Caregivers have been hit, scratched, and even bitten by their loved ones. A person with Alzheimer’s disease, or related dementia, might become insulting, acting out with anger or rage. And these aggressive behaviors, caused by changes in the brain, can come from out of nowhere. Someone who was always kind can turn violent from dementia.
Caregiving is already difficult and emotional work, but when a loved one becomes aggressive it can often lead to major changes, like deciding to make the move into assisted living where staff are trained to handle such behaviors. The good news is there are ways 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 this behavior, who are known to be kind or sweet throughout their lives, can also 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 seem unusual.
In most types of dementia (not just Alzheimer’s disease, but also vascular, frontotemporal, Lewy body and others) these issues develop in the mid-to-later stages. You might see aggression spike at the same time as the person starts needing more hands-on help with activities of daily living (ADLs) like getting dressed and eating. About half of people diagnosed with dementia become so agitated that they’ll strike back with physical abuse or verbal threats. Fortunately, these “behaviors that challenge,” 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 things will probably calm down.
That said, when recall starts to fade in later stages, family and friends become harder to remember and the lack of recognition can also 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.
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 seems angry and is acting aggressively, check for pain first. Someone with dementia may not know how to express discomfort or pain. 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
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.
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. Being constipated or sitting too long can make someone who can’t explain it miserable. So can being sick: Infections have been shown to cause sudden 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. Being too hot or cold can also cause problems.
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 hallucinations and delusions that may 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 and / or hearing can cause disorientation which, in turn, can lead to aggressive behavior. There are 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. 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 yelling.
How you handle aggression 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. Above all, be empathetic; treat the person as an individual with their own thoughts and feelings, not simply a problem that needs to be solved.
– 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.
– 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.
– Turn on music. Music therapy has been demonstrated to help with several symptoms of dementia, and the right song at the right time can calm someone who’s upset.
– 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.
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.
– 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.
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. More.
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.
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 helping with 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.
The staff in an assisted living home for people with dementia (often called “memory care”) should be uniquely capable at handling aggression in people with dementia. In fact, how a memory care community handles residents who have issues with aggression is a good gauge of whether it’s the right place for your loved one. If staff seem annoyed by aggression, or disdainful, then they aren’t good for mom or dad.
To know if a memory care home can handle your loved one with dementia’s aggression issues, look for these signs:
– Staff gets to know residents, becoming like friends. If they form a connection or bond to residents, employees at memory care homes will have a better understanding of 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 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. 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.