Is being stubborn a sign of dementia?

Is Stubbornness a Sign of Dementia?

Stubbornness alone is not a diagnostic sign of dementia, but new-onset personality changes—including increased rigidity, inflexibility, or what family members may describe as "stubbornness"—can be an early behavioral manifestation of neurodegenerative disease and warrant formal evaluation. 1

Understanding Behavioral Changes in Dementia

Behavioral and personality changes are recognized early features of dementia that patients and family members often fail to connect to cognitive decline. 1 The critical distinction is whether this represents:

• A change from baseline personality (new-onset stubbornness in someone previously flexible)
• Progression of a lifelong trait (always been stubborn, now just older)

What Clinicians Should Probe For

When family members report "stubbornness," you must clarify what they actually mean, as lay terminology often differs substantially from clinical definitions. 1 Specifically ask about:

• Apathy or loss of initiative (refusing activities due to lack of motivation, not true oppositional behavior) 1
• Executive dysfunction (inability to adapt to changes in routine, appearing as inflexibility) 2
• Depression or anxiety (withdrawal or avoidance behaviors misinterpreted as stubbornness) 1
• Obsessive-compulsive behaviors (rigid adherence to routines due to emerging frontotemporal pathology) 1
• Loss of insight (refusing help because they don't recognize their deficits) 1, 3

When to Pursue Formal Evaluation

You should conduct a comprehensive dementia workup when behavioral changes like "stubbornness" are accompanied by: 1, 3

• Corroborating evidence of cognitive decline from a knowledgeable informant 3, 2
• Functional impairment in instrumental activities of daily living (managing finances, medications, appointments) 3, 2
• Other warning signs: missed appointments, showing up at wrong times, difficulty following instructions, decreased self-care, or new-onset depression/anxiety 1

The Diagnostic Algorithm

1. Obtain collateral history using structured tools (AD8, IQCODE) to document changes in cognition, function, and behavior from baseline 3, 4

2. Perform objective cognitive testing with MoCA (preferred for mild impairment) or MMSE 1, 3

3. Assess functional status using validated instruments (FAQ, Lawton IADL Scale) 3

4. Document neuropsychiatric symptoms systematically with NPI-Q or MBI-C 3

5. Rule out reversible causes (thyroid dysfunction, B12 deficiency, depression, medications, sleep apnea) 3

Critical Clinical Nuances

Personality changes can precede obvious memory problems, particularly in frontotemporal dementia. 1 In one study, more than half of patients who developed dementia had depression or irritability symptoms before cognitive impairment became apparent. 1

The interplay between psychiatric symptoms and dementia is complex. 1 New-onset behavioral changes in older adults—including what appears as stubbornness, irritability, or social withdrawal—may represent:

• Early dementia (especially frontotemporal or Lewy body variants) 1
• Late-onset depression with cognitive features 1
• Mixed pathology (both conditions simultaneously) 1

Common Pitfalls to Avoid

• Don't dismiss behavioral changes as "normal aging" or "just their personality" without objective assessment 1
• Don't rely solely on patient self-report—lack of insight is common, and informant corroboration is essential 3
• Don't attribute everything to depression without ruling out neurodegenerative disease, as mood changes are often early dementia symptoms 1
• Don't overlook atypical presentations—not all dementia starts with memory loss, particularly in younger patients (<65 years) 2, 5

Bottom Line for Clinical Practice

When family reports new "stubbornness" in an older adult, ask specific questions about what behaviors they're observing, obtain detailed informant history about changes from baseline, and use validated screening tools to objectively assess cognition and function. 1, 3 If there's documented decline in multiple domains with functional impairment, proceed with comprehensive dementia workup including neuroimaging and laboratory evaluation for reversible causes. 3, 5