(Alzheimer’s Society) People with dementia may sometimes behave aggressively, either physically or verbally, and this can be very distressing for the person and for their carer, family and friends. This factsheet explains why a person might act aggressively. It gives practical tips that carers can use to help prevent and manage aggressive behaviour. It also looks at the types of support that may be available.
What is Aggressive Behaviour?
Aggressive behaviour is not unique to people with dementia. However, more than one third of people living with dementia have at times behaved aggressively, particularly in the moderate to severe stages of the condition. There are reasons why a person with dementia may act in an aggressive way and this will be explored further in this factsheet.
Aggressive behaviour can be very stressful and upsetting for the person with dementia and their carers. It can also be a factor in the decision to move the person with dementia into a care home.
Aggressive behaviour may be:
- verbal – eg swearing, screaming, shouting, making threats
- physical – eg hitting, pinching, scratching, hair-pulling, biting.
Aggression may be linked to the person’s personality and behaviour before they developed dementia. However, people who have never been aggressive before may also develop this type of behaviour.
Aggression is one type of challenging behaviour that can result from dementia. Other behaviours that challenge include agitation, restlessness, walking about, and being sexually inappropriate. It can also be hard for carers to deal with restlessness, repeated questioning and being followed around. For more information about these types of behaviours, see factsheet 525, Unusual behaviour.
Causes of Aggressive Behaviour
People with dementia have the same needs as everyone else, including comfort, social interaction, stimulation, emotional wellbeing and being free from pain. However, people with dementia may be unable to recognise their needs, know how to meet them, orcommunicate what they need to others. This may cause them to act in ways that are seen as challenging, including aggression. The aggressive behaviour might be the person’s way of meeting the need, an attempt to communicate it, or an outcome of the unmet need. For example, if a person with dementia is not getting enough stimulation they might become bored, and this may lead to them behaving in a way that is seen as challenging, such as walking about or following their carer. Meeting the need by providing stimulation to the person may stop the behaviour as they will no longer be bored.
Understanding what is causing the person’s behaviour can help carers to find a solution. Some possible explanations for aggression are listed below. The causes could be biological, social or psychological.
- There may be pain, illness (including infections) or physical discomfort (including being constipated or thirsty, or from sitting for too long).
- Side effects and/or taking too many medications may mean that a person becomes more confused and drowsy. This means they may be less able to problem-solve their way out of distressing situations.
- The environment may not meet their needs or may be over-stimulating. It could be too hot or too cold, noisy or too bright.
- Poor eyesight or hearing can lead to misunderstandings and misperceptions.
- Hallucinations (where people see things that aren’t there) and/or delusions (where people believe things that aren’t true) can be confusing and frightening, leading the person with dementia to respond to them in an aggressive way.
- The physical effects of dementia may have affected the person’s judgement and self-control. They may have lost their inhibitions or have a decreased awareness of what kind of behaviour is appropriate.
- Lack of social contact and loneliness.
- Boredom, inactivity and sensory deprivation.
- Different carers coming in with a different approach or changing the established routine.
- Not liking or trusting a particular carer.
- Trying to hide their condition from others.
- The person with dementia may have a perception that their rights are being infringed or that they are being ignored. This may be due to misperceptions,memory difficulties or problems processing information, but it may also be true.
- The person may become frustrated at not being able to complete tasks, eg making a cup of tea.
- There may be depression or other mental health problems.
- A carer’s intentions may be misunderstood. For example, personal care may be seen as threatening or an invasion of personal space. Accepting help with intimate tasks such as washing, dressing or going to the toilet is understandably distressing and stressful.
- Others may assume that the person with dementia can no longer do things for themselves or leave them out of decisions that affect them. This can cause the person with dementia to become angry because they are not being listened to or are being ignored.
- The person may feel threatened by an environment that appears strange or unfamiliar. They may think that they are in the wrong place or that there are strangers in their home.
- People may have difficulties understanding and interpreting the world around them, and may experience a different sense of reality from others. For example, if the person believes that they need to collect their children from school, they may become aggressive if they are prevented from doing so.
Tips for Carers: Reacting to Aggressive Behaviour
At the time
- It is often necessary for you to make changes to how you approach the situation. It is important to adapt to the perspective and needs of the person with dementia. It can be frustrating but it is important to understand that reasoning or logical argument are unlikely to result in insight and change on the part of the person with dementia.
- Before you react, take a deep breath, step back to give the person space and take some time. You may need to leave the room until you have both calmed down.
- Try to stay calm and avoid any potential for confrontation. A heated response may make the situation worse.
- Try not to show any fear, alarm or anxiety, as this may increase the person’s agitation -although if you feel threatened, this is easier said than done. If you do end up feeling threatened, call for help.
- Try not to shout or initiate physical contact – this could be misinterpreted as threatening behaviour. If the person’s behaviour is physically violent, give them plenty of space and time. Unless it is absolutely necessary, avoid closing in or trying to restrain someone, as this can make things worse.
- Reassure the person and acknowledge their feelings.
- Try not to take the behaviour personally – the person is most likely trying tocommunicate a need, not attacking you on a personal level. If you find the cause of the behaviour, you may be able to prevent future incidents.
- Listen to what they are saying. This shows that you are not against them and that you want to help.
- Maintain eye contact and try to explain calmly why you are there. Encouragecommunication.
- Try to find out what is causing the behaviour.
- Try to distract their attention if they remain angry.
- Ask yourself if whatever you are trying to do for the person really needs to be done at that moment. If you are able to give them space, come back later and try again – you may be able to avoid a confrontation.
After the incident
- Don’t punish the person for their behaviour; try to carry on as normal and be as reassuring as possible.
- Focus on the person, not the behaviour that they displayed. They may still be upset and distressed after the incident.
- Take some time and talk through your feelings with others – for example, the GP, family, counsellor or dementia support worker.
- Bottling up your feelings may make it harder to care for the person with dementia and also mean that you find yourself focusing on the behaviour instead of the person.
- The person may forget the behaviour and if you punish them for it after the incident it may lead to them becoming upset and distressed.
Preventing and Managing Aggressive Behaviour
Finding ways to prevent and manage the behaviour will improve the quality of life for both the person with dementia and the carer. It will also make the caring role easier. Working out what is causing the aggressive behaviour will make it easier to find a solution.
It is important to consider the person’s perceptions – whether accurate or not – when looking at ways to manage aggression. It can also help to tailor your communication with the person in ways that let them know that they are being listened to andrespected.
To reduce or prevent aggressive behaviour, carers will need to look at the person as an individual and work out why they are behaving in a certain way. It is important to see what is happening from the perspective of the person with dementia and to identify the reason for the behaviour. The person with dementia is probably trying to communicatesomething and the challenge is to find out what it is and why. There is no ‘one size fits all’ solution, and carers will need to tailor their approach to each situation. They should use what they know about the person, including their personality, likes and dislikes.
The problem-solving approach
A problem-solving approach may help manage the aggressive behaviour.
The first step is to define the problem:
- Is it the behaviour of the person with dementia that is causing the problem?
- Is it the reaction or attitudes of other people?
- Is it the living situation?
- What are the other factors? Is the person in pain? Are they getting enough stimulation? Is the environment suitable?
Next, you should consider the situation:
- Look at all the circumstances that might be contributing to the problem.
- When and where does the problem happen?
- Does the person always act in the same way in the same place?
- Does it always happen with the same person or in similar circumstances?
- Who are the other people involved? Visitors, a family member, a friend?
- Look for patterns in the behaviour. It may be helpful to make a diary of when aggressive behaviour occurs, noting down everything that was going on at that time that could have triggered the behaviour.
Assess the person in the situation. Are they:
- unwell, in pain, uncomfortable?
- overtired, overstimulated, bored, anxious or frustrated?
- embarrassed, ignored, misunderstood, feeling patronised?
- delusional, having hallucinations, depressed?
- under-stimulated, lacking in social contact?
- in a suitable environment?
Use what you know about the person to think about whether they could be reacting to:
- an unpleasant incident or association
- a memory
- provocation or a personality conflict.
Next, develop a strategy to manage the behaviour. Talk to the person with dementia and other people who they spend time with to come up with a plan. Start to make some changes and then assess whether or not they have made a difference to the person’s behaviour. It might take some trial and error to find effective solutions. Look at making a range of changes, for example changing the way that you talk to the person during care, as well as altering the environment. The person with dementia should always be at the centre of the solutions.
Go with the person to see their GP so that they can be checked for any physical problems that might be causing them to behave aggressively. Pain is common in people with dementia but it is often not recognised, even in formal care settings like care homes. Carers should look for signs that the person is in pain or discomfort, and look for things that could potentially cause the person pain. Signs may include:
- rubbing or pulling at a particular body part
- facial expressions – looking scared or clenching their teeth
- body language – are they huddled or rocking, for example?
- a change in appetite
- being more restless
- new swellings or inflammations
- having a temperature.
Causes may include:
- infections including chest infections and urinary tract infections (UTIs)
- existing injuries such as cuts or bruises
- existing conditions such as arthritis
- being in an uncomfortable position or being moved in an uncomfortable way
- toenails or fingernails that need cutting
- toothache, earache or problems with dentures.
The person should also have their hearing and eyesight tested, and get glasses or hearing aids if needed.
In the past, antipsychotic drugs were regularly prescribed for ‘challenging’ behaviours, including aggression. However, these can suppress the behaviour without addressing its cause, and may add to the person’s confusion. There is now an effort to reduce prescriptions of these drugs so that they are only used when absolutely necessary. Non-drug approaches should be the first method for treating aggressive behaviour. Antipsychotics should only be used when there is evidence of psychosis (delusions orhallucinations) and the person with dementia is in severe distress, or immediate harm will be caused to them and/or anyone who cares for them. If these drugs are to be used, they should be regularly reviewed and monitored. For more information, seefactsheet 408, Drugs used to relieve behavioural and psychological symptoms in dementia.
The following suggestions may help with aggressive behaviour, and should be tried before drug treatments.
Communication – One of the key ways to deal with aggressive behaviour is by using the information you have gained during the problem-solving approach to communicateand engage with the person in ways that are likely to manage the situation. The content, pacing and tone of words, along with good body language, are all important in helping the person feel they are being respected and listened to.
Music – Listening to the favourite music of the person with dementia may help to reduce aggressive behaviour. For example, if there is a certain time of day when the person tends to become aggressive, it may help to put on some music that you know they enjoy at that time. If a particular activity such as bathing can lead to the person behaving aggressively, put on some music before you begin.
Social interaction and stimulation – We all have a need to spend time with other people. Lack of social interaction can make someone feel bored, isolated and unhappy. Make sure that the person with dementia regularly receives some good one-to-one interaction. It could just be a chat or reading together, but it is important to have proper time for this, when the person with dementia can have your full attention. Planning newactivities that you both enjoy, or adapting daily talks so that the person can still take part in them, will help to keep the person stimulated. If you find something that works well, keep doing it.
Reminiscence – Reminiscence or life story activities involve recalling and talking about past experiences of the person with dementia. These should be positive and personally significant, such as a family event or favourite football match. They have been found to improve the mood of people with dementia, reducing the risk of aggressive behaviour. It is important to note that people may have negative memories as well as positive ones, and you should be prepared to support the person with both types of memories.
You could try making a memory box of photos and familiar items, which the person can go through with a friend or relative. Developing a life story book may also be an option. These help to keep the person with dementia at the centre of their care, as well as helping people see beyond the dementia.
Changes to the environment – Think about the person’s surroundings, as these will have an effect on their behaviour. It may be that you can make small changes to the home that will make it a better environment for the person with dementia. For example:
- Is there enough light?
- Is it too hot or too cold?
- Can the person with dementia find the toilet?
Making sure that the path to the toilet is free from obstacles and putting a sign on the toilet door with both pictures and words can help. It should also be clearly visible and in the person’s line of sight.
Exercise – Physical activity and exercise can help to reduce agitation, as well as improving sleep. See factsheet 521, Staying involved and active, and factsheet 529, Exercise and physical activity for people with dementia for more information.
Other methods that may work include:
- hand massage
- sensory stimulation such as nature sounds or familiar, repetitive actions such as folding clothes or sorting buttons
- cognitive stimulation – this involves activities and exercises that are designed to improve memory and communication skills; they are based on day-to-day interests, reminiscence and information relating to the current time and place
- light therapy or bright light therapy – this involves a person sitting in front of a light box that provides about 30 times more light than the average office light, for a set amount of time each day
- animal-assisted therapy
- doll or toy therapy
- arts therapy (including dance, drama, drawing, painting). For more information on some of these see factsheet 434, Complementary and alternative therapies and dementia.
Carers’ Responses to Aggressive Behaviour
Carers of people with dementia can find aggression to be challenging, frustrating and often very upsetting. Some carers may hide the person’s aggressive behaviour from their family and friends and become reluctant to seek help. This can lead to them feeling isolated and losing their social life, and some carers may become depressed. It is very important to seek support if the person you are caring for is acting aggressively. Fewer incidents of aggressive behaviour will lead to a better relationship between you and the person you care for and a better quality of life for you both.
It is important to remember that the person is not being aggressive deliberately. The behaviour is due to their unmet needs. The behaviour may appear to be targeted at you, but that is probably just because you are there. The fact that the person is aggressive towards you doesn’t mean that their feelings for you have changed.
Even if you manage not to take it personally, any aggressive behaviour may well leave you feeling shaken. Over time, this kind of behaviour might contribute towards feeling exhausted. Find ways to help yourself recover, both immediately after an incident and in the longer term, and tap into sources of support. This may be joining a carers’ support group, speaking to your GP, attending counselling, talking to the memory clinic or having input from an occupational therapist.
Try not to bottle up your feelings or resentments – find ways to talk things through. If you do lose your temper, try not to feel guilty – it is a highly stressful situation that you are dealing with – but do discuss things with a friend, professional or another carer who may be able to suggest ways of handling these situations more effectively.
Everyone is different and carers will find a range of ways to cope. These suggestions may help:
- Chat things through or just have a cup of tea with a friend, relative or neighbour.
- Take some time to unwind on your own. Ask a friend or relative to look after the person with dementia or use a day care centre or respite care so that you can have a break.
- Talk to the GP, community psychiatric nurse or other professional.
- If you are a carer, join a carers’ group to share experiences and offer mutual support. Many carers find that support groups can make a big difference.
- Phone a helpline, join an online discussion forum or see a counsellor.