Unfortunately, the sad truth is that caregivers have been hit, scratched, and even bitten by their loved ones. A common symptom of Alzheimer’s or dementia is a change in personality, mood, and behavior. These aggressive behaviors, caused by changes in the brain, can come from out of nowhere. Someone who has always been regarded as a kind and level-headed person can turn violent from dementia.

Caregiving is a difficult and emotional job. When a loved one becomes aggressive it can often become overwhelming which can start the process of major changes. This means things like deciding when to move into an assisted living or memory care facility where staff is trained to handle such behaviors. There are ways of managing these behaviors, including strategies on what to do at the moment and how to make future incidents less likely.

 

What Aggression Looks Like

Aggressive behavior in dementia patients is shown by lashing out and typically takes one of two forms:

– Verbally which involves behaviors like cursing, yelling, making threats, and insults.

– Physically which involves behaviors like hitting, kicking, scratching, pinching, biting, pulling hair, and throwing things.

Some people have aggressive personalities before they develop dementia. A person prone to become angry and striking back physically or verbally will probably stay that way after developing Alzheimer’s and can worsen. People who have never exhibited behaviors like this, who are known to be kind or sweet throughout their lives, can also change and become aggressive. Remember, the way your loved one behaves can be a symptom of the disease.

 

Aggressive Behavior by Stage of Dementia

The middle stages of dementia are when anger and aggression are most likely to start. This can occur as other symptoms like wandering, hoarding, and compulsive behaviors can be seen by your loved one. In most types of dementia, (not just Alzheimer’s disease, but also vascular, frontotemporal, Lewy body, and others) these issues are not seen in the early stages. You might see aggression spike at the same time as the person starts needing more assistance with activities of daily living (ADLs) like getting dressed and eating. About half of people diagnosed with dementia become so agitated that they will strike back with physical abuse or verbal threats. These types of challenging behaviors have been known to fade. It may take years, but usually, the change is not permanent, and things will probably calm down.

Another important factor to remember is that as your loved one’s memory and recall starts to fade in the later stages of the disease, family and friends will become harder to remember and that lack of recognition can also cause aggression. A person who can not remember a person can become confused or outright scared by their company. Paranoia can also be common. This is why maintaining routine and using smart strategies to communicate is important.

 

Why Aggressive Behavior Happens

Aggressive behavior is almost always triggered by something. Figuring out what your loved one’s triggers are will improve quality and ease of life. If your loved one seems angry and is acting aggressively, check first to see if they are in pain. Someone with dementia may not know how to express their discomfort. To identify the cause of aggression, 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

– Constipation

Question if this is a reaction to other people. Is something wrong with the environment? Does aggressive behavior happen at the same time every day, or in the same place? Was the person tired? Uncomfortable? Embarrassed about something? Finding a pattern will help explain and manage your loved one’s aggression. One helpful idea is to keep 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 so they can form an informed medical opinion.

Remember that personal preferences and dislikes do not go away after they are diagnosed with dementia 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 could be a current trigger for them now.

The root cause of a problem that will lead a person with dementia to act aggressively can be broken down into two categories: physical and emotional. Physical needs are some tangible issues in the room and emotional needs are what is going on in your loved one’s head.

 

Physical Causes

Pain or Illness – Discomfort or outright pain can be a problem, but it’s much worse for someone who has difficulty communicating. Being constipated or sitting too long can make someone who can not explain their discomfort miserable. So can being sick, infections can cause sudden and dramatic changes in behavior.

Medications – One of the drugs for symptoms of dementia is memantine, which is known to cause fatigue. Medications that cause drowsiness can make it harder to communicate which causes distress. Other medications your loved one is taking can affect them as well.

Environment – If someone with dementia is in an overstimulating place because it is too busy or bright or loud or not stimulated enough with nothing to do can lead to them acting out. Also, being too hot or cold can cause distress.

Hallucinations and/or Delusions – Among the possible side effects of Alzheimer’s and other dementias in their mid-to-late stages, are hallucinations and delusions. These can scare someone and lead to acting out. Lewy-body dementia, in particular, is known for causing hallucinations and delusions that can trigger an angry response.

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 or hearing can cause disorientation and lead to aggressive behavior. There are hearing and vision tests designed specifically for people with dementia who have challenges with traditional tests.

 

Emotional Causes

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. These feelings can lead to lashing out.

Boredom – People with dementia typically have a harder time moving around. Being confined to an area without something to do can be boring, which leads 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. They can feel like their home is being violated.

Limitations – Dementia takes away the ability to complete normal tasks. For example, someone used to having a cup of tea in the afternoon and not being able to make their tea by themselves can be upsetting. Losing independence is agitating and can lead to aggression as well.

Loss of Reality – Someone in the later stages of dementia does not perceive the world the way the rest of us do. Not understanding what is going on can be frightening and lead to anger which turns into aggressive behavior.

Loss of Control – The inability to control oneself is another unfortunate side effect of dementia. If your loved one is upset about something, they may not have the internal capability to prevent themselves from hitting or yelling.

 

Solutions for Managing Aggression in Dementia

How you handle your loved one’s aggression depends on whether you are in the middle of an aggressive episode or not. The following tips are broken into sections on what to do during problematic behavior and good habits before and after episodes. This will hopefully get your loved one calmer and less prone to act aggressively. Remember, be empathetic and treat the person as an individual with thoughts and feelings and not a problem that needs to be solved.

 

When it’s Happening

– 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. Breathe slowly and keep your voice even.

– Calm the room. Turn down anything playing music, turn off the TV, and ask people who are there to step outside for a short while. Make the environment more soothing.

– Do not shout.

– Do not act out physically in response to them.

– Acknowledge their feelings. Your loved one might mistakenly believe there is 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.

– Turn on the music. Music therapy has been demonstrated to help with several symptoms of dementia and a song at the right time can calm someone upset.

– Try again later. If a particular task is causing distress and leading to aggression, step back and return to it another time after tempers have cooled.

Massage, aroma therapy, pet therapies, and any strategy to improve your loved one’s mood are useful for leveling out aggressive tendencies. Keep your loved one as happy as possible for as long as possible. It sounds like common sense, but this can be easy to overlook and forget.

 

For Managing Aggression Longer-Term

– 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 their 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.

 

Does Medication Help with Aggression?

Antipsychotics and other drugs may help with your loved one’s aggression. Generally, they are considered the last option for helping to manage symptoms. It is recommended to try to find non-drug solutions first. These are therapies that find solutions to improve communication, comfort, and the environment. When these methods do not work, prescription drugs can help. Medication does not solve the problem of causing your loved one to act out but improves their quality of life. Check with your loved one’s doctor about which medication is best for managing their symptoms. Medication is considered a last resort because of the negative impact their side effects can have. This is especially true with dementia and Alzheimer’s patients who can be extra sensitive to changes in their body. The medications that are prescribed to dementia patients for aggression are broken down into different categories: anxiolytics, antipsychotics, and antidepressants.

Anxiolytics

If your loved one suffers from severe panic attacks and emotional outbursts, anxiolytics can help by calming and relaxing them. These drugs can be habit-forming and have side effects. They can affect breathing and drowsiness, making it so that doctors usually recommend taking them for less than two weeks at a time. Elderly people can be particularly sensitive to side effects, so monitor your loved one closely on these drugs. The typical drugs (and their generic names) that are commonly prescribed to dementia patients are:

– Ativan® (Lorazepam)

– Buspar® (Buspirone)

– Klonopin® (Clonazepam)

– Serax® (Oxazepam)

– Valium® (Diazepam)

– Xanax® (Alprazolam)

 

Antipsychotics

Antipsychotics are prescribed to help manage difficult behaviors when anxiolytics do not work. They are normally prescribed for patients with mental illness, like someone who is bipolar. Antipsychotics lessen and remove symptoms of aggression, hostility, agitation, and anger by changing how neurotransmitters work in the brain. These effects help your loved one feel more relaxed and less agitated. While each drug has its side effects, they all affect balance, coordination, and mobility.

As of May 2023, the FDA approved the first prescription medicine to treat the aggression symptoms associated with Alzheimer’s disease. Rexulti (also sold under the generic name brexpiprazole) was originally approved to treat depression and schizophrenia in 2012. While other medications have been prescribed to help aid with symptoms, this is a breakthrough because it is the only approved antipsychotic for dementia patients. In clinical trials that were fast-tracked for FDA approval, dementia patients show improvement in their symptoms of agitation. That was done by testing patients using the Cohen-Mansfield Agitation Inventory, which is a question-and-answer test examining your loved one’s behavior. In Rexulti’s third clinical trial, out of 345 patients who took the medicine or a placebo, those who took the drug scored 5 points more on the exam after 3 months of taking it. With as many benefits as this newly approved drug can bring, it is important to remember that all medications have side effects and dementia patients can be especially sensitive to them. The largest side effect of Rexulti is that patients have an increased mortality rate. This is normal in all antipsychotic medications and according to the FDA, it falls within a “normal” range. For some patients, Rexulti’s benefits outweigh the risks and their severe agitation and behavior problems can decrease causing a positive benefit to their quality of life.

The other commonly prescribed drugs to dementia patients are:

– Abilify® (Aripiprazole)

– Zyprexa® (Olanzapine)

– Clozaril® (Clozapine)

– Haldol® (Haloperidol)

– Seroquel® (Quetiapine)

– Risperdal® (Risperidone)

– Geodon® (Ziprasidone)

 

Antidepressants

Antidepressants help dementia patients by improving their mood and desire to want to function. There are mixed results in their effectiveness. Some studies have found antidepressants worsen symptoms of dementia and others say they can improve overall mental health. Antidepressants increase neurotransmitters, chemicals in the brain that regulate mood and emotion. This makes patients feel less depressed and anxious. A common side effect is that they can cause a change in mental clarity and confusion. The antidepressants normally prescribed to dementia patients are:

– Zoloft® (Sertraline)

– Celexa® (Citalopram)

– Remeron® (Mirtazapine)

– Desyrel® (Trazodone)

– Prozac® (Fluoxetine)

 

For Caregivers

Do not blame a person with dementia for their behavior. It is important as a caregiver to remember that anger and aggression are symptoms of the disease and 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.

Find an outlet. Join a group or just find a friend who can listen to what you’re going through. It is essential to manage caregiver stress because a stressed-out caregiver will not be as effective in emotionally helping 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. Exercise and socialization are good for caregivers too!

Be open to change. You may need to learn to speak and communicate differently or make house adaptations to eliminate triggers.

 

Aggressive Behavior in Memory Care / Assisted Living

The staff in assisted living homes and memory care facilities should be uniquely capable of handling dementia-related aggression. How a memory care community handles residents who have issues with aggression is a good gauge of whether it is the right place for your loved one. If the staff seems annoyed or disdainful by aggression, then they are probably not a good fit for your family. To know if a memory care home can handle your loved one with aggression issues, look for these signs:

– Staff gets to know residents, becoming friends. If they form a connection or bond with residents, employees at memory care homes will better understand what triggers aggression and how to cool it down.

– Communication with loved ones outside the community is encouraged. A memory care home that handles aggression well will want loved ones to be accessible. They should take your phone number so you can be reached quickly to help if the person with dementia decides they need to speak with you.

– Incidents of aggressive behavior should be documented in reports. This can identify causes of outbursts and show patterns unique to individuals.

One way to figure out if a home is good at handling dementia-related aggression is to visit during the evening when angry outbursts are more likely to occur because residents are tired and the transition from daytime to dinner to preparing for sleep can be difficult. Watch for staff to ask questions of residents, have conversations with them, and respond quickly but calmly if an aggressive episode occurs.

Ask about training. Is there regular training and continuing education for employees, and do they learn techniques to deal with aggressive behavior in residents?

These communities have rules against allowing residents to act in ways that are dangerous to themselves or others. Lashing out physically or verbally may count as dangerous behavior and may lead to eviction. This is why it is very important to understand a residence’s policy on aggressive behavior. When does aggressive behavior cross the line from manageable to problematic? Memory care homes almost always have the right to reject and evict someone whose actions are dangerous. Is verbal aggression considered dangerous? Each facility will have its procedure.