Dementia, including Alzheimer’s Disease, can be difficult for older adults, their caregivers and family members to manage. While there are many difficult behavioral and psychological symptoms of dementia, aggressive behaviors ¹ are among the most challenging.  As Bryan Hansen, PhD(c), MSN, RN, FNE-A Hansen points out in his recent NYC Elder Abuse Center guest blog, aggressive behaviors are common for older adults who have dementia and often meet the definition of abuse. In addition, caregivers coping with challenging behaviors are at an increased risk to respond in an abusive manner, which can create situations where both individuals may perpetuate and/or experience elder abuse.

This blog provides elder justice professionals with an understanding of the causes of aggressive behaviors, tools to help mitigate situations involving aggressive behaviors and tips to prevent future potentially abusive situations, both from the person with dementia as well as their caregiver.

For people with dementia, who, because of their condition, can no longer communicate in the ways s/he has in the past, behaviors become a primary mode of communication. Behaviors, particularly aggressive behaviors, most often represent an expression of frustration or attempt to communicate an unmet need.

Too often we focus on what the person is doing as opposed to exploring why the person is doing what s/he is doing.  When responding, it’s important not to react right away and to try to understand exactly what is causing the behavior.  When reacting or responding to the “what,” the opportunity to address the unmet need in a meaningful way is missed. Instead, it is important to consider the “why” and address the unmet need as opposed to the behavior itself. With this approach, the behavior is more likely to be reduced or even eliminated.

Common causes of aggressive behaviors include hunger, physical discomfort (including pain from an illness or infection, such as Urinary Tract Infections), fear, boredom or isolation, changes in routine, masking impairments, disorientation from home or family or frustration. These behaviors can also be reflexive, particularly when bathing or changing a person with dementia as they may see the contact as a threatening.

When interacting with a person with dementia, it is crucial to remember that aggressive behaviors are not intentional and/or controllable and are part of the disease process.  Helpful tips include the following:

• Schedule appointments early in the day. This helps avoid symptoms of sundowning and the accompanying confusion and agitation. ²

• Foster comfortable, quiet locations with minimal distractions. This promotes focus for the person with dementia and decreases possible triggers that may cause agitation. ^{3 4}

• Create situations where a person can safely move about a room. This is crucial to understand because wandering is a common symptom of dementia, which means that the person will likely get up and walk around. Often people with dementia wander to search for something (such as a bathroom), escape from something (keeping background noise down can help with this), or because they are reliving the past (such as trying to leave for work in the morning as they would have in their previous routine). ⁵

•  Ask simple questions and/or give one step directions. This communication style engages the person with dementia and fosters productive and informative communication. ⁶

• Pay attention to triggers and try to recall what happened just before the behavior was exhibited. This practice helps  with identifying the stimulus behind the aggressive behavior so it can be prevented and mitigated in the future. ^{7 8 9 10}

• Remain alert to body language, verbal, and non-verbal cues (such as fidgeting). This helps with becoming aware when a  person is becoming frustrated or restless. ^{11 12}

Aggressive behaviors can, and often do, escalate to a point where caregivers may be physically harmed (we covered a case example of this in a recent blog post). For clients and families frequently responding to ongoing aggressive behaviors, it is critical to to create a safety plan so that caregivers know what steps to take if, and when, a situation escalates. This discussion can include reassurance that care schedule flexibility is acceptable. Caregivers should be encouraged to pause certain care tasks (such as bathing or dressing) if the person with dementia becomes agitated.

In addition, there are pharmacologic interventions that may help reduce aggressive behaviors if non-pharmacologic interventions have failed. Discussing these options with a physician may help to ensure increased safety and quality of life for both the person with dementia and their loved ones.

The New York City Chapter of the Alzheimer’s Association, which is a NYCEAC partner organization, runs a 24-hour Helpline (800-272-3900) that is available in 180 languages+. The organization also holds free trainings for family and formal caregivers about how to understand the disease process as well as provide tools for reducing and responding to challenging situations. They urge even the most seasoned professionals to reach out for resources and trainings for both their own organizations and for the caregivers they serve.

Aggressive behaviors are one of the biggest challenges in caring for someone with dementia and are often directed towards older adult caregivers, or can contribute to a caregiver responding violently. It is important for elder justice professionals to understand how to best respond to these behaviors. Below we’ve provided additional resources and scholarly journal articles including information about dementia and elder abuse. We hope that you will share your experiences, thoughts on the topic and advice for others in the comments section below.

Please visit the following sites for additional resources:

The Alzheimer’s Association webpage: Features resources about behavioral and other challenges in dealing with dementia and also connects to local chapter resources and events.

Alzheimer’s Foundation of America: Partners with 1700 member organizations, focuses on increasing the quality of care for people with dementia, and features a tip sheet titled Behavioral Challenges: Coping with… Anger and Aggression.

Alzheimer’s Society: Provides resources to individuals and families affected by dementia, and has provided a Factsheet: Dementia and aggressive behavior, which is available in both print and audio versions.

Dementia Today: Provides information and resources about caring for someone with dementia.  Their post Dementia and Aggressive Behavior details tips to deal with the behavior and to promote self-care for caregivers.

National Clearinghouse on Abuse in Later Life: Provides many resources for professionals on safety planning for the victim and worker.

Please click on the following link to access a list of Scholarly Articles on Dementia & Elder Abuse & Aggressive Behaviors.

By Elizabeth Bloemen, MPH NYCEAC Social Media Associate & Contributing Author Matt Kudish, LMSW, Senior Vice President of Caregiver Services, Alzheimer’s Association, New York City Chapter, with special thanks to Dr. Mark Nathanson, Psychiatric Mobile Outreach Crisis Team Medical Director at Mount Sinai, Elmhurst Hospital & Fellowship director for Geriatric Mental Health & Geriatric Psychiatry at Columbia University and Dr. Bob Abrams, Professor of Clinical Psychiatry, Weill Cornell Medical College, for their input on this piece.

1. “Aggressive behaviors” are defined by Bryan R. Hansen, PhD(c), MSN, RN, FNE-A, in a recent NYCEAC guest blog, as either physical or verbal, and directed against self, others, or objects. Behaviors may include hitting, scratching, kicking, biting, pinching, spitting, hair-pulling, swearing – also known as cursing – or yelling. https://nyceac.org/elder-justice-dispatchaggressive-behaviors-in-dementia-delivering-care-while-perceiving-threat/
2. Alzheimer’s Association. (2014) Aggression and Anger. Accessed October 14,2014. http://www.alz.org/care/alzheimers-dementia-aggression-anger.asp.
3. Alzheimer’s Association. (2014) Aggression and Anger. Accessed October 14,2014. http://www.alz.org/care/alzheimers-dementia-aggression-anger.asp.
4. Alzheimer’s Foundation of America. (2014) Behavioral Challenges: Coping With…Anger and Aggression. Accessed October 14,2014. http://www.alzfdn.org/EducationandCare/anger.html 
5. Alzheimer’s Association. (2014) Aggression and Anger. Accessed October 14,2014. http://www.alz.org/care/alzheimers-dementia-aggression-anger.asp.
6. Alzheimer’s Foundation of America. (2014) Behavioral Challenges: Coping With…Anger and Aggression. Accessed October 14,2014. http://www.alzfdn.org/EducationandCare/anger.html
7. Alzheimer’s Association. (2014) Aggression and Anger. Accessed October 14,2014. http://www.alz.org/care/alzheimers-dementia-aggression-anger.asp.
8. Alzheimer’s Foundation of America. (2014) Behavioral Challenges: Coping With…Anger and Aggression. Accessed October 14,2014. http://www.alzfdn.org/EducationandCare/anger.html 
9. Alzheimer’s Society. (2014) Dementia and Aggressive Behaviour. Accessed October 14,2014  http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=96.
10. Dementia today (2011). Dementia and Aggressive Behavior. Accessed October 14, 2014. http://www.dementiatoday.com/dealing-with-aggressive-behavior/
11. Dementia today (2011). Dementia and Aggressive Behavior. Accessed October 14, 2014. http://www.dementiatoday.com/dealing-with-aggressive-behavior/
12. Alzheimer’s Foundation of America. (2014) Behavioral Challenges: Coping With…Anger and Aggression. Accessed October 14,2014. http://www.alzfdn.org/EducationandCare/anger.html