Caregivers have been hit, scratched, and even bitten by their loved ones. A person with Alzheimer’s disease, or related dementia, might become insulting, spouting rage and anger with seemingly no motivation. These aggressive behaviors, caused by changes in the brain, can come from out of nowhere.
Caregiving is already emotional work, but when a loved one becomes aggressive it can lead to major changes, like deciding to make the move into assisted living. The good news is there are means of managing these behaviors, including strategies on what to do in the moment and how to make future incidents less likely.
Aggressive behavior is lashing out, usually in anger, and typically takes one of two forms:
– Verbal: cursing, yelling, making threats, insults
– Physical: hitting, kicking, scratching, pinching, biting, pulling hair, throwing things
Some people have aggressive personalities before they get dementia. A person prone to become angry and strike back physically or verbally will probably stay that way after developing Alzheimer’s, and may actually worsen. But people who have never exhibited these types of behaviors, who are known to be kind or sweet throughout their lives, can also suddenly change and become aggressive. Remember that this isn’t a choice your loved one makes, it’s a symptom of the disease.
The middle stages of dementia are when anger and aggression are most likely to start occurring as symptoms, along with other worrying habits like wandering, hoarding, and compulsive behaviors that may be unusual for your loved one.
In most types of dementia, not just Alzheimer’s disease, these issues develop in the mid-to-later stages. About half of people diagnosed with dementia become so agitated that they’ll strike back with physical abuse or verbal threats. Fortunately, these behaviors, if they’re not characteristic or normal for your loved one (if he or she wasn’t an aggressive person before the disease), have been known to fade. It may take years, but the change is not permanent, and your loved one will probably calm down.
That said, when recall starts to fade in later stages, and family and friends become harder to remember, the lack of recognition can cause aggression. A person who can’t remember people becomes confused or outright scared by the company. Paranoia can be common. This is why maintaining routine and using smart strategies to communicate are important.
The root causes that might lead a person with dementia to act aggressively can be broken down into two categories: physical and emotional. Physical needs are some tangible issue in the room, while emotional needs are going on in your loved one’s head.
Pain or Illness – Discomfort or outright pain can obviously be a problem, but it’s much worse for someone who has difficulty communicating. So is being sick: Infections have been shown to cause sudden and dramatic changes in behavior.
Medications – One of the drugs for symptoms of dementia is memantine, which lists fatigue as a side effect. Medications that cause drowsiness can make it harder to communicate, causing distress. Other medications your loved one is taking may contribute as well.
Environment – If someone with dementia is in a place that is overstimulating (too busy or bright or loud) or not stimulating enough (nothing to do), this can cause distress that may lead to acting out.
Hallucinations and / or Delusions – Among the possible side effects of Alzheimer’s and other dementias, particularly in the mid-to-late stages, are hallucinations and delusions, which can scare someone and, again, lead to acting out. Lewy-body dementia, in particular, is known for causing hallucination and delusions that may trigger angry responses.
Diet – Poor nutrition can lead to changes in behavior, including aggression. Make sure you’re feeding your loved one good, healthy meals. If your loved one is hungry or thirsty, but has difficulty expressing it, this can also result in aggression.
Diminished Sensory Perception – loss of vision and / or hearing can cause disorientation which, in turn, can lead to aggressive behavior. There are both hearing and vision tests designed specifically for persons with dementia who may have challenges with traditional testing.
Loneliness – Dementia can be extremely isolating. Even when surrounded by family and friends, your loved one might feel like a burden or have too much difficulty following conversations, and these feelings can lead to lashing out.
Boredom – People with dementia typically have a harder time moving around, and being confined to an area without something to do can be boring, leading to frustration and ultimately acting out.
Distrust – People with dementia need extensive medical care, and this means doctors’ appointments, caregivers, and maybe physical or occupational therapy. New people coming and going can make someone who has memory problems feel uncomfortable and angry, like the home is being violated.
Limitations – Dementia takes away the ability to complete normal tasks. For someone used to having a cup of tea in the afternoon, for instance, not being able to make the tea alone can be devastating. Losing independence is agitating and can lead to aggression as well.
Loss of Reality – Someone in the later stages of dementia may not perceive the world like the rest of us. Not understanding what’s going on can be frightening and provoke anger, leading to reactions that may be aggressive.
Loss of Control – The inability to control oneself is another unfortunate side effect of dementia. If your loved one is upset about something, there may be an inability to prevent the most instinctual response, which is sometimes hitting or acting aggressively.
How you handle aggressive behavior by your loved one will depend on whether you’re in the midst of an aggressive episode or not. The following tips are broken into sections on what to do at the time of problematic behavior, and then good habits for before and after to hopefully get your loved one calmer overall and less prone to act aggressively.
– Step back. It can be a good idea to take a deep breath and get away from your loved one for a few minutes. Space and time can make a situation calm down.
– Control your reaction. If your loved one is lashing out violently, try to stay calm. This can be difficult, but people with dementia take cues from others, and if you respond with anger it will probably make the situation worse.
– Don’t shout.
– Don’t be physical in response.
– Acknowledge feelings. Your loved one might mistakenly believe there’s a task to be completed, like cooking a meal or picking up a friend from the airport. Instead of correcting these ideas, acknowledge how frustrating it must be and try to change the subject. Assure that everything is fine.
– Maintain eye contact.
– Try again later. If a particular task is causing distress leading to aggression, step back and return to it another time after tempers have cooled.
– Always remember to communicate well. For tips on communication with someone with dementia, click here.
– Using labels and signs for rooms or objects can make it less likely your loved one becomes confused, and confusion sparks anger.
– Know your loved one’s routine. If morning is a more lucid time of day, then that’s when to schedule things like social activities and doctor appointments. Doing things at bad times of day can cause agitation leading to aggression.
– Exercise regularly. Mood, memory, balance, and more are improved with regular moderate exertion, like going for a walk.
– Listen to music. Music therapy has been demonstrated to help with several symptoms of dementia, and can calm someone who’s upset.
Massage, aroma therapy, pet therapies, and any strategy to improve your loved one’s mood are useful for moderating aggression. Keep your loved one as happy as possible for as long as possible. It sounds like common sense, but this can be easy to forget.
Antipsychotics and other drugs may alleviate aggression but should be considered a last resort. Medicating does not address whatever underlying cause is making your loved one act out. Seek solutions first that are related to communication, comfort, the environment, etc. These drugs also may have serious side effects.
Aggressive behavior is almost always triggered by something. Figure out what that something is and you’ll both be much happier.
If your loved one is acting aggressive, check for pain first. Someone with dementia may not know how to express discomfort or pain. Look for these signs:
– Stroking or pulling on a particular part of the body.
– Facial contortions like clenched teeth or inverted eyebrows.
– Body language, like rocking or pulling away.
– Appetite change
– An existing condition like arthritis
– Dental problems like a toothache
– Nails that are too long
Is it a reaction to other people? Is something wrong in the environment? Does the aggressive behavior happen at the same time every day, or in the same place? Maybe a particular person coming to visit will cause your loved one to get upset.
Finding a pattern will help explain, and ultimately manage, your loved one’s aggression. One good idea to help is keeping a caregiver diary that lists what was happening when your loved one became angry. Details like time of day, what activities were going on previously or were anticipated, and how exactly the lashing out occurred can be useful in identifying the problem. If you need to see a doctor to address behavior issues, having notes will be helpful for forming a medical opinion.
Was the person tired? Uncomfortable? Embarrassed about something?
Remember also that personal preferences and dislikes don’t go away when someone’s brain is compromised, but the ability to articulate the problem may. Try to remember what made your loved one upset in the past, before the disease, and think about whether it’s a problem right now.
Don’t blame a person with dementia for their behavior. It is important as a caregiver to always remember that anger and aggression are symptoms of the disease, not a decision by your loved one to be rude or mean. If you can stay reassuring and understanding, that kinder demeanor may be reflected back, and aggression will be less of a problem.
Find an outlet. Join a group or just find a friend who can listen to what you’re going through. It is very important to manage caregiver stress, because a stressed-out caregiver won’t be as effective in managing emotions or reacting to aggressive behavior. Your loved one may not be able to communicate, but people with dementia can read body language and will respond poorly if you express frustration in any way. Exercise and socialization are good for caregivers too!
Be open to change. You may need to speak differently during conversations, or alter the house in some way that eliminates a trigger.
If your loved one is prone to aggressive behavior, this can be a problem in memory care (assisted living for people with dementia). These communities have rules against allowing residents to act in a manner that is dangerous to self or others. Lashing out physically or verbally, as described above, may count as dangerous behavior and may lead to eviction. This is why it’s very important to understand a residence’s policy on aggressive behavior.
In fact, how a facility handles residents who have issues with aggression is a good gauge of whether it’s the right place for your loved one. Think about it: If the practice is sedation (chemically with mind-numbing drugs or physically with tied restraints), then they don’t have the coping and training skills to manage emotions. Using practiced non-drug techniques is, of course, much better. If staff seems annoyed by aggression, or disdainful, then they aren’t good for mom or dad.
Good staffers will remain calm and friendly, and ask empathetic questions to understand what’s wrong. Good staffers will try to have a conversation with the person, to calm them down by talking. Being responsive is important, as is staying cool.
Ask about training. Is there regular training and continuing education for employees, and do they learn techniques to deal with aggressive behavior in residents?
There should be a policy for aggressive behavior, some specific regulations on how they’re handled. Are incident reports written? If so, check one out. When does aggressive behavior cross the line from manageable to a problem? Memory care homes almost always have the right to reject or evict someone whose actions are considered endangering, so ask what specifically is considered as a danger to self or others. Is verbal aggression considered dangerous? Homes will vary.