After eighteen years of working with people living with dementia in Japan, I have come to believe that behavior is rarely the real problem. Behavior is a message. When we treat it as a message rather than a symptom to be suppressed, our entire approach changes. In this article, I want to share what I have learned, researched, and tried on the floor — not from a place of having everything figured out, but from a place of ongoing exploration.
What you will learn
- Why Japanese caregiving philosophy frames “problem behavior” as unmet need
- Practical approaches to wandering, agitation, and refusal of care
- How environmental design and daily rhythm can quietly reduce distress
- The role of life history and personal identity in shaping responses
- How caregivers can protect their own composure during difficult moments
- Ideas I am still researching and would consider trying if circumstances allowed
Reframing “Problem Behavior” as Communication
In Japanese caregiving education, we often use the phrase BPSD (behavioral and psychological symptoms of dementia) — things like agitation, wandering, calling out at night, resistance to bathing, or accusations of theft. Early in my career, I saw these as behaviors to manage. Over time, and through reading and observation, my view has shifted. Research consistently suggests that most BPSD arise from unmet physical, emotional, or environmental needs. Pain, thirst, boredom, fear, overstimulation, loneliness — any of these can appear on the outside as “difficult behavior.”
Once we accept this, the caregiver’s first job is not to stop the behavior but to ask: what is this person trying to tell me? A resident who paces the hallway after dinner may not be “wandering” — she may be looking for her children, or feeling that it is time to go home from work, echoing a lifelong evening routine.
Person-Centered Care in the Japanese Context
Person-centered care is not a uniquely Japanese concept, but the way it is practiced here often emphasizes quiet observation, restraint, and respect for the person’s dignity and social role. In many facilities I have visited or worked in, staff spend considerable time gathering life history: what work the person did, family relationships, food preferences, hobbies, regional dialect, religious background. This information is not decoration in a chart — it becomes the foundation for every interaction.
For example, one gentleman I cared for had been a schoolteacher. When he became agitated in the afternoon, addressing him as “sensei” and asking his opinion on something small often helped him settle. He was not being managed; he was being seen.
Practical Approaches to Common Situations
Wandering and Restlessness
Rather than blocking movement, many Japanese facilities design circular corridors and safe walking loops. The person can walk as much as they need to. Staff try to walk alongside rather than redirect abruptly. If a resident says “I need to go home,” arguing rarely works. What often helps is acknowledging the feeling first — “You must be worried about home” — and then gently shifting attention to something grounding, like a cup of tea or a familiar song.
Resistance to Bathing and Care
Bathing refusal is one of the most common challenges. Some approaches I have found useful, or seen colleagues use effectively:
- Adjust the timing to match the person’s lifelong habits (morning bathers vs. evening bathers)
- Warm the room and towels in advance so the transition feels less shocking
- Explain each step just before doing it, rather than announcing everything at the door
- Offer choices where possible — “shall we start with your hands or your feet?”
- If refusal is strong, step away and try again later rather than forcing
Agitation and Calling Out
When a resident becomes agitated, the caregiver’s own state matters enormously. If we approach with tension, they feel it. I try to lower my voice, slow my movements, and come into their line of sight before speaking. Sitting down to be at eye level can change the whole atmosphere. Many caregivers I know report that simply being present, without trying to fix anything, often calms the situation over time.
Accusations and Suspicion
Being accused of stealing is painful, but arguing back rarely helps. What tends to work better is validating the emotion — “That must be upsetting, let’s look for it together” — and then helping the search. Sometimes the missing item is found; sometimes attention shifts naturally. The point is not to win the argument but to preserve the relationship.
Environment and Daily Rhythm
Something I continue to research is how much environment shapes behavior. Sundowning, for instance, often worsens with poor lighting, background noise, and the general fatigue of late afternoon. Simple adjustments — brighter light earlier in the day, quieter dining rooms, familiar music, predictable routines — seem to make a real difference over time, though the effect varies by person.
Meaningful daytime activity also matters. Folding towels, sorting laundry, preparing vegetables, tending to a small plant — these are not “activities” in the recreational sense but expressions of the roles people have held their whole lives. When residents feel useful, restlessness at night often lessens.
The Caregiver’s Inner State
One thing that took me many years to accept is that my own emotional condition is part of the care environment. If I arrive at a shift already exhausted or irritated, residents pick up on it, and difficult moments escalate more easily. Japanese caregiving culture increasingly acknowledges this, and there is growing attention to caregiver mental health, though we still have far to go.
Some simple practices I have tried, and which many colleagues describe as helpful:
- Taking a slow breath before entering a resident’s room
- Briefly naming, silently, what I am feeling before responding to a difficult moment
- Debriefing with a trusted colleague after a hard shift, rather than carrying it home
- Reminding myself that a resident’s harsh words are shaped by illness, not by who they are
None of these are magic. But over time, they seem to protect both the caregiver and the quality of care.
Ideas I Am Still Exploring
There are approaches I have read about but not yet had the chance to implement fully. Sensor-based night monitoring that could reduce intrusive checks, digital life-history tools that any staff member could access at a glance, and structured non-pharmacological programs for agitation are all areas I would like to explore further if the opportunity arises. I am cautious, though. Technology can only ever support the human relationship — it cannot replace the moment of sitting beside someone and simply being there.
What Family Members Can Take From This
Families caring for a loved one at home often ask what they can do differently. The honest answer is that many of the same principles apply. Slow down. Assume the behavior has a reason. Protect your own composure. Preserve the person’s dignity even when it is hard. And ask for help before you are at the end of your strength — because sustained care depends on the caregiver, not just on technique.
Summary
Dementia behavior management, in the Japanese tradition I have grown up in professionally, is less about controlling behavior and more about listening to what behavior is trying to say. It rests on knowing the person, shaping the environment, honoring daily rhythm, and caring for the caregiver as much as the cared-for. The techniques matter, but the attitude behind them matters more. After eighteen years, I am still learning — and I think that willingness to keep learning is itself part of good care.
About the Author
Written by the operator of AI Kaigo Kaze, a Japan-based certified care worker (Kaigo Fukushishi), care manager, and social worker with 18 years of frontline caregiving experience.
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