Aggressive Behaviour

If you are caring for someone with dementia you may find that they sometimes seem to behave in a very aggressive way. They may be verbally abusive or threatening, for example, or kick or pinch or they may lash out violently at people or property. If such behaviour occurs, you are likely to feel distressed and anxious about the best way to cope. Here are some suggestions.

People with dementia may react in what appears to be an aggressive manner if they feel frightened or humiliated, or frustrated because they are unable to understand or make themselves understood. They may also become aggressive if their sense of judgement and self-control have been eroded by the illness so that they are no longer restrained by normal inhibitions and cannot remember how they should behave.

Sometimes their aggressive behaviour may seem like an over-reaction and they may shout or scream or become very agitated as a result of a very minor setback or criticism.Although any form of aggression is very upsetting it is important to remember it is not deliberate and that the person cannot help themselves. They are likely to forget the incident very quickly.

Triggers for aggression

If you look carefully at the situations in which the person becomes aggressive and the events leading up to them you may be able to identify what triggers the reaction and gain some understanding of what may be troubling them. If there seems to be no pattern to their behaviour and it is very difficult to manage, seek professional advice.

Possible reasons for aggressive behaviour include situations in which the person:

• feels frustrated, pressurised or humiliated because they are no longer able to cope with everyday demand
• feels their independence and privacy are threatened because they are forced to accept help with intimate functions such as washing, dressing or going to the toilet
• feels they are being judged or criticised perhaps because they have forgotten something or made a mistake
• feels bewildered or frightened because there is too much noise or too many people or there has been a change in routine, for instance, and they cannot cope.
• feels anxious or threatened because they no longer recognise certain places or people. They may be convinced they are in the wrong place or that a relative is a stranger who has broken into their home
• feels frightened because of a sudden noise, sharp voices, abrupt movements or someone approaching them without warning from behind.
• feels discomfort, pain, boredom or thirst.

Preventative measures

If you can find out what may be upsetting the person with dementia you may be able to reassure them or you may be able to find ways of handling situations that will be less distressing. Ask for advice from professionals or other carers. If appropriate you might:

• reduce demands made on the person, if they do not seem to be coping, and ensure that there is an unrushed and stress-free routine
• explain things to the person, wherever possible, calmly and in simple sentences, allowing time for them to respond. Click here for more information on communicating with someone with dementia
• find tactful ways of offering help without seeming to take over. Guide or prompt the person and break down tasks into small easily-manageable steps so that they can do as much for themselves as possible
• try not to criticise the person or show any irritation you may feel and avoid situations where they are bound to fail. Praise any achievements and focus on their remaining abilities rather than on what they can no longer do.

In addition:

• Watch out for warning signs such as anxious or agitated behaviour and offer more reassurance, if appropriate.
• Avoid sharp voices and sudden movement. Too much noise or too many people may also add to their confusion.
• Avoid confrontation. You might distract the person's attention if they seem upset or leave the room for a few moments.
• Make sure the person has regular health checks and consult the GP immediately if they seem to be ill or in discomfort.

Coping measures

Preventative measures will not always work. Do not blame yourself if aggressive behaviour occurs. Concentrate instead on handling it as calmly and effectively as possible.

At the time

• Try to remain calm and do not allow yourself to be drawn into an argument however upset you feel. A heated response is likely to make the situation worse.
• Take a deep breath or count to ten before you react. Speak in a reassuring voice and attempt to distract their attention or leave the room if necessary.
• Try not to show any anxiety as this may increase the person's agitation.
• If they are physically violent give them plenty of space. Closing in or trying to restrain the person, unless absolutely necessary, can make matters worse. You may need to leave them till they have calmed down or call for help.

Afterwards

• Do not try to punish the person by withdrawing a treat, for example. They are unable to learn from experience in this way and will probably forget the incident very quickly. Try to behave as normally and reassuringly as possible.
• If aggressive incidents are frequent or worrying discuss them with a professional such a psychogeriatrician or community psychiatric nurse. They may be able to offer support and suggest other ways of handling the situation.
• Generally it is best to avoid treating aggressive behaviour with drugs as these can add to confusion. However, if it does seem that such drugs are unavoidable the doctor will want to prescribe the minimum effective dose and to review the treatment very regularly. Click here for more information on drugs

Your own feelings

It is important to remember that, although much of the aggression may be directed at you, it is not intentional but simply because you are there. However, any incident will probably leave you feeling quite shaky. A cup of tea with a neighbour, a phone call to a friend or a little time spent quietly on your own will help you recoup your resources.

Don't feel guilty if you do lose your temper. You are under great stress. But do talk things over with a professional or another carer who may be able to suggest ways of handling such situations more calmly.

Don't bottle up your feelings or resentments. Talking things over with a friend, a professional or within a carers group may help.

For some thoughts on the importance of looking after yourself, click here.

October 1997

Page Text supplied by The Alzheimer's Disease Society of Great Britain