Aggression and Agitation in People Suffering with Dementia
Aggression and Agitation in People Suffering with Dementia
People with Alzheimer's disease may become agitated or aggressive as the disease gets worse. Agitation may cause pacing, sleeplessness, or aggression, which is when a person lashes out verbally or tries to hit or hurt someone.
These two words are used interchangeably, but they are not quite the same. Agitation is a generic term and it refers to both non-aggressive verbal and physical behavioral problems, such as when a patient is confused they may get worked up, or pace, but it also does include behavioral problems and verbal problems that are aggressive.
Aggressive behavior means actual hostility, either verbal, or physical that is directed towards the self or other people. So, on the verbal end we see threatening, swearing, and yelling. The person also has things like sex talk, or obscene language. In other words inappropriate sexual talk is considered aggression, but then you have more physical types of aggression, like spitting, hitting, kicking, throwing things, pushing, could be use of a weapon against another person, or the self, and of course, self harm is a form of aggression.
There is also an area called catastrophic reaction where somebody with dementia may overreact as a resultant of maybe asking them a question, or a minor setback, or criticism. I want to clarify though that just because somebody is crying out for help or pacing, and wandering that is not aggression. Aggression is pretty common in people suffering with dementia. The bottom line is about 96% it occurs in the course of dementia. This means that if you are a caregiver you are likely to content with some form of aggression during the course of your taking care of someone as the dementia progresses. It occurs roughly in 20 to 50% of people, but it can be as high as 96%.
One study has shown though that within about the first year of diagnosis almost 16% of people who are being cared for with dementia might act violently towards the caregiver. Aggression works both ways, so sometimes about 5% or so of the caregivers in that first year were aggressive towards the patient and then in about 4% of cases within that first year of diagnosis it was mutually aggressive. Sometimes when the patient is aggressive a loved one can return that behavior and they react in an aggressive way, then it becomes mutual. People might want to know when does agitation or aggression happens and does it matter what kind of dementia might their loved one has, and really the answer is it varies. Think about somebody with Alzheimer’s disease, it tends to occur in the more moderate stages as the severity of the dementia gets worse, but in diseases like frontal temporal dementia, which often presents with a personality change, or a behavior change early on that tends to happen more earlier in that type of dementia.
In people with Lewy body dementia it can happen during sleep, and this is a form of aggression that is not intentional in any way, not that aggression is, but this type of aggression happens during REM sleep where people with Lewy body dementia often have what we call a REM sleep behavioral disorder where they act out their dreams and these dreams are often violent in nature, or very vivid and so the person may be acting to defend themselves in the dream and this can result in physical behavior like fighting, kicking, and punching. The person who is acting those dreams has no awareness that this is going on, they have not even a memory for the events, and sometimes form of aggression, verbal aggression, personality changes can happen before dementia onset is actually identified, and diagnosed. Sometimes, retrospectively people notice that their loved one is more irritable, they might be more verbally aggressive, or abusive, and once a person is diagnosed looking back they will say, “You know what, I know this person was different even before they were diagnosed with Alzheimer’s disease.” The consequence of aggression is the one reason why we are concerned. First of all it is harmful, obviously it can result in danger, or harm to the patient, or to the caregiver, or other people that are interacting, or around the patient, but it is also upsetting to the patient.
Patients who are aggressive are not happy, and it is a major source of caregiver stress, it adds to the burden that caregivers just already have when they care for someone with dementia. Aggressive behavior can be difficult to control, and they definitely result in premature nursing home placement. According to studies a lot of nursing homes are long-term care facilities either will not accept someone with dementia, or they will not keep somebody there who has dementia. Therefore, this can result in very negative consequences, including restraints, either physical, or chemical (meaning that somebody is medicated to calm them down).
The causes of aggressive behavior are really multi-dimensional. The first thing to know is it is a disease; it is not something that is intentional, it is not something that is meant personally, but it is definitely the disease process, and the few reasons why this happens first has to do with what parts of the brain are affected by dementia. A number of studies show the frontal lobes of the brain, which are important for managing behavior like filtering your behavior, inhibiting behavior that is not appropriate, being able to have judgment, being able to foresee consequences of your actions; these parts of the brain are affected in dementia, and so people lose those abilities to kind of hold back, and judge their own behavior in a situation. Other parts of the brain too though are affected, like other cortical regions like the anterior temporal lobes, the parietal lobes, and even areas underneath the cortex, such as the caudate nucleus can be sites of what we call lesions or abnormalities in the brain. There are also changes in neurotransmitters and in hormones that may affect whether somebody behaves, or has a propensity to behave aggressively, and again we talked about the cognitive deterioration, especially these functions that are controlled by the frontal lobes like judgment.
When one thinks about it, the dementia itself sets up vulnerability for these kinds of aggressive behavior. We have on top of it a few categories for things for you to think about that add to this and might trigger, or essentially release, or set the stage for these dis-inhibited behavior to occur, so one includes difficulties with communication. So when someone has dementia they have really language problems. This includes difficulties understanding behavior, difficulties communicating their feelings, and their thoughts, and they are not necessarily able to formulate a concept about what is going on around them. Somebody with dementia cannot tell you “I’m upset; I don’t understand what you are trying to say to me.” They may act out behaviorally with their frustrations, and their confusion. Usually if there is some kind of agitation going on it is helpful to think about it as somebody is having a communication problem, they are trying to tell you something one has to be very vigilant, and intelligent, and figure out what it is.
There are internal factors that means what is going on inside the patient, and this could be anything from psychological factors like they are feeling fear, or anxiety, or it could be biological factors like they have an infection. So we often see urinary tract infections causing delirium, which in return is confusion, agitation, and people can lash out aggressively. Sometimes medicines, and definitely alcohol can unleash these kinds of behaviors, and finally there is the environment, like what is going on around the patient, and it can be anything from who is in the room, what your behaviors are as the caregiver, what is going on the television set, what is the temperature like, all these things that perhaps are bothering the patient, and they cannot communicate with what is going on, they do not understand what is going on and in such circumstances they may act out and lash out.
Let us look a little bit more closely at these types of problems. This is a good way to think about it. It is usually somewhere among these three, or all three in combination with each other. Usually what we call something that sparks, or releases, or causes a behavior to manifest is called a trigger. We talked about those three major categories, but let us split a few hairs here and look more closely. If you come across somebody who is acting out you should be thinking about any of these possibilities. Someone again has psychological factors like depression, fear, anxiety. They are not able to communicate, they are frustrated, they cannot do a task, a task that they used to do, or a task you are asking them to do. It is too complicated, or they do not understand it. They could be in a new surrounding a place where they have not been before, or the place where they are does not seem familiar to them anymore; could be loud noises in the environment like chaos, people coming and going, violent shows on TV, because people with dementia have a difficult time separating what is real from what is not real, and physical discomfort like pain, hunger, thirst, and biological factors like delirium, and other illnesses, or infection.
If somebody has depression, or mania, if they have anger, if they are frustrated, these could be considered triggers, more along the psychological spectrum of aggressive behavior. Paranoia and suspiciousness, delusions can trigger aggressive behaviors. Here are some examples, if you are a caregiver you may have heard these before like “my daughter is trying to poison me, my daughter is trying to put me away, my husband is cheating on me,” and particularly these delusions about cheating spouse can engender aggression in a patient sometimes towards the spouse and sometimes towards the person they think is cheating on them with the spouse.
If your loved one has a tendency to have been aggressive, or very reactive in the past, this can be a behavior that is more easily manifested once dementia sets in. Again if you think about it, it is the frontal lobe functions that a person does not dis-inhibit anymore. Think about when you are driving along the road and you get road rage, you might be very angry at someone, but you are not necessarily going to run them down with your car. Somebody with dementia would not be able to really inhibit that behavior. So what you do in these situations is you try to treat the underlying psychiatric problem, if somebody has depression, or mania you would want to treat it, and again if you are interacting with someone maybe you are giving them too complicated instructions, you are asking them to do things that they no longer do, you want to change your communication style and rethink how you are interacting, and what you are asking that person to do.
Environmental factors include what is going on around the patient, things that you may not think about and you simply go and turn down the thermostat, a patient who cannot do that might get testy, or edgy if it is too hot, or too cold. The main thing here to notice is attitude of the caregiver. Even though patients may not be able to communicate well they can pick up on emotions. If you are angry, you are stressed, if you are impatient, if you are rushing someone, this can help trigger aggressive types of responses and reactions in someone.
In long-term care facilities, nursing homes, roommates can trigger aggression in somebody, because for example let us say somebody is yelling, and screaming in the bed next door, or somebody wanders into another person’s room by accident. This can trigger an aggressive response. Taking somebody on vacation sounds like fun, but this can cause confusion in a loved one, and sometimes it results in someone acting out and lashing out. Finally, changes in personnel like having a lot of turnover of caregivers can result in these types of lashing out behaviors. They do not know who they are, remember it takes a long time to learn and get to know someone, and they cannot even sometimes recognize them from time to time, so changes in caregivers can be a source of lashing out and aggression.
In these cases if it is you and your attitude, you try to change your behavior and try to adjust to the environment. Pain is another factor, it definitely can result in people being cranky, irritable, and acting aggressively. Constipation has come up in the number of studies as a source of potential acting out of aggressive behaviors, because it is painful, because people are uncomfortable, and they cannot tell you, and they may not understand that this is what going on with them. Some medications, and medication interactions and drugs like Benzodiazepine, Ativan, Valium, and drugs in that family of medications can dis-inhibit patients. Some medications like dopamine can cause aggression in patients that take those medications like patients with Parkinson’s disease. Definitely, alcohol intoxication in someone who is intoxicated and they have dementia they definitely can act aggressively. So what you do in these cases is you treat the underlying medical condition and if your loved one is showing these changes, talk to your doctor, perhaps they need medication reconciliation, they need a review, and definitely eliminate alcohol from their diet, their recreation, and their relaxation.
One of the things that happen in dementia is that patients tend to not recognize who they are relating to. They may not recognize a caregiver. They may not even recognize their own adult child. So that person can be perceived as a stranger and so they may act defensively. They might perceive just being cared for as a threat. So giving medications, especially if someone is delusional or they think they are being controlled that might be a way that the caregiver would trigger aggression. Confrontational, punishing, impatient, and critical attitudes from the caregiver to the patient is not a winner, it is going to create this type of aggressive response. When you are with the patient try to remember that you are dealing with someone who cannot control their behavior, it is not personal and whatever you do, do not confront, and escalate a situation. The sex of the caregiver is an issue especially in the cases of inappropriate sexual behavior, sometimes you are better off with the same sex caregiver especially if you have a male patient who is acting inappropriately towards a female caregiver. It could also be sometimes people feel during bathing they become very private, they feel like any of us would, modesty is an issue, and so having a caregiver of the same sex sometimes does not work, especially for men, but sometimes having a caregiver of the opposite sex again does not work for both men and women. That is a trial and error situation, and sometimes it is just a specific person has nothing to do with the behavior of that person, but that individual may remind them of someone that they have had a contentious relationship with before.
What keeps an aggressive behavior going? That is called a reinforcer and this can happen, this can be completely inadvertent on your part, or even unexpected, but a patient gets a desired outcome and that outcome keeps that behavior going. It is like a reward. Avoiding something that somebody does not want to do like taking a medication, or getting a bath, coming out of one’s room, by chasing someone away, or acting aggressively, they do not get the medication, then the patient learns that that is a behavior that will bring about that desired outcome.
The role of the caregiver plays a major and vital role in treating patients with dementia. In some cases medication will not work, it is the winning, soothing, cajoling actions of the caregivers can bring about the desired result. By addressing the distressed veteran in a one-on-one manner, share their concern, do some detective work to figure out the problem, and send a message that you can help. The person assigned to take care of patients should act logically, and behave very tactfully, like moving the patients who are subjected to discomfort from an overly stimulating environment by using positive verbal interactions and acting on a series of hunches about common unmet needs. For people in distress use positive physical approach and hand-under-hand technique; these skills allow the veteran and staff member to make a connection, feel in the same side, and tuned in to cues on what underlies the distress. The caregiver turns a difficult group situation into a positive outcome and provide the distressed with excellent care, and concern.
This content is accurate and true to the best of the author’s knowledge and is not meant to substitute for formal and individualized advice from a qualified professional.
© 2020 Putcha Venu Madhav