The Ness team are often asked by families how they should deal with aggression in dementia. A common public misconception is that those living with dementia will at some point in the future become aggressive. This is an unhelpful, inaccurate myth. In fact, the research suggests that less than 20% of those living with dementia will develop a behaviour that requires professional intervention and management through specialist medication or individuals. Most individuals can live well with dementia expressing only mild behaviours that challenge the carer if supported and enabled with empathy and understanding.
When an individual does become frustrated, angry, upset, or aggressive it is normally a reasonable emotion within their immediate context. In this blog, I am going to look at two reasons why an individual might become upset and display reasonable anger, and then offer some tips on the best way to manage these episodes. It is a complex topic and so I will work on this topic over two blogs and tackle hyper-arousal and environment in the second part.
Agency or control of the world we live in
I have mentioned this in previous blogs, however, 2 things can often occur after someone is given a diagnosis of dementia. The first is that well-meaning carers or families will often begin to do everything for the person living with dementia. The person with dementia will no longer cook, clean, lay the table, or decide where to go or what to do. The primary carer unconsciously has disempowered their loved one, taking away their self-esteem and sense of control.
Secondly, the person living with dementia begins to feel out of control, they can’t recall what they were doing, why they are in the room, what was being said etc. This sense of being out of control can feel terrifying, it is worth pausing for a moment and imagining not being able to recall what happened 20/30 seconds ago or 5/10 minutes ago. It is a scary feeling and the natural reaction when your sense of control is taken from you or you feel out of control is to become defensive and to impose control on the small minor things you can control; for example not washing in the morning, refusing to get out of bed, insisting on leaving the house or not eating/drinking.
In the context of the person living with dementia, this makes sense and allows them to feel like an adult who can make their own decisions. If someone stops us or forces us to do something we have every right to become angry, to shout or worse. Once you, as their loved one/informal carer, understand the importance of offering an illusion (or real) sense of agency then you withdraw potentially aggressive conflicts.
So the first tip to deal with aggression in dementia is to offer the individual a sense of control and avoid battling over personal decisions made by the individual with dementia. Instead agree on praise and if needed distraction. For example, if the individual with dementia states “I’m going for a walk,” the informal carer might say “But you only came back 10 minutes ago and it is raining?” The loved one with dementia might respond “I don’t care I am going for a walk”. The informal carer can then say “Great idea, sounds lovely, can I come with you as I always enjoy your walks.” 2 minutes later the informal carer might say “I can’t find my shoes, damn, I need help. Please can you help me find my shoes? You check upstairs and I’ll check in the cupboard. Meet you in 5 in the kitchen.”… And so on. The carer has recognised the need to agree, avoided confrontation and built a sense of self-esteem while trying to distract.
I should caveat that I recognise this isn’t always simple and those with dementia may at times insist on a course of action that is harmful or over time could become harmful (like not washing for weeks). In this situation, the carer can’t go along with that decision and needs to force the issue and my advice in this situation is to bring in another person/organisation. Avoid the immediate conflict and look for an alternative person to come in and insist on a refused course of action. The individual with dementia may be more pliant with a Ness member of staff than a family member. Sadly in dementia, no solution is foolproof.
Communication
Communicating empathically and intelligently can be challenging with a loved one who you have spent 30+ years speaking to; we all have communication patterns that couples or families fall into. This might be banter, teasing, sarcasm, bickering, or logical disagreement. However, relatively early on in the disease progression an individual’s ability for complex communication deteriorates and those old patterns of communication become unsupportive and unhelpful.
The person living with dementia can’t follow a reasonable argument, they may no longer understand teasing and misconstrue the teasing as an insult. An informal carers communication pattern needs to change and this can be a challenge for the husband or wife of 50 years. The informal carer or family need to take a moment to imagine how their loved one is feeling, which is often confused, anxious, or out of control, and in their communication tackle that feeling, not necessarily the question or statement. All of us when feeling confused and out of control will act defensively and sometimes verbally aggressive. That is normal and not aggression in dementia.
Once you recognise this then your communication should (most of the time) have 3 objectives, to offer the individual a sense of:
- Safety or love
- Self-esteem or worth
- Control or self-agency
If communication offers those 3 things then conflict diminishes and aggression in dementia and the self-defence action/language will diminish.
Albert Mehrabian, a researcher of body language, was the first person to break down the components of a face-to-face conversation. He found that communication is 55% nonverbal, 38% vocal, and 7% words only. For someone living with dementia nonverbal communication dramatically increases to as much as 90% of face-to-face communication; this means tone of voice, eye contact, smile, touch, laughter and love are far more important than explanation or persuasion.
All of us respond differently to different forms of communication, therefore take time to explore and take note of the ways that are most likely to improve mood and reduce anxiety and frustration. The person living with dementia can no longer change or learn but we can, although I should warn it can be tiring and require a great deal of patience hence getting outside help is always a good idea.
Let us help you deal with aggression in dementia
As I mentioned at the start, The Ness families discuss aggression often and our teams are experts at managing those with challenging symptoms and we very rarely see any anger or aggression in our hubs. If you would like more advice or to speak to one of our health professionals sign up to our membership portal or give us a call on 01626 774799.