How to Handle Dementia-Related Aggression

For much of her life, Jennifer Walden^* envied her mother Bess’ ability to defuse family squabbles with a smile and a plate of her signature lemon poppy seed cake. When Bess was worried or annoyed, she’d occasionally argue with Jennifer’s dad, but she was never out-of-control angry. In the past six months, however, Jennifer has been astonished by the erratic, hostile person Bess, now 84, seems to be turning into.

“She screams at me for no reason at all, and the other day, she pushed me when I offered her a shawl,” says Jennifer, the family caretaker for Bess. “Getting her into the shower has become nearly impossible. Last week, she told me I’m the worst daughter in the world. I feel like I don’t even know—or like—her anymore.”

Jennifer’s heartbreaking situation is extremely common for adult children and other family caregivers of older adults with dementia. Up to 96 percent of people with dementia will eventually exhibit verbal or physical aggression at some point, says Linda Ercoli, PhD, Director of Geriatric Psychology at UCLA and a member of TheKey’s Scientific Advisory Board.

And while it’s normal to want to yell back at someone who’s yelling at you, caring for a loved one with dementia requires a far more measured approach. Aggression and other notable behavioral changes in someone with dementia may occur for several reasons. One has to do with brain-related changes, such as those to the frontal lobe, which can impact motivation and impulse control. Another important possible reason for aggression stems from their inability to express an unmet need.

“All behavior is communication,” says Anne Basting, PhD, founder of TimeSlips, a network of artists and caregivers committed to creatively engaging older adults and a Scientific Advisory Board member for TheKey. Trying to figure out what your loved one’s behavior is conveying and adjusting your response accordingly is often the best way to treat your family member—and yourself—with compassion and respect. Read on for strategies that will help you do that.

5 Ways to Defuse an Aggressive Situation with Compassion

1. Repeat: “It’s Not Personal”

Dementia causes physical changes in the brain that lead to the deterioration of cognitive abilities. For a person living with the condition, good judgment and the ability to regulate emotions often falter. At the same time, a loved one with dementia might not understand what you’re telling them or recall what you explained five minutes ago, which can cause a frustrated outburst. Or they may be trying to tell you something and get upset when they can’t find the words to express it.

It’s natural to feel angry or offended when your loved one yells at you. Still, it’s important to keep your facial expressions and body language as neutral as possible in the face of aggression, says Dr. Ercoli. Yelling back at them will only escalate the situation. “Tell yourself that this is part of the disease; it isn’t a vendetta against you,” she advises.

2. Distract and Redirect

Distraction is often the best way to mitigate flare-ups. Take a breath, then change the subject and direct your loved one’s attention toward a different activity—like taking a walk or having a snack—and try to come up with a way to make the current situation more pleasant to them (and you) rather than continuing to force the issue.

For instance, if you’re at the doctor’s office and your loved one angrily refuses to get out of the car, telling them they have no choice can make them even more upset. Instead, suggest singing or humming a favorite song while you both get out of the car and walk into the doctor’s office, recommends Dr. Basting. “Make it something playful that you do together rather than pushing them to do something they’re uncomfortable about,” Dr. Basting explains.

3. Practice This Empathetic Technique

Many older adults with dementia become aggressive because they feel misunderstood. Before you can attempt to understand or change their behavior, start by validating whatever they’re feeling by using a technique Dr. Basting calls echoing.

“It’s about affirming their emotional and physical response,” she explains. The goal is to make it clear that you’re on their side and trying to support them by meeting them in the emotional state they’re in. “For example, my mother has gotten upset about a person who lives next door to her in her memory care unit,” Dr. Basting says. “She has started to say, ‘I hate him.’ When she does that, I make the same exact expression on my face that she’s making, so she can see what it looks like. That way, I’m affirming her experience. Then I say, ‘Tell me more; I want to understand.’” That allows your loved one to feel heard and can initiate a conversation about why they feel the way they do.

4. Do Some Detective Work

There are several common triggers of aggression in people with dementia. These include unfamiliar surroundings, loud noises, physical discomfort they can’t communicate (including pain or needing to go to the bathroom), and simple frustration about their circumstances. Sometimes the older adult has an unmet need that you don’t realize, says Shadi Gholizadeh, PhD, MPH, Director of Memory Care for TheKey. The unmet need coupled with challenges in communication and a lowered threshold for stress can manifest as aggressive behavior. “Maybe you’re giving them their coffee, and they’ve always liked it hot. But this one is kind of lukewarm, so it gets thrown in your face,” she says.

Anxiety, medication side effects, and new-onset symptoms like having hallucinations, which can happen as dementia progresses, might play roles as well. These are all things you can discuss with their physician, who may be able to help remedy the situation—perhaps by switching their medication or lowering the dosage.

Also, keep in mind that older adults often have visual and hearing impairments in addition to cognitive issues. This can make simple interactions—such as Jennifer draping a shawl over her mother’s shoulders without first telling her what she was doing—seem very sudden and scary.

Dr. Ercoli recommends keeping a written behavior log that includes details about what might have triggered the aggressive episode. For example:

• What kind of aggressive behavior it was (pacing, cursing, hitting, etc.)
• What happened right before the behavior occurred
• Who was involved
• How and when it happened (the time of day, the situation)
• What happened right after the episode occurred (the person left the room, you tried to soothe them, you got upset, etc. )

Review these details over time and see if you notice any patterns. Maybe your loved one dislikes water falling on their head during a shower. In that case, a handheld shower head could be helpful. Sometimes the sound of the water hitting the drain bothers them, or perhaps they dislike morning showers because they don’t want to get out of bed early. If you can figure out what the specific issue is, something as simple as draping a towel near the drain to dampen the sound or switching their showering time to the afternoon might go a long way.

It’s not always easy, but if you can get to the root of what’s causing the aggression, you should be able to defuse the situation more quickly or prevent it from happening in the future.

5. Give Yourself a Time-Out

If your loved one is acting aggressively or you feel like an interaction is headed in that direction, de-escalate the situation. When in doubt, walk away for a few minutes, then come back later and try a different approach, says Dr. Ercoli.

It’s also crucial to note that even older adults can pose a physical danger to others as well as to themselves. If your loved one begins acting physically violent, contact their doctor right away. The 24-hour Alzheimer’s Association Helpline (800-272-3900) is another good resource. And be sure to lock up or remove from the home anything dangerous they could grab, like guns or sharp objects, says Dr. Ercoli. Put child locks on cabinets or drawers that contain things you use regularly but could be harmful to them. Prevention goes a long way. You need to keep them—and yourself—safe.

Dealing with dementia-related aggression can be extremely difficult. Understanding why it can happen, and practicing compassion for your loved one and yourself, can help you respond to challenging behavior in a way that helps you both. To get started, Dr. Gholizadeh recommends watching this video for family caregivers from Kristin Neff, PhD, a psychologist who specializes in self-compassion.

^*Name has been changed for privacy.