Screaming Among People With Dementia in the Nursing Home Setting

Dementia is one of the most frightening disorders of older age and can be one of the most devastating to the patient and caregiver alike. Later-life dementias are associated with not only cognitive and self-care deficits, but also with noncognitive psychiatric or behavior disorders.¹ These disorders, which can include anxiety and depression, sleep disorders, agitation, and verbal or physical aggression, are frequent and result in significant suffering to the patients and their families. It has been estimated that approximately 90% of persons with dementia will develop some type of significant behavioral problem during the course of the disease. Up to 75% of nursing home residents will develop a behavioral disturbance, with verbal aggression/threats and physical aggression/agitation often cited as the 2 most commonly seen in those with Alzheimer’s disease and related dementias.¹

Screaming is common among residents of nursing homes who have dementia, tends to occur along with the development of other related agitated behaviors, and has been attributed to a variety of causes, including vulnerability, suffering, sense of loss, loneliness, physical pain (including hunger), clinical depression, and, more abstractly, as a call for help or need to fill a void with sound or emotion.^1-3

In their 2010 study Bourbonnais and Ducharme used critical ethnography analysis to interpret information collected from 7 triads of patients/caregivers within a nursing home setting (triads consisted of an older person with dementia who screamed, a primary family caregiver, and either 1 or 2 staff caregivers). They found that screams were influenced by the stability and/or flexibility in the nursing home setting, as well as by the reactions of others, with each person’s scream to be interpreted as their own “unique language,” which could be learned and used to effect care.³

The same researchers followed up with a more recent study that examined the effects of social positioning within similar care triads in the long-term care setting. They found that older persons were capable of positioning and repositioning themselves in relational patterns within the triads, and that family members as well as formal caregivers socially positioned the older person according to their own beliefs about the person or his or her experiences. It is possible that better understanding of the complex social positioning and emotional reactions persons with dementia in the nursing home may help to promote healthy relationships in triads and enhance long-term quality of care.⁴

Aggressive behaviors like screaming typically develop in the later stages of dementia, when the person’s use of language begins to diminish and confusion or cognitive loss has advanced. Much research shows that behavioral disturbances can be recognized and managed early, and ultimately, prevented, using a multifaceted approach that includes nonpharmacologic interventions (eg, music, touch, positive reinforcement, thoughtful adjustments to the person’s environment or routine) in a way that supports the person’s dignity and promoted quality of life for him/her as well as for caregivers and family members.^1,5

References

1. Desai AK. Grossberg GT. Recognition and management of behavioral disturbances in dementia. Prim Care Companion J Clin Psychiatry. 2001;3(3): 93-109.
2. Groulx B. Screaming and wailing in dementia patients. Part II. Can Alzheimers Dis Rev. 2005;8(1):7-11.
3. Bourbonnais A, Ducharme F. The meanings of screams in older people living with dementia in a nursing home. Int Psychogeriatr. 2010;22(7):1172-1184.
4. Bourbonnais A, Ducharme F. The social positioning of older people living with Alzherimer’s disease who scream in long-term care homes. Dementia (London). Published online ahead of print December 2, 2013.
5. Desai AK, Schwartz L, Grossberg GT. Behavioral disturbance in dementia. Curr Psychiatry Rep. 2012;14(4):298-309.