Unusual or embarrassing behavior

A person living with dementia may start to say or do things they never would have before. They may make a rude comment about a stranger's weight, undress in the living room, or take food off someone else's plate. Doctors call this disinhibition. It means the brain's "brakes" no longer work well, so the person acts on an urge without stopping to think about the rules or how others will feel.^2,3

These moments can be painful and embarrassing for families. It helps to know that the behavior comes from damage in the brain, not from a bad character. This page explains why it happens, how to respond in the moment, and when to get help.

What disinhibition looks like

Most of us have a quiet inner voice that says "not here" or "don't say that." Disinhibition happens when that voice fades. Researchers describe two main kinds. One is breaking social rules or personal boundaries. The other is impulsivity, which means not being able to hold back from doing something.³

Common examples include:^1,2,5

• Making blunt, rude or hurtful comments, often about how someone looks
• Talking to strangers as if they were old friends, or standing too close
• Sharing very private matters in public, or loudly
• Singing, shouting or laughing at the wrong time, such as during a church service
• Eating from other people's plates or grabbing food in a store
• Taking items from a store without paying, or spending money carelessly
• Touching strangers, undressing in public, or other sexual behavior that is out of character

The person often does not see that anything is wrong. This lack of awareness is also caused by the illness. It is not stubbornness.^1,2 Our page on anosognosia explains more.

Why it happens

The front part of the brain, especially the area just behind the eyes, helps us weigh choices, read social cues and stop ourselves. Parts of the temporal lobes (near the ears) help us understand other people. When disease damages these areas, the brakes weaken.^1,3

Frontotemporal dementia (FTD)

Disinhibition is one of the most frequent and telling signs of behavioral variant FTD, the most common form of frontotemporal dementia.^1,3 In bvFTD, personality, judgment and empathy often change first. Memory may stay fairly good early on.²

FTD tends to start younger than Alzheimer's. About 60% of people with FTD, or roughly 3 in 5, are between 45 and 64 years old.¹ Because the first signs are about behavior, bvFTD is often mistaken for depression, another mental illness, Alzheimer's, Parkinson's disease, or alcohol or drug problems.²

Alzheimer's and other dementias

Disinhibition is not only an FTD problem. In a large study of older adults with dementia in Utah (the Cache County Study), about 1 in 3 people (31%) showed disinhibition at some point over five years.⁴ It may come and go. In that study, the share showing it at any one visit ranged from about 2% to 15%.⁴

For other changes that often come as the disease moves on, see middle-stage dementia.

Rule out other causes first

A behavior change that comes on over hours or days is a reason to call the doctor soon. Some causes can be treated.

• Delirium. This is a sudden state of confusion. It can come from a urinary tract infection, pneumonia, dehydration, surgery, or a medicine. Older adults and people with dementia are at higher risk. Delirium needs a medical check, and it often gets better when the cause is treated.⁹
• Medicines. Some medicines used for Parkinson's disease and restless legs, called dopamine agonists, can cause strong urges that are unusual for the person. These can include gambling, shopping, binge eating or increased sexual urges.⁷ Other medicines can also affect judgment.
• Pain, hunger, boredom or needing the toilet. A person who cannot explain a need may act it out instead. Undressing in public, for example, can mean the person is too hot, their clothes are uncomfortable, or they need the bathroom.

If behaviors appear suddenly, talking with the person's doctor or neurologist can help rule out medical causes.⁵ Bring a list of all medicines, including over-the-counter ones. Never stop or change a medicine on your own. Talk with the doctor or pharmacist first. See also treatable conditions that look like dementia.

How to respond in the moment

Your calm reaction is the most useful tool you have. The person usually cannot learn from being corrected, and arguing tends to make things worse.

1. Take a breath. Remind yourself that this is the disease talking, not the person you love.
2. Stay gentle. Use a calm voice. Do not scold, shame or lecture. A patient, kind response works better.⁵
3. Redirect. Offer something else to do, to look at or to eat. "Come help me find the bread" can pull attention away from a stranger.⁵
4. Move to a private place if the behavior is personal or sexual. Guide the person away quietly.⁵
5. Reassure. Comforting touch, like holding a hand or rubbing a back, can meet the need for closeness and calm the person down.^5,6
6. Let small things go. If no one is harmed, it may be fine to let a silly comment pass. Choose your battles.⁵

The Center for Brain/Mind Medicine at Brigham and Women's Hospital sums this up as the "4 Rs": reassure, reconsider, redirect, and relax.⁵

Going out in public

Many families stop going out because they fear a scene. Some planning can make outings easier.

Other ideas that may help:

• Go at quiet times, like weekday mornings, and keep trips short.
• Choose familiar places where staff know you.
• Have a snack and a simple activity ready, like a photo book or music on headphones.
• Plan an exit. Know where the restroom and the door are.
• If shoplifting is a risk, shop with the person, keep their hands busy, and check pockets kindly before you leave. Some families talk with store managers ahead of time.
• If spending or giving money away is a problem, lower card limits, set up account alerts, and think about a durable power of attorney. Disinhibited people can also be easy targets for scammers. See scams and financial abuse.

Sexual behavior

Sexual behavior that is out of character is one of the hardest changes for families to talk about. It can include touching oneself in public, undressing, sexual comments, or advances toward others.

These behaviors are a symptom of the disease. They do not always mean the person wants sex. Often the person is looking for closeness, comfort or attention.⁶ Giving more attention, reassurance and gentle affection, like hugs or holding hands, can help meet that need.⁶

Other practical steps:

• Calmly say the behavior is not OK here, then guide the person somewhere private or toward another activity.⁵
• Check for simple causes, such as tight clothing, itching, a full bladder or being too warm.
• Clothes that open in the back or are harder to remove may help with public undressing.
• Tell the doctor. Some people need medicine to manage these behaviors, and the doctor can help you decide on next steps.⁶

If you are a spouse, these changes can bring grief and confusing feelings. You are allowed to set limits on your own body. Our page on caring for a husband or wife with dementia talks about intimacy and touch.

What about medicines?

There is no cure for FTD and no medicine that slows it. Treatment focuses on managing symptoms.¹ For most people, changes to routine and the way others respond come first.

Some people need medicine to manage these behaviors.⁶ Doctors may try it when behavior is severe or risky. Some of these are antipsychotic medicines. They carry a warning that older adults with dementia who take them may have a higher risk of death. Risperidone, for example, is not FDA-approved to treat behavior problems in older adults with dementia.⁸ Ask the doctor about the possible benefits, the risks, and how you will know if it is helping. Our page on medicines for agitation and behavior explains the options.

Keep a simple record

Writing things down can show patterns. Note what happened, when, where, who was there, and what came just before. You may find that problems happen when the person is tired, hungry, bored or in a noisy place. Bring the notes to doctor visits. Our behavior diary can help. For the bigger picture of why behaviors happen, see dementia symptoms and behaviors.

Taking care of yourself

Living with these changes is exhausting. Many caregivers feel embarrassed, angry or alone. These feelings are normal.

• Find people who understand. A caregiver support group, especially one for FTD families, can be a relief.
• Take breaks. Respite care and adult day care give you time to rest.
• Share the load with family. See sharing care with siblings and family.
• Watch for signs of caregiver stress and burnout.

If you feel hopeless or have thoughts of harming yourself, call or text 988 to reach the Suicide and Crisis Lifeline any time.

When to get help

Call the doctor soon if:

• Behavior changes come on suddenly, over hours or days
• The person seems more confused, sleepy, feverish or in pain
• A new medicine was started or a dose was changed recently
• Sexual or impulsive behaviors are increasing or putting others at risk
• Someone younger than about 65 has a big change in personality or judgment

Call 911 if the person or anyone else is in immediate danger, if there is violence, or if the person suddenly cannot be woken or has trouble breathing. For aggressive outbursts, see agitation and aggression. For more crisis options, see Get help now.

Is the person doing this to embarrass me?

No. Disinhibition comes from damage to the brain areas that control impulses and social judgment. The person often does not realize the behavior is unusual.^1,2

Should I explain to them later what they did wrong?

Usually this does not help. The person may not remember or understand, and it can cause shame or anger. Focus on preventing the next time and on your calm response in the moment.

Will it get worse?

It depends on the type and stage of dementia. In Alzheimer's, it may come and go.⁴ FTD has no treatment that slows it, so symptoms usually change and grow over time.¹ Ask the doctor what to expect.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.