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Changed behaviours

Residents & families Aged care staff 11 min read

Almost everyone with dementia will develop changed behaviours at some point — agitation, calling out, resistance to personal care, wandering, aggression, apathy, or psychosis. These are the symptoms that most distress families, most exhaust staff, and most often trigger a prescription. They are also the symptoms where getting the approach right makes the biggest difference.

Numbers in the text link to the 9 sources listed at the foot of this page.

Behaviour is communication

The single most useful reframe available in dementia care is that changed behaviour is almost always a person attempting to communicate an unmet need with a brain that can no longer do so in words. The resident who becomes combative during showering is not being aggressive; they are frightened, cold, in pain, or experiencing an intimate act they do not understand from a person they do not recognise.

This is not a soft observation. It is supported by trial evidence. In a cluster-randomised trial across 60 Norwegian nursing home units, systematically treating pain with a stepwise analgesic protocol reduced agitation by 17% over eight weeks compared with usual care 49 — a larger and safer effect than most psychotropics achieve, in residents whose agitation had been assumed to be a dementia symptom rather than a pain symptom. Agitation returned during the washout period 49.

The common unmet needs behind changed behaviour

Work through these before considering medication. In practice, a cause is identified more often than not.

  • Pain. Under-recognised and under-treated in people who cannot report it. Use an observational tool such as PAINAD or Abbey. Consider a trial of regular paracetamol — in the Norwegian trial, paracetamol alone accounted for much of the observed benefit 83.

  • Constipation and urinary retention. Both extremely common, both readily missed, both capable of producing florid agitation.

  • Infection. Urinary tract, respiratory or skin. Often without fever in frail older adults.

  • Sensory deprivation. Flat hearing aid batteries, missing glasses, impacted cerumen. Cheap to fix, frequently overlooked.

  • Hunger, thirst, needing the toilet. Basic and easily addressed, but only if someone asks.

  • Fear and loss of control. Particularly around personal care, which is intimate, non-negotiable in the resident’s experience, and often rushed.

  • Boredom and understimulation. Long unstructured afternoons produce more calling out and wandering than almost anything else.

  • Overstimulation. Noise, crowding, television, multiple staff, shift handover. The opposite problem, and just as real.

  • Medication. Anticholinergics, benzodiazepines, opioids, steroids and antibiotics can all precipitate confusion and agitation.

The ABC approach

A structured way to analyse a behaviour rather than simply react to it. Used properly, it converts a vague report of “Mr K was aggressive again” into a plan.

  1. Antecedent. What was happening immediately before? Who was present, what time of day, what was being done to or around the person, what had changed?

  2. Behaviour. Describe precisely what the person did, in observable terms. Not “agitated” — “pushed the carer’s hand away and called out repeatedly for her mother”.

  3. Consequence. What happened next, and did it make the behaviour more or less likely to recur? Staff withdrawal, an argument, a PRN dose, or a successful redirection all shape the next episode.

What actually works

A network meta-analysis of 163 randomised trials involving over 23,000 people with dementia compared pharmacological and non-pharmacological interventions for aggression and agitation 48. Multidisciplinary care, massage and touch therapy, and music combined with massage and touch were more efficacious than usual care and, on the whole, non-pharmacological interventions outperformed drugs 48.

A separate network meta-analysis of 43 randomised trials found exercise added to usual care ranked highest for reducing overall neuropsychiatric symptoms, with massage and music showing benefit for depressive symptoms and agitation 68. Interventions delivered to carers matter too — a network meta-analysis of 71 trials involving over 8,000 dyads found multicomponent carer interventions produced sustained improvements in both the resident’s symptoms and the carer’s distress 69.

The honest caveat: much of this literature is methodologically weak, effect sizes are modest, blinding is impossible, and the certainty of evidence is generally low to moderate. But the comparison that matters is against antipsychotics, whose effect sizes are also modest and whose harms are unambiguous. On that comparison, non-pharmacological approaches win.

Practical approaches with reasonable supporting evidence

  • Individually tailored activity. Matched to the person’s history, interests and remaining abilities. Personally tailored interventions ranked among the most effective for agitation in network meta-analysis 84.

  • Music. Preferred music from the person’s own era and culture, delivered individually rather than as background noise.

  • Exercise and movement. Regular structured physical activity, ranked the top intervention for overall neuropsychiatric symptom burden in one network meta-analysis 68.

  • Massage and touch. One of the more consistently supported interventions for agitation across multiple analyses 4884.

  • Environmental modification. Reducing noise, improving lighting and contrast, signage, secure outdoor access, and consistent staff allocation.

  • Changing how care is delivered. Slowing down, explaining each step, offering choice about timing, using bathing-without-a-battle techniques, and accepting that a shower can wait until tomorrow.

  • Staff training with a structured protocol. A cluster-randomised trial of a stepwise multidisciplinary protocol (STA OP!) across 12 nursing homes reduced agitation and depression scores and reduced psychotropic use 67.

For families: what you can do

You know the person better than any staff member ever will, and that knowledge is clinically useful. Tell the facility what your relative did for work, what music they loved, whether they were an early riser, what frightens them, what soothes them, how they take their tea. A one-page life story in the care plan changes how a stranger at 3am interprets a person calling out.

Do not take aggression personally, and do not correct or argue. If your mother believes she needs to collect the children from school, contradicting her creates distress without creating insight. Acknowledging the feeling — “you’re worried about the kids” — and redirecting usually works better.

And do ask questions. If your relative is prescribed a sedative or antipsychotic, you are entitled to know what it is for, what was tried first, what the review date is, and what the risks are. Under Australian aged care law you may also be the person whose informed consent is required 54.

Sources cited on this page

  1. 48 Watt JA, et al. Comparative efficacy of interventions for aggressive and agitated behaviors in dementia: a systematic review and network meta-analysis. Ann Intern Med. 2019;171:633–42.
  2. 49 Husebo BS, et al. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ. 2011;343:d4065.
  3. 54 Australian Government Department of Health, Disability and Ageing. Restrictive practices in aged care — a last resort. View source
  4. 64 Australian Commission on Safety and Quality in Health Care. Delirium Clinical Care Standard. View source
  5. 67 Pieper MJC, et al. Effects of a stepwise multidisciplinary intervention for challenging behavior in advanced dementia (STA OP!): a cluster randomized controlled trial. J Am Geriatr Soc. 2016.
  6. 68 Yin Z, et al. Comparative efficacy of multiple non-pharmacological interventions for behavioural and psychological symptoms of dementia: a network meta-analysis of randomised controlled trials. Int J Ment Health Nurs. 2023.
  7. 69 Meng X, et al. Comparisons of nonpharmacological caregiver interventions for behavioural and psychological symptoms of dementia: a systematic review and network meta-analysis. Int J Nurs Stud. 2025.
  8. 83 Sandvik R, et al. Impact of a stepwise protocol for treating pain on pain intensity in nursing home patients with dementia: a cluster randomized trial. Eur J Pain. 2014. (Benefit was apparent in the paracetamol group from week 2.)
  9. 84 Leng M, et al. Comparative efficacy of non-pharmacological interventions on agitation in people with dementia: a systematic review and Bayesian network meta-analysis. Int J Nurs Stud. 2019. (65 randomised trials; massage therapy, animal-assisted intervention and personally tailored intervention ranked highest.)

See every source cited across the dementia section →

General information only, reflecting the interpretation of Umbrella Aged Care’s GPs of the published evidence as at September 2026. It is not individual medical advice, does not create a doctor–patient relationship, and must not be used to start, stop or change any treatment. Evidence and Australian regulatory and PBS arrangements change — always confirm current advice with the treating GP, pharmacist or specialist.

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