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What do you do when the person with dementia in your care becomes aggressive? Aggression in dementia is more common than not, but there are ways of dealing with it. Here are 10 tips for caregivers.

Researchers tell us that over 90 percent of people who have dementia present behavioral issues at some point in their disease. These problem behaviors tend to occur in clusters. One of the larger clusters of troubling behaviors in dementia is agitation, defined by the as “excessive motor activity with a feeling of inner tension and characterized by a cluster of related symptoms including anxiety and irritability, motor restlessness and abnormal vocalization, often associated with behaviors such as pacing, wandering, aggression, shouting, and nighttime disturbance.”

Aggression is a subset of agitation. Aggression consists of harmful behaviors which are clearly intentional. Agitation mostly affects the person who is agitated. Aggression affects at least one other person who is the intended object of the behavior. "Aggression: isn't always clearly defined, but it's something that "you know when you see it."

Taking care of someone who has dementia is a demanding task. Aggressive behaviors are the problem that wear down family members and nursing staff fastest. A meta-analysis of 35 studies found that 50 percent of caregiver reported that their own fatigue was due at least in part to dealing with aggression, more than those who cited depression of the family member (40 percent) or lack of sleep (43 percent).

The standing recommendation of experts in major neurocognitive disorders is that agitation and aggression should be treated with behavioral measures, not with medications. The reality of nursing home life is that the staff often gets a pro re nata (PRN, "use as needed") order for a strong antipsychotic like Seroquel or Haldol after the first or the first incidents of aggressive behavior. Dementia patients tend to die more quickly when they are given antipsychotic drugs at any time during their treatment, and especially if they are given antipsychotic drugs for more than 180 days.

But nursing homes that have the staff do not always have to resort to drugs that "knock out" both the undesirable behavior and the emotional range of the patient, and family members who aren't physicians taking care of dementia patients at home have some non-pharmaceutical tools at their disposal. A little later in this article we'll cover 10 commandments for dealing with aggression in dementia. But first let's look at two areas of aggressive behavior that can become life or death situations.

Aggressive behavior is frequently the reason families have to take the car keys away

Many people who have dementia still drive during the early stages of their disease, but when dementia begins to cause anger and acting out, it is usually also time to restrict driving privileges. (In my family, we not only had to search every possible copy of the engine keys, we also had to remove the distributor cap and take off the alternator belt.) As the brain loses its ability to interpret cues from other people, paranoia takes over. Some people with dementia may conclude that other drivers are "out to get them". Even a small amount of alcohol can make aggressive behavior much worse.

If you are searching for a way to judge whether your loved one is still safe to drive, consider whether you would let your own child ride with them. If not, it's time to take away the keys. This doesn't have to be a major confrontation. If you confront someone who has dementia with "Your driving is terrible and you are not going to drive any more," you are likely to get an angry response. If you give them an easier out, for example, with "I am worried that you might not be able to stop at a red light," you may find the confrontation less emotional. Since driving is a badge of independence in many cultures, cushion the loss of one form of independence with expansion of another whenever possible. Expand food choices. Get that electronic device that has been asked for. Do something fun with your loved one. Do your best to distract them from the reality that they cannot drive any more.

Biting, pinching, kicking, and taking a swing at caregivers or family members sometimes can be prevented

Combativeness is usually part of a catastrophic reaction. Tensions rise until they explode. It is important to recognize that tensions are rising to prevent violence from erupting.

When it is necessary to change routine, move slowly and explain as much as possible. It's not unusual for patients to blow up during hair care. The barber or hairdresser is unfamiliar, the scissors seem dangerous (and actually are), and the caretaking event has to take place on a busy schedule. Tensions may be too much and the beautician gets bitten or the barber gets a punch in the nose. Other tension points include introducing new staff, visits from people the patient does not remember, and almost any kind of waiting, especially waiting for a scheduled meal.

Look for signs of increasing emotional distress. Turning away can be a signal of tension. So can an angry jutting lip or slapping against a table or repetitions of requests, then orders to stop. It is sometimes necessary physically to restrain someone with dementia from causing harm, but holding someone back is sure to make their anger and frustration worse. Do your best to pay attention to warning signs that emotions are about to boil over and stop the actions or procedure that the patient is not ready to deal with. And make sure the patient does not have access to knives or guns.

It can help to keep notes on the behaviors that precede an outburst. If you see them again, you can deescalate the situation to avoid a catastrophic reaction that results in aggressive behavior. It can also help to brainstorm with family members, caregivers, and administrators to come up with a comprehensive list of cues that a catastrophic reaction is imminent.

Ten commandments for defusing aggression in dementia

1. Take things one step at a time, and explain what you are doing at each step.

Don't just, for example, remove a patient's shirt. Explain "I'm going to unbutton your shirt now." Then explain, "Now let's get your arms out of the sleeves," and so on. Some patients will tell you that it's OK, you don't need to give them that much information. Others will understand but not respond. Going slowly so what you are doing is understood step by step reduces the chances of mounting frustration and an aggressive outburst.

2. Plan demanding tasks for the patient's best hours of the day.

Avoid doing things when the patient is tired. If the patient is sundowning, avoid complicated tasks in the late afternoon.

3. If someone is having frequent aggressive outbursts, remove excessive stimuli in the room.

Simplify the environment so the brain does not have to process as many signals. This may mean closing the door to keep out hallway noise and blaring television, limiting the number of visitors, and minimizing the number of difficult tasks attempted during a single day.

4. Do the hard parts of a task yourself.

If the patient is having difficulty with a series of steps to accomplish a necessary task, do the hard parts yourself. For instance, let the patient but his feet in shoes, but tie the laces yourself.

5. But modify tasks to emphasize independence.

Instead of lace-up shoes, offer slip-ons, for instance. Instead of cutting up the patient's food, serve food that has already been cut.

6. Let people do for themselves until they begin to show frustration.

Take over a task at the first signs of frustration.

7. When someone seems more irritable than usual, check for symptoms of illness or pain.

Someone who has dementia may not be able to communicate symptoms. You will have to observe carefully.

8. Don't argue with people who have dementia.

As someone who has dementia gets upset, their ability to reason is diminished even further. State yourself clearly, calmly, and kindly, but do not argue. And never lose your own temper.

9. Be careful with expressions of reassurance.

Sometimes holding someone's hand is interpreted as restraint. A pat on the shoulder can be misinterpreted as an assault. 

Therapeutic touch usually helps to reduce aggressive behavior. This could be because therapeutic touch practitioners sometimes only place their hands near the patient's body. However, when therapeutic touch is discontinued, aggressive behaviors usually become worse.

10. Don't take aggressive behavior personally.

Someone who has dementia has shrinking resources for understanding and responding to the world. Their limitations are not your fault, even if their only defense is to pretend they are.

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  • Ornstein K, Gaugler JE. The problem with “problem behaviors”: a systematic review of the association between individual patient behavioral and psychological symptoms and caregiver depression and burden within the dementia patient-caregiver dyad. Int Psychogeriatr. 2012 Oct. 24(10):1536–52.
  • Photo courtesy of SteadyHealth

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