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Dementia Care: Coping with an Aggressive Patient

One of the most frightening and distressing behaviors displayed by your loved one with dementia is aggression. Here are some of the steps you can take to help defuse the situation when your loved one may be combative.

In people with dementia, aggression often involves swearing, screaming, throwing objects, slamming doors, resisting care, biting, or attempting to hit others. Verbal aggression is more common than physical aggression, while sexual aggression is the least common.

While many people with dementia will exhibit aggressive behavior, many things can be done to decrease or eliminate its occurrence, to deflect it into another activity or behavior, or to minimize the risk of harm.

Certain factors tend to make a person with dementia more likely to engage in aggressive behavior. These can include:

Male gender

Frontotemporal dementia

More severe cognitive impairment

Difficulty communicating

Significant problems with activities of daily living

Other psychological and behavioral problems, such as depression

Often a trigger leads people with dementia to act aggressively. In some cases, your loved one may feel that his or her personal space has been invaded and needs to be defended.

This can occur when you or another caregiver is helping the person bathe or get dressed. It often occurs when a doctor is evaluating your loved one. Aggressive behavior may also occur when people with dementia do not understand why they are asked to do something. They may misinterpret certain actions or mistrust you and others around them and then lash out aggressively.

In addition, aggression may be a sign of an underlying medical or psychiatric problem your loved one cannot communicate. For example, a urinary tract infection, pain, physical illness, depression, anxiety, lack of sleep, or frustration may cause the person to act out. In about 11 percent of cases, however, aggression occurs without any identifiable cause.

What you can do

It’s important to keep an account of the events that surround acts of aggression so that possible causes can be identified. The account should describe:

What happened just before the outburst (potential “triggers”)

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What the behavior entailed (does it really need to be changed?)

The outcome of the situation

How often aggressive behavior occurs

If anyone else is present when the behavior happens

What, if anything, reduces the behavior

A doctor should evaluate the person with dementia to rule out the possible physical causes for aggressive behavior.

Treating an aggressive patient starts with uncovering a pattern in the behavior. For example, if a person typically is aggressive when unable to find items such as clothes or dishes, try labeling drawers and cabinets.

If your loved one becomes combative when trying to make choices about eating or dressing, limit the number of options you present. If outbursts occur when he or she receives instructions on how to do something, avoid general directives and instead give instructions that contain only one step.

For example, say “Put this shirt on” rather than “Get yourself dressed.” Routine is important for many people with dementia. Some caregivers find that maintaining a regular daily routine and following it every day helps avoid outbursts. Playing music the person enjoys during problem times such as bathing also may be useful. In addition, a regular, gentle exercise program can help reduce aggression.

If your loved one lives in a nursing home, it’s important to analyze their surroundings to see if any changes can be made to improve their behavior. For example, the facility may be overcrowded or the person may be over- or understimulated. In some circumstances, changing roommates may be very helpful.

Learning caregiving techniques also can help you take better care of your loved one. Contact the Alzheimer’s Association in your area to find out if there are caregiver-training programs or caregiver support groups in which you can learn how other people cope.

How to handle an aggressive episode

Despite your best efforts to prevent and treat aggression, episodes may still occur from time to time. Knowing what to do can help defuse the situation. If a person with dementia becomes aggressive, here are some helpful tips:

• Focus Try your best to stay calm and stop whatever it is you are trying to get the person to do.

• Detach Give the person enough space so that he or she doesn’t feel threatened.

• Accept limitations Don’t argue, make degrading comments, or punish the person physically or psychologically. Recognize what they can no longer do and try to avoid pushing them to do it.

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• Distract Talk about a subject the person enjoys.

• Remove potential precipitants Removing triggers and distracting may stop the problem very quickly.

Medications may help

If behavioral modifications do not help control aggression, and no medical or psychological causes can be identified, medication may be necessary. Although there are no drugs specifically approved to treat aggression in dementia, research shows that a number of medications may be helpful.

These include:

Antipsychotics

Anticonvulsants

Antidepressants

The blood pressure–lowering drug propranolol (Inderal)

Remember, because of the person’s illness, he or she likely will not recall the aggressive event or be able to learn from it. Talk to the person in a calm, non-threatening voice, using easy-to-understand language.

If a television or radio is on, turn down the volume or turn it off. Try to ignore the aggression or distract the person by switching to another subject.

If none of these tactics work, try to calm the person by hugging them, telling them you love them, that no harm will come to them, and that you are in charge. This often reassures a frightened person with dementia. Some caregivers find it helpful to distract the person with a calming activity like sitting in a rocking chair.

Some final words of advice: Try your best to remain calm, patient, and compassionate. Kindness is always realized and appreciated, even if you are perceived as a complete stranger by your loved one.

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