Dementia & Alzheimer's: Surviving Aggressive and Combative Behavior

If you're a caregiver for a loved one with Alzheimer's or dementia, you're on a journey filled with both profound love and significant challenges. Encountering aggressive or verbally combative behaviors can be particularly trying and may stir a mix of emotions, from frustration to sadness.

And while you may feel alone, the Journal of Geriatric Nursing reports that about half of all dementia patients will exhibit aggressive behavior at some point, with high likelihood of occurrence in later stages of the disease. It's important to remember, these moments are part of the illness and not a reflection of your loved one's true feelings towards you. You're doing an incredible job in a complex role, and we're here to support you every step of the way.

Reframing the narrative

When faced with aggressive behavior from individuals with Alzheimer's or dementia, it's so important to reframe our perspective and see these actions not as acts of defiance or hostility, but as attempts to communicate.

Due to the way that both Alzheimer's disease and dementia impact our ability to take care of and express ourselves, traditional forms of communication can become challenging (or impossible), leading to frustration and distress that manifest in what we perceive as aggression.

By understanding these behaviors as their way of expressing unmet needs, discomfort, or confusion, we can approach these situations with greater empathy and patience. This shift in perspective enables caregivers to respond more effectively, seeking to understand the root of the problem and finding ways to meet their needs, ultimately fostering a more supportive and calming environment for both the caregiver and the individual in care.

So whether it's you, or there are other caregivers or family members in the mix, it's good to reframe the conversation from behaviors that are being expressed to needs that are not being met.

No matter how it feels, it's important to remember that in most cases, Alzheimer's and dementia patients who exhibit aggressive behavior are trying to communicate something. Whether it's a physical or emotional need, they are attempting to share those needs with you via their actions.

Over the years, the medical community has documented various dementia behaviors. According to the National Library of Medicine, about 90% of people facing a brain disease like dementia will exhibit notable symptoms:

• Verbal aggression: This includes shouting, using harsh words, or threats. It's a direct outcome of the individual's inability to articulate their needs or feelings, often stemming from confusion, fear, or frustration with their communication limitations.
• Physical aggression: Manifestations like hitting, biting, scratching, or throwing objects can occur when the person feels cornered, misunderstood, or in pain. Such actions might also be an attempt to communicate a specific need or discomfort that they cannot express verbally.
• Refusing care: When an individual resists help with personal care tasks such as bathing, dressing, or eating, it might indicate discomfort with the process, a need for control, or simply not recognizing the need for these activities due to cognitive decline.
• Wandering or pacing: This restlessness is not only a potential sign of agitation but might also indicate an attempt to fulfill an unexpressed need, such as hunger, thirst, or the need for physical activity, or it could stem from confusion and disorientation.
• Throwing tantrums: These outbursts can be a reaction to the frustration of not being able to communicate effectively, feeling overwhelmed by the environment, or not understanding what's happening around them.
• Property destruction: Engaging in breaking items or causing damage can reflect deep frustration, an effort to convey dissatisfaction, or a response to a misunderstanding of their surroundings.
• Paranoia and Delusions: In Alzheimer's and dementia patients, the brain's deterioration can lead to paranoia and delusions, manifesting as unfounded suspicions or mistaken beliefs about theft, betrayal, or harm from caregivers and loved ones.
• Repetitive Actions: Alzheimer's and dementia can cause individuals to engage in repetitive behaviors, such as asking the same question multiple times, repeating the same word or phrase, fidgeting, or tapping.

When caring for an older adult or someone with Alzheimer's or dementia, it's essential to look beyond the surface of challenging behaviors like physical aggression or verbal outbursts. In most cases, these behavioral symptoms are a clue that something larger is going on. Common things that can trigger an aggressive response are:

• Physical pain or discomfort: Sometimes, pain or discomfort, such as from dental issues, ill-fitting clothing, temperature or other environmental factors can lead to agitation. Regular check-ups and ensuring comfort in their daily attire can make a big difference.
• Basic needs: Hunger or thirst, and the need for bathroom breaks, might not always be communicated directly. Establishing regular, predictable routines for meals and restroom use can help meet these basic yet crucial needs.
• Overstimulation: Environmental factors can be overwhelming for dementia patients. Too much noise or a cluttered environment can be overwhelming and trigger an aggressive response. Creating a calm, quiet space with minimal distractions can reduce stress and agitation.
• Understimulation: On the flip side, too little to do can lead to boredom and frustration. Engaging in simple, enjoyable activities together can uplift their spirits and provide a sense of connection.
• Confusion and fear: Unfamiliar places or faces can trigger anxiety. Keeping a familiar item on hand, or gently explaining the current situation, can offer comfort and reassurance.
• Need for autonomy: The desire to maintain independence is strong. Offering choices, even in small matters like clothing or snacks, can foster a sense of control and dignity.
• Emotional distress: Feelings of isolation or misunderstanding can be deeply distressing. Providing a listening ear and showing empathy can go a long way in easing emotional turmoil.

Caring for someone who sometimes shows aggressive behavior can feel like navigating a stormy sea. It’s tough, and it takes much more than just a deep breath to make it through. By keeping a calm presence, understanding what's behind the behavior, and using a few key techniques, you can create a more peaceful environment for both you and your loved one.

• Stay calm and patient: During an aggressive episode, maintaining a calm demeanor is crucial. Speak slowly and softly to convey your presence as non-threatening. This can help de-escalate the situation and prevent further agitation.
• Identify triggers: Pay close attention to what might have triggered the aggressive behavior. Common triggers include physical pain or discomfort, overstimulation, or a break in routine. By identifying these triggers, you can take steps to avoid or minimize them in the future.
• Ensure safety: Make sure the environment is safe for both you and your loved one. Remove any objects that could be harmful, and ensure there's enough space between you and the individual to prevent accidental harm.
• Use distraction techniques: Redirecting the person’s attention to a different activity or topic can sometimes halt the aggression. Suggest a favorite song, a walk, or looking at photos together as a way to shift focus from the trigger of the aggression.
• Offer reassurance: Sometimes, all a person needs is to feel understood and reassured. Acknowledge their feelings without judgment and offer comfort through words, a gentle touch, or a favorite item or snack that brings them joy.
• Reduce environmental stimuli: Overstimulation can be a significant trigger for aggressive episodes in dementia patients. Turn off the tv, give them some personal space by asking family members to leave the room, dim the lights or draw the curtains.

In patients with Alzheimer's and dementia, the brain undergoes significant changes that can impact cognitive function and behavior, which can cause patients to act aggressively. These neurological alterations are central to understanding why aggressive dementia behaviors occur in the first place:

• Affected Brain Regions: Brain regions that are normally able to curb aggressive behaviors - found in the frontal lobe - can be damaged during Alzheimer’s Disease. This can result in the emergence of aggression and agitation behaviors in people who did not previously show these behaviors. 
• Neurodegeneration: Alzheimer's and dementia are characterized by the progressive loss of brain cells and reduced communication between those cells in the brain. This results in the death of brain tissue, especially in areas responsible for memory, judgment, and behavior control,  and results in  symptoms such as confusion, frustration, and aggressive responses to seemingly normal situations.
• Chemical imbalances: Neurotransmitters, the chemicals responsible for communication between neurons, are often imbalanced in the brains of those with dementia. Such imbalances can affect mood, perception, and behavior, causing a loved one to act aggressively.
• Plaques and tangles: Alzheimer's disease is characterized by the buildup of amyloid plaques and tau tangles in the brain; which are abnormal clumping formations of naturally occurring proteins. These formations disrupt normal brain function, impairing cognitive abilities and emotional regulation, and can contribute to aggressive behavior.
• Stress response: The brain's ability to manage stress deteriorates in Alzheimer's and dementia patients. As a result, situations that might previously have been manageable can provoke anxiety, fear, and aggressive reactions as the patient's ability to process and respond to stress is diminished.
• Disrupted sleep patterns: Changes in the brain can also affect sleep regulation, leading to sleep disturbances. Lack of restful sleep can increase confusion and agitation during the day, contributing to aggressive behaviors.
• Overlap with other psychiatric conditions: Individuals who have suffered neurological and psychiatric conditions are at elevated risk for agitation and aggression. These include stroke, traumatic brain injuries, bipolar disorder, schizophrenia, alcohol abuse and meningitis.

According to the Alzheimer's Association, there are many treatment options that can help people who are struggling to manage aggressive behavioral symptoms. Therapy and medication, under the right circumstances, can help folks with dementia experience less confusion, pain, and other problems that trigger aggression.

Depending on the person and their diagnosis, engaging in more than one form of therapy can prove to be helpful. At different stages of dementia, some therapy options may have more optimal benefits than others.

If you're unsure of how someone you care about could benefit from therapy or prescription medicine, hashing this out with a medical professional may be advantageous. A doctor may ask when aggression occurs and what symptoms your loved one faces as a result of their diagnosis.

Therapy options

• Examination of Overall Health: Clinicians will likely track history of brain and body health to identify potential causes of pain or discomfort – such as fall injuries, fever and dehydration. These simple measures can understandably be missed during the care of someone with Alzheimer’s who are often unable to communicate these problems to their caregivers. Clinicians may use behavioral tests such as the Modified Overt Aggression Scale (MOAS) or the Pittsburgh Agitation Scale (PAS) to identify the frequency of aggressive and agitative episodes.
• Talk therapy: Therapy can be a major lifeline for someone facing sleep troubles, daily confusion, and trouble with their own body. Many folks living with dementia find talk therapy (also known as psychotherapy) to be a great support system. During talk therapy sessions, people work with a professional to understand their actions, thoughts, and experiences.
• Art and Music Therapy: Art and music therapy offer innovative ways to stimulate brain activity in individuals with dementia. By working with a music therapist, patients can see improvements in speech and communication as they engage parts of the brain less affected by disease. Art therapy, on the other hand, allows for expression through drawing, painting, and other creative outlets, making it easier for patients to communicate using colors, shapes, and designs. Both forms of therapy can significantly reduce combative behavior, improving relationships between patients and their caregivers.
• Bright Light Therapy: This therapy involves exposing individuals to controlled levels of artificial light or sunlight, aiming to trigger chemical changes in the brain that address sleep-wake cycle disorders. It's especially beneficial for older adults struggling with insomnia, helping to regulate sleep patterns and enhance overall mood and well-being. By aligning the circadian rhythm, bright light therapy can contribute to a more structured and restful sleep schedule, offering relief from sleep disturbances commonly associated with dementia, as is often observed during sundowning.
• Cognitive Stimulation Therapy: Designed to bolster memory, communication skills, and other cognitive functions, cognitive stimulation therapy is a valuable tool for those facing Alzheimer's or other forms of dementia. Through engaging activities like word games, puzzles, and discussions about past and current events, this therapy works to improve short-term memory and mental agility. Sessions are tailored to exercise the brain, aiming to maintain and enhance cognitive abilities, thereby granting patients a greater sense of control and independence.

Medication options

An older person with Alzheimer's or dementia may find that medicine makes their lives easier and less debilitating. While there's no cure for either one of these diseases, having the right prescription can help lower the risk of verbal combativeness and hostile behavior patterns.

Some of the most common prescription drugs for Alzheimer's or dementia target emotional moods, mental functions, and even blood pressure. Memantine, Rivastigmine, and Galantamine are each used to treat these brain disorders by regulating emotional and mental wellness.

Evidence shows that atypical antipsychotics, such as brexpiprazole, risperidone and olanzapine, can be used to reduce agitation. However, these drugs should only be prescribed under the care of trained clinicians that are knowledgeable about the patient’s medical history and about side-effects such as increased drowsiness. Additionally, selective serotonin reuptake inhibitors (SSRIs), such as citalopram, may also be considered.

Over time (and at different stages of the illness) some prescriptions may prove to be a better fit than others. Adults who take medications for dementia or Alzheimer's and see positive results could need lower doses over time.

Anyone who's considering taking medicine or making changes to their doses should first sit down with a healthcare professional. This specialist can evaluate each individual, answer questions, and take note of any physical, emotional, or psychological changes in the aftermath of taking certain drugs.

Sometimes, a person who has dementia sees even more improvements when they combine prescription medicine with therapy. This can improve cognitive function, manage their emotional states, and make a good night's rest easier. Of course, before taking any kind of medicine or mixing it with therapy, people with dementia or Alzheimer's should consult a medical professional.

Looking out for the well-being of someone with dementia can make them less prone to aggressive actions. Taking notice of various patterns also goes a long way. Someone who's not getting enough sleep could potentially benefit from therapy or changes to the medications they're taking.

Likewise, if a loved one seems to be in emotional pain, music, nature sounds, or having helpful caregivers nearby may help soothe them. For a senior loved one who's starting to show signs of paranoia or delusion, there may be an immediate cause that a doctor can best diagnose.

In many cases, people with Alzheimer's or dementia respond well to long-term in-home care. Professional providers can help older adults with bath time, getting to and from therapy sessions, and other day to day tasks.

Sometimes, a family member or friend can become overwhelmed when they're constantly exposed to verbal combativeness or hostile behavior from someone they love. Over time, this can adversely impact their mental health, making it harder for them to care for someone facing a challenging brain disorder.

If coming into contact with these behavioral symptoms is taking a toll on your relationship with an older person, a professional caregiver may be more qualified to provide the necessary support.

Caregiver resources

If you or a loved one is struggling with caregiver or feels at risk, the following resources are available round-the-clock:

• Alzheimer's Association 24/7 hotline: 800.272.3900
• Alzheimer's Foundation of America hotline: 866-232-8484