencer Scott, author of the book Surviving Alzheimer’s: Practical Tips and Soul-Saving Wisdom for Caregivers. I invited her to share an article on this topic, since many in our community are coping with dementia behaviors. — Dr. K)

The odd behaviors of Alzheimer’s and other dementias can be so frustrating and stressful for families.

I’m talking about the kinds of behaviors that try patience, fray relationships, and drive us in desperate search of help:

“First she thinks the caregiver is stealing her sunglasses and now she accused me of having an affair.”

“When I tried to help Dad wash up, he hit me.”

“My husband follows me so closely I can’t stand it. But if I go in another room he’ll wander out of the house.” 

“Mom started unbuttoning her shirt in the middle of the restaurant!”

“Just when I’m completely exhausted at the end of the day, he seems to get revved up. He keeps peeking out the windows, convinced that someone is trying to break in. Now he won’t sleep.”

A common approach to sundowning and difficult behaviors is to go right to medicating them with tranquilizers, sedatives, or antipsychotics. But that’s risky and often not what’s best.

In fact, experts recommend trying behavior management first, and for good reasons: It tends to be more effective in the long run than “chemical restraints,” has no dangerous side effects, and leads to a better care relationship. But people often don’t know how to do this.

I’ve learned how.

I’ve lived through five close family members’ experiences with Alzheimer’s and other forms of dementia. Lots of trial and error, and insights from dozens of top dementia experts (whose brains I’ve been lucky to pick as a journalist and dementia educator), got me through regular scenes with…

• My father-in-law, who needed a walker to move yet spent hour after hour for several days straight hauling all his clothes and toiletries from his room to our driveway, insisting that his (imaginary) new wife was about to pick him up
• My dad, a formerly sharp dresser who wore the same shirt and pants every day no matter how dirty
• My grandmother, who insisted on going “home,” when she was home
• And other relatives, in dozens of similar scenes.

In this article, I want to share what I wish someone had explained to me early on: the “Why-This, Try-This” approach to dealing with difficult behaviors.

This is a mental framework that can help you get unstuck from unproductive responses that get you nowhere or make things worse.

It can bring calm -– to both of you — whether the issue is verbal or physical aggression, agitation, confusion, wandering, disinhibition, delusions, hallucinations, or a restless or repetitive behavior (like pacing, shadowing, rummaging). It also works well with milder irritants like repetitive questions and indecision.

Then, I’ll boil down the Why-This, Try-This concept to a 7-step process you can use every time. These “7 R”s give you a basic platform for responding to any frustrating behavior:

1. Reassure the person
2. Review the possible causes
3. Remove any triggers
4. Redirect behavior or attention
5. Restore yourself
6. Review what happened
7. Reach out for help as needed

The “Why-This, Try-This” Approach

You can’t reason with the person to get out of these situations.

You need to look for the reason why it’s happening in the first place.

To turn things around, consider:

• WHY This? There’s almost always a “WHY” behind a dementia behavior.
• TRY This! Build off that insight to TRY different ways of shifting the behavior to something less intense, more appropriate, or more positive.

WHY This?

Believe it or not, there actually is a “why” behind nearly all dementia behavior. Often there are multiple reasons at once.

Fundamentally, a challenging behavior is a reaction to a set of circumstances, expressing something that the person may be otherwise unable to convey.

As cognitive and communication abilities wane, it becomes harder for a person with Alzheimer’s to say things like, “I’m confused” or “I’m feeling anxious” or “I just want to be left alone.”

The natural response to all these challenges is frustration, defensiveness, anger, anxiety, or fear. We all act on certain ways when we’re feeling uneasy, mad, insecure, frustrated and so on. These are magnified in someone with dementia, who is even less equipped to deal.

Certain types of dementia can bring added stressors. With Lewy body dementia, for example, visual hallucinations are common. With frontotemporal dementia, impulse control erodes, so you’re more likely to encounter problems like uncharacteristic cursing or sexual behaviors.

Just reminding yourself that there IS a “why” can help extend your empathy and patience.

TRY This!

There’s no single right way to respond to most situations. In many cases, several different things could work, depending on the person and the circumstances.

But here’s what pretty much never works: things like sharp words, attempting to reason with the person, or worse yet, using force.

Instead you’ll need words and actions that are more gentle, more loving – and yep, sometimes downright creative. Although you can’t always stop an irritating behavior, you often can make it less bothersome, safer, or more acceptable, and even over time lower its frequency.

Be ready to do some trial-and-error. If one response isn’t doing the trick, you can almost always try something else that will.

Now with this “Why-This, Try-This” framework in mind, let’s go through the seven steps you can use to put this in action.

7 steps to managing difficult dementia behaviors

1. REASSURE the person

The hard truth: the person with dementia can’t change the way he or she is. You have to change — your reaction and the environment or situation.

So putting the person first in your thinking as you react is paramount.

Reassuring brings anxiety, upset, or other stress down a notch. It communicates I’m on your side. I take you seriously. Not feeling understood makes anyone more distressed. For someone with dementia, you create a floor to what must feel like bottomless uneasiness.

The catch: To reassure someone else, we first have to collect our own feelings. This can be hard because these are almost always emotionally charged situations!

It’s easy to feel annoyed when your parent is about to drive off yet another caregiver with false accusations.  Or scared when your spouse lashes out or hits.  Or embarrassed when Mom’s blouse comes off. Or worried Dad will fall or get lost. We want to REACT!

Showing emotional intensity only makes things worse. It puts the other person on the defensive and adds to their instability (more combative, less cooperative). Also, people with dementia tend to be very sensitive to others’ moods, mirroring their demeanor. If you’re upset, they’re apt to continue to be upset or become more upset. If you’re calm and reassuring, you have a much better chance of transmitting that state.

And avoid making the mistake of assuming they’ll forget your angry moment. Research suggests that although people with dementia quickly forget what was said, the emotional impact of an encounter (whether it was negative or positive) lingers for much longer.

How to reassure:

Collect yourself. Do whatever works for you but know that it’s useful to have a “go to” strategy before you dive in. Examples: Take a deep breath. Count silently to three. Have a “silent scream” in the bathroom. I’d consciously remind myself, “It’s not him (or her); it’s the dementia!”— and I needed to enter my relative’s reality.

Approach slowly and from the front. You’re less likely to startle, confuse, or provoke.

Avoid urging, “Calm down!” Seems like the most natural response in the world, right? But when someone is feeling out of control, it’s like grease on fire. It feels dismissive, rather than reassuring. Also avoid asking, “What’s wrong?” The person with dementia likely can’t articulate it and is left feeling more helpless, rather than helped.

Stop yourself from reacting with logic (no matter how tempting). You CANNOT reason with the person, win an argument, or use facts or “proof” to prove your point. It won’t work. So set that impulse aside.

Respond to the emotion being expressed, rather than the behavior. Instead of saying things like, “Don’t do that!” or “What are you doing?!” focus on validating the person’s mood as you assess the situation.

Even before you understand what’s going on, you can play back what you think they’re feeling: “You sound upset.” “You look like you’re in a hurry.” “You look sad; can I help?” “I know this bothers you a lot. Let me see how I can help.”

Some people respond to a special saying or soothing mantra that you can repeat as needed: “I’m here.” “Everything’s all right.” “Not to worry, love.”

Use body language that matches your words. More than half of any message we give (to anyone) is conveyed nonverbally. But this is especially true when someone has dementia. Avoid sighing or rolling your eyes. Relax your posture. Make eye contact. Smile. Nod. Use a friendly tone of voice. All make the listener more open to what you have to say. Touch can also reassure and guide, such as lightly placing your fingers on a forearm, outstretching your hand in invitation, or putting an arm around a shoulder.

2. REVIEW the possible causes

Upsetting behaviors are seldom done “on purpose” or to spite you or annoy you. That requires a sophisticated level of cognition that the person with dementia is struggling to maintain or has more likely lost.

Usually, several factors together influence behavior. My widower father-in-law, lonely and probably bored, and prone to delusions, invented several wives; he’d waken from a nap (where maybe he dreamt about them) and expect one to be in the room. If she wasn’t, she must have “stepped out” or “went in the hospital” and he needed get there PRONTO! Eroded thinking skills make it hard to process reality.

Another common example: Someone who misplaces her sunglasses can’t mentally retrace her steps to figure out where she left them, so she explains away the gap as theft.

How to try to understand the “WHY”:

Consider the timing. Is this a change that’s come on over recent hours or perhaps the last few days? Suspect delirium due to illness, or something about the immediate situation. A recent change in medications could also be the culprit.

Ask yourself if there’s a pattern to when or where the problem seems to happen. Is there something about the light, noise, or activity at that time (or place) that’s different? A common escalation of restless behaviors in late afternoon or early evening is known as sundowning (as in, when the sun goes down). One theory is that there’s a disruption of the body clock in some people with dementia related to light. Vision problems, low lighting, shadows, and fatigue can all increase sundown syndrome.

Make a mental sweep of what’s new or different that might have set the person off. Was there a change in routine? A new aide? A changed or new prescription? Houseguests? Are there other symptoms of illness?

Consider possible unmet needs. At the root of odd behaviors is often:

• A basic physical need. Hunger makes anyone hangry—and people with dementia often forget to eat or get distracted easily during meals. Does an incontinence product need to be changed? Is the space particularly hot or cold for how the person is dressed? A poor night’s sleep, or chronic bad sleep, adds confusion and crankiness by day and leads to exaggerated reactions.
• Pain. People with dementia are notoriously bad at reporting pain. If you ask, you might hear “no.” Watch for body language, like wincing, moaning, or rubbing/favoring a body part (like an arm, forehead, or side). Less obvious sources to consider include ill-fitting dentures, tooth decay, cuts or sores on the feet from poorly fitting shoes or diabetic ulcers, and pressure sores from sitting or lying in one spot.
• Another physical cause. Constipation or mild dehydration can easily influence dementia behavior.
• Overstimulation. Are there a lot of people around? Fast-paced activity? A need to rush? Too much going on can fuel anxiety and meltdowns. What’s the sound level? Background noise (even things like a dishwasher running) can make it hard to hear, adding frustration for someone who already has trouble following conversations.
• Understimulation/boredom. Many repetitive behaviors (pacing, skin picking, rummaging) have roots in not having enough to do. They become default modes that provide both stimulation and comfort, even if they drive others crazy. Wandering is often the expression of an old habit (walking or driving, feeling free and mobile) coupled with a need for stimulation. People who have been busy their whole lives, such as caring for a family or working at a job, have a deep-wired yearning to stay busy.
• Frustration. Is the activity at hand frustrating because it’s too challenging or the person can’t remember how? Does he feel misunderstood when no one believes a delusion? The struggle to keep up and hold it together all day can take a toll; the person snaps.
• Feeling unsafe or insecure. A new situation (a different aide, a crowded public place) or a deviation from routine (air travel, a doctor appointment during nap time) can fuel anxiety or fear. Hallucinations or physical issues can create unnerving misperceptions; poor vision can turn shadows ominous, for example. Someone who feels unsure, threatened, or taken by surprise might lash out verbally or physically.

Ask the person questions that show you’re on their side—which might also yield clues to what’s going on. Avoid “Why?” because the person can’t articulate feelings and motives. (“Why do you think that?’ “Why are you doing that?”)

Better: Interested questions that use the other W’s (who, what, when, where). “When did you notice?” “Where did she go?”

Riff off what they’re saying or doing: To someone insistent on going home, you might ask, “Who’s at home?” or “What would you like to do when you get home?” With a wanderer, the conversation might go like this: “Where do you need to go?” “To work.” “What will you do at work?” “Meetings!” “Oh, what are the meetings about today?”

Four terrific words to use: “Tell me about it.” It’s a respectful, open-ended way to gather info and insight.

3. REMOVE any triggers

By eliminating what sets off a behavior, you might be able to end it.

My father kept taking a stopped clock off the wall every time he walked past it. I mean every time! He wanted to repair it but had lost the thinking skills to follow-through. Stupidly, I kept putting it back up—until I realized it was directly in his line of vision on his way to the bathroom, a visual reminder all day long of his need to “fix” it. I moved the clock. Out of sight, out of mind, problem solved.

Common triggers for difficult behaviors:

Many triggers for dementia behaviors will fall into one of the following categories:

Visual triggers. They’re common and easiest to address (like my dad and the clock). Some wanderers are triggered by the sight of keys or a coat by a door, for example; relocate them to another spot. Repeated comments and questions often have a visual trigger.

Activity triggers. At dinnertime, my mother-in-law used to ask over and over, “Should I be doing something?” The sounds of meal prep cued her deeply wired habit to be busy and productive. Told no, everything was fine, she’d say okay…and then ask again a few seconds later. Once we found a way to give her a task—even something as simple as stirring a pot or folding a single napkin repeatedly—her anxious questioning improved.

Misperception triggers. A man who’s combative during bathing may misinterpret the help gestures as an invasion of privacy. An aggressive person is often saying, “I’m overwhelmed and out of control.” Withdraw, even if the action seemed (to you) as mild as offering a washcloth. Try again another time.

Sensory misperceptions can also occur. If streetlights and tree shadows look like people, close the curtains after dark. If tree branches are striking the house, have them trimmed or play soothing, favored music in the evening.

It’s also fair to use “therapeutic lying”—a white lie that enters their reality: “The police are checking to make sure everything is safe.” No longer recognizing one’s own reflection in a mirror is common. Thinking you see a stranger in the bathroom is understandably agitating; it it’s upsetting, remove or cover the mirror.

Discomfort triggers. Address the source: food for hunger, a fan if it’s hot. Don’t overlook glare, feeling personally crowded, or pain. Sometimes stripping happens when fabric is itchy or the style uncomfortable. If unbuttoning becomes a nervous tic, switch to pullovers or back buttons that are harder to remove. A “fidget quilt” with buttons and zippers can be an effective substitute for busy hands.

Frustration triggers. Sometimes when you “give” in fantasy what you can’t in reality, it soothes the distress of not feeling understood: “Oh I wish we could go to that old house right this minute. Let’s plan what we’d do there.”

To get my father-in-law to stop hauling his worldly goods to the curb via walker, we finally stopped putting them back at night. We told him we’d store them in the garage because it looked like rain. He was satisfied (we’d listened!) and this, with the visual trigger of the goods gone, stopped his back-and-forthing. If an activity is beyond ability, offer support or casually end it. Retreat and rest is key when just trying to keep it together all day overwhelm.

4. REDIRECT behavior or attention

You may also need to break the loop of upset by redirecting the person’s behavior or attention. To redirect literally means to change the direction of things. Your goal is to move away from the stressful thing and toward calm.

The many different ways to do this are all most effective once you’ve invested a little time reassuring and calmly connecting with the person. Validating my father-in-law’s perceptions always calmed him at least a little bit, putting him in a more receptive frame of mind to then be diverted by some cookies or opera music.

Some ways to redirect:

Introduce a diversion without belaboring the reason for it: “Hey, I have an idea, let’s….” “Oh wow, look at the funny birds at the birdfeeder….” “Dad, I need your help with….”

Offer a choice of two things the person likes to do: “Would you rather eat your ice cream now or rock on the porch with me?” For someone who has difficulty making choices, express it as a yes/no question: “Are you ready for your ice cream?”

Lead the person to a change in scenery. It might be a different chair, another room, or from inside to outdoors. You can’t physically force them along, which only creates more stress. Instead, try using body language. Beckon and offer your hand. “Where are we going?” the person may ask. “It’s a surprise,” you say. That word alone can be diverting—everyone’s intrigued by a surprise. (The “surprise” can be as simple as a snack, a look at clouds, a YouTube baby video, or a baseball game on TV.)

Shift to an entirely different kind of activity. Sensory experiences, like playing music, gardening, rocking in a rocking chair, or helping to prepare food, are known to bring positive emotional associations.

Use bridge phrases to change the topic of conversation. Certain transitional words “build a bridge” to a new direction—away from the thought or image that got the person stuck. “It’s a mystery about your sunglasses. But that reminds me of the time you bought them for that wonderful whale-watching trip and the whale splashed us.”

This approach is handy when someone is stuck on a repetitive question or comment. More examples:

What I’d really like to know is….
Yes, that’s true, and…
You know, I’ve also heard that…

Steer toward a cheerful past. Some people are soothed by comfort objects, like a stuffed animal to pet, a doll to hold, a toolbox to arrange—often things linked with positive memories of their past. You have to use trial and error to see what’s effective but respectful in an individual case. Music, sports games, or talk of weddings (any wedding!) are among popular topics for revisiting.

You know the person best. Even when dementia has altered personality, many core preferences, motivations, and traits remain and you can work with these to find a solution.

5. RESTORE yourself

When a rough episode is over, give yourself a moment. Collect yourself. Give yourself some credit. There’s a tendency to focus only on the person with dementia, but it’s really fortifying to pay attention to yourself, too.

Take a few deep breaths. Scrawl in a journal. Text a friend. Go back in that bathroom for another silent scream. Anything that lets off some of the stress that even a well-handled incident can create.

And one more thing: Go easy on yourself going forward.

You’ll say or do things that don’t help. You won’t see a crazy situation coming. You’ll feel blindsided. You’ll lose patience and complain to your friends. You might even yell or lose it. I know because I’ve done all those things.

It’s okay. Self-kindness isn’t optional. It gives you the patience and resilience that caregiving requires.

A few things that help:

• MORE hands-on help. 365/24/7 dementia care is impossible to provide solo. Can you have groceries delivered? Find someone to cut hair at home? Have you researched local support programs through your Area Agency on Aging?
• MORE downtime. Even 15 minutes a day helps, or one long weekly stretch. Look for respite from a hired elder companion, a volunteer, or an adult day program.
• MORE stress outlets. Among the best: Sleep, exercise, friendships, safe places to vent and share your frustrations.  Support groups – whether in virtual communities or a local group – have the added benefit of being places where you can pick up tips as well as let off steam.

Remind yourself, “I’m only human.” Celebrate small victories and “good enough” care.

6. REVIEW what happened

You can’t always know what ignited a crazy behavior. But once you’re in the habit of searching for clues, you’ll start to gain insight into the possibilities. And this, in turn, can help you nip future problems more quickly, or prevent them.

Try keeping a written log of incidents. Jot down what happened, the time of day, anything unusual you remember about what was going on, and what seemed to help.  You think you’ll remember, but in the stress of everyday dementia care, incidents run together. You’ll be better able to track patterns. Having a record of frequency is also helpful if you need to involve medical help.

Two other things are worth mentioning for their power to help prevent extreme behaviors:

1.Routine. The more patterned the day, the less off-kilter your loved one. Routines are reassuring and serve as timekeepers for someone whose sense of time is eroding. It’s best to stay close to former routines—morning showers, if that’s been a lifelong habit, for example. Within reason, a little flexibility and spontaneity can be fun, but hew as regularly as you can to meals and bedtime.

2. Activity. Physical and mental stimulation won’t prevent dementia’s progression at this point. But the effects of movement on mood and sleep, especially, are strong. Build some kind of exercise into every day, even if it’s just walking around the house. Exposure to daylight can also help with sleep. Try not to do everything for the person or park them in front of the TV endlessly. You don’t have to play cruise director—few of us have time for that. You may find, though, that weaving stimulating activities into the day takes less effort than dealing with problematic behaviors they can help you avoid.

7. REACH out for more help

Depending on what you’re dealing with, you may need reinforcements to help you address the behavior.

First, look for help figuring out non-drug approaches to dementia behaviors. Some ideas:

• Dr. Kernisan’s Helping Older Parents Membership 
• Other virtual communities for dementia caregivers
• Local Alzheimer’s (or other dementia) support groups
• Consultations with a dementia-care expert, like a geriatric care manager
• A course or workshop you can take
• Books about dementia care. In my book Surviving Alzheimer’s, for example, dozens of different behaviors are discussed in depth, with specific tactics to try for each.

Finally, talk to the person’s doctor. He or she can evaluate health-related causes and explore other approaches. Medication for dementia behaviors isn’t a first resort and is often risky, but sometimes works.

Two top reasons to get medical help quickly:

If you feel unsafe (due to aggression, violence, or unpredictable behaviors). When behavior management doesn’t stop hitting, lashing out, throwing things, or other kinds of violence and threats, reporting them to the person’s doctor is the kinder and safer path. Keep yourself safe! Medications may be justified.

If the person’s sleep issues are undermining your sleep.If the person with dementia is disrupting sleep for the whole household, tell his or her doctor. There are ways to optimize the sleep of someone with dementia – and solving a sleep problem improves the quality of life for everyone involved. You may also want to get yourself a checkup, to make sure that you’ve been checked for common medical problems that can worsen sleep.

Why NOT Try This?

Challenging dementia behaviors can be super-stressful. (I’ve called them worse things in my personal experience!) This basic approach can help stretch your patience and move you both toward a more peaceful quality of life.

Best of all, you can start using the “Why-This, Try-This” approach right away, even if you’ve been responding differently before.

To make these steps simple to refer to, I’ve compiled a free downloadable PDF, “7 Steps to Managing Difficult Dementia Behaviors — Without Medication, A Surviving Alzheimer’s Cheatsheet.”

Questions, suggestions, or “try” tips that work well for you? Please post them below!

Paula Spencer Scott is the author of Surviving Alzheimer’s: Practical Tips and Soul-Saving Wisdom for Caregivers .