Ideas on How to Handle

Anger and Aggression

Ideas for Dealing with Anger and Aggression

Alzheimer's aggression with angry outbursts
Alzheimer's aggression with angry outbursts

Unintentional Anger and Aggression

    Many family caregivers provide care to family members who have dementia (i.e., someone with memory loss), either as their main reason for needing care or as one of many reasons. Caregivers and dementia patients often struggle with anger and aggression confrontations. These conflicts may be one of your greatest challenges as a family caregiver.

Unexplained Anger

     When we think of someone being angry or aggressive toward us, we tend to think first about the person who willfully attacks us with a planned intent or purpose for the harm. However, when we experience anger and aggression from a dementia family member, we realize they may not know why they attack us or remember the attack after it occurs. Dementia patients may demonstrate aggressive behavior verbally or physically without warning, for no apparent reason, making it difficult to identify the trigger that agitated them.

Potential Causes

     For caregivers, trying to determine the trigger behind the explosion of anger can be very frustrating. Due to the loss of memory and thinking functions, the individual cannot say what causes them to feel angry.

So, the game of 20-questions begins for the caregiver.

  • Are they in pain or hurting somewhere?
  • Do they have an infection, or are they feeling ill?
  • Are they tired from lack of sleep or overexertion?
  • Are they hungry or thirsty?
  • Have they gotten frustrated attempting to do something and need help?
  • Are they overstimulated by noise, people, activities, lights, or something else?
  • Is this a side effect of a new medication?
  • Are they picking up on your irritability and stress or someone else’s?
  • Are you asking them too many questions or giving them too many instructions at one time?
  • Are they feeling overwhelmed?
  • Are they afraid? Feeling lost and alone?

     If you can identify the cause, then you can work toward correcting it. Knowing the cause allows you to work with your family member to develop a strategy to prevent the explosion next time.  From your family member’s perspective, the underlying reason for the outburst is reasonable and justifiable. You may even be able to see the merit in their thought processes once you know the background. Sharing a solution may be a way of coming closer together.Share how you feel with someone you trust

Helping Provide Calm

     Any of the above situations could lead to the development of agitation, and ultimately anger and aggression. The difference between someone who has dementia and someone who does not is control.  A dementia patient may feel their emotions developing and certainly sense themselves spiraling out of control; however, they have no clue what to do about it. They do not recognize what is happening to them or know how to calm themselves. That’s where you, as the caregiver, step in to rescue them.

You can help keep them from losing it by

  • learning to identify what sets them off (i.e., their triggers),
  • creating a calm environment for them,
  • monitoring their comfort level,
  • simplifying tasks and routines, and
  • providing them with opportunities to work or play-off excess energy.

Preventing Anger and Aggression - 1-2-3-

1. Overstimulation Builds Tension – Avoid It

Introduction

    Studies involving individuals with anxiety disorders show that overstimulated individuals become angry and have greater difficulty with appropriate social interactions. They become easily frustrated and escalate to anger quickly. Although research could not connect the dots between overstimulation and anger, a strong indirect connection seems to exist. That being the case, one way to keep anger from getting out of hand is to prevent overstimulation. The following suggestions may help with that effort.

Avoid foods likely to produce feelings of tension or hyperactivity like excess sugar and caffeine. 

     Examples include cakes, cookies, ice cream, coffee, soft drinks, power drinks.  Foods that are high in sodium which can cause fluid retention.

Caregiver supporting family member with mental health memory issues.
Caregiver supporting family member with mental health memory issues.
Remove (i.e., turn off) irritating, loud, erratic, or chaotic sounds that increase tension.  

     Examples include low electronic humming, loud music, underlying erratic continuous sounds, bugs that have come inside and made noise, light bulbs that need changing, high-volume television shows, high-pitched noises on other equipment, etc.

Change or remove continuously flickering or strobing lights. 

     Dying fluorescent light bulbs flicker, strobe, and pulsate for hours before shining their last. If you can’t remove the bulb, turn off the light, bring in a lamp, or take the person to another room.

Limit the number of people in small spaces.

     The noise of the multiple conversations in a small space becomes deafening and confusing.

Create an environment with 1-2 color themes and textures, limiting tactile and visual stimulation further.

     Too much variety (i.e., too many textures, tastes, colors, sounds, or other stimuli) is overwhelming for some people and increases agitation. Limiting choices and stimuli to only a few makes achieving peace easier for them to reach.

2. Avoid Displaying Personal Frustrations to Family Member

Introduction

     As a person’s caregiver, you hold all power over their well-being from their perspective.  You control when they eat, sleep, what they do, and when they do it. Their well-being and safety are within your control, and if you wanted to ignore that responsibility, they would be at your mercy.

 

Your Anger May Cause Fear

     If you are acting frustrated and angry with them, they may be afraid that you could harm or neglect them. The anger and agitation you see may be a defense mechanism. Your family member may sense a need to protect themselves from your anger in reading your body language. You may have no intention of ever causing them harm, but they may not have the cognitive ability to understand that to be true. Your family member sees signs of anger, and to them, it means danger. 

 

Family Member May See Danger in Signs of Frustration
  • Stiff or rigid posture stooped shoulders, muscles tense.
  • The facial expression implies a desire to with-hold care as retaliation or in defiance for behavior. The bottom lip is tight; eyes are cold, eyes roll up and away with comments, no direct eye contact.
  • Voice tone is cold, words clipped, comments derogatory, answers with grunts or not at all, may engage in arguments.
  • Touch may be rough, rapid, without kindness or caring.

 

3. Monitor for Physical and Mental Well-Being and Comfort

Introduction

     Family members experience increased strain that progresses to agitation as emotional stress, physical pain, illness, or environmental discomfort continues for extended periods.

 

Identify Cause of Discomfort

     It’s important to identify the underlying cause of the discomfort and initiate corrective action or treatment as early in the cycle as possible to stop the chain of events’ progression.

  • As pain and suffering increase, tolerance and patience decrease leading to a greater incidence of anger.
  • Low blood sugar from not eating enough, dehydration due to insufficient fluid intake, and electrolyte imbalances from not eating the right combination of foods can impact a person’s ability to tolerate others.
  • Personal anguish, stress, fear, substance abuse, grief, and other family crises can disturb a family member’s mental status, throw them off balance, and produce anger episodes.

Tips on how to Approach Someone Displaying Anger and Aggression

     Use caution when approaching a person with dementia or who has a mental health problem who is angry, even if they are close relatives. They may not recognize you. During the anger episode, they may see you as a stranger who is present to cause them harm.  If so, they will defend themselves, and one of you may get hurt.  Therefore, be aware of your surroundings and have an escape plan in mind if your conversation does not go well and you need to leave quickly.  Safety first always.

Escape Plans –

     If you plan to meet with someone known to be explosively angry, before you go into a room with them, plan for safety first. Over the years, I handled several meetings with individuals who posed potential safety threats to me (I dealt with de-escalating potential workplace violence situations in my job at times). I was trained in setting up my environment for my safety and theirs by the police and counselors and found that these principles work well. You do not have to let yourself be placed in harm’s way if someone has a mental illness or dementia and is violent.

 

Here’s what I recommend:

  1. If you can get them to a room, you can set up in advance, arrange the room so that there are no objects in the room available as weapons.
  2. Remove all objects that are heavy and mobile (can be used to hit you or throw at you), breakable (glass, ceramic), aerosols (spray in your eyes), or sharps (pens, pencils, letter openers, knives, forks, etc.).
  3. Arrange for someone to be in another room nearby, if possible, to listen for you to call for help in case it’s needed and give them instructions on what to do if you need assistance.
  4. When you enter the room, let the angry person enter first to go further into the room, leaving you closer to the door. You want to always be closest to the door.
  5. Keep a pathway open to your exit and, if possible, a desk or coffee table between you and the person to slow their progress if you need to leave.
  6. Sit across from them; not next to them, at opposite ends of the table is best (greatest distance away – arm’s length if possible)
  7. Exit out the door if they start to come after you physically and shut the door behind you. Call for help.

     When you approach your family member, speak to them with a slow, calm, and respectful tone even though they might be yelling and screaming at you. It’s important not to raise your voice to match theirs. Speak with a positive, warm tone of voice. People tend to mimic the voice levels of the person with whom they are speaking. By lowing yours, you may be able to get them to follow your lead and lower theirs.

When dealing with verbal aggression, here are three approaches:

    1. Rather than argue an opposing point, agree with them. You cannot persuade a dementia patient to change their mind.  The best way to calm them down is to acknowledge their feelings and attempt to see things from their perspective.
    2. Try apologizing, even if it’s not your mistake, to defuse the situation.
    3. Leave your family member alone to give them time to cool off.

     Pretend not to know why they are angry and ask them to help you understand the reason. Tell your family member who you are and why you are there. Try to say something to make them smile to see if you can distract them.

     Politely explain that you want to find out what is bothering them, and you hope they will talk to you about it. Keep your body language open and relaxed. Let your body language “message” to your family member be that you care about what’s bothering them and have plenty of time to listen.

     As you speak, face them, making good eye contact. If they stand, you stand. If they sit, you sit. Speak on their level, so they don’t feel threatened.  Always stand where they can see you; otherwise, they become suspicious about what you are doing.

     Try to maintain a positive, caring facial expression during difficult conversations (I know, this one may be nearly impossible at times, but try).

 

     You can also try a simple touch on the hand or gently rub their back. However, a word of caution! Some people do not like to be touched.  Know whether your family member is likely to respond positively or become more upset if you touch them before you do so. Touch is a very intimate action, and I advise you to consider how you use it carefully.     If you are talking to someone who draws back as you draw near or moves their hand if your hand or body is near, do NOT touch them. It will only agitate them more.

     If your family member starts pacing back and forth, and suddenly decides they must leave the room, do not try to stop them. Let them go. You can follow behind them to confirm they are safe but let them leave. You might even want to take along a folding chair so that you will have a place to sit if he wanders far.

     When someone with dementia becomes very angry, understand that you cannot convince them to change their mind about what they believe or what they think they might see. If your family member has dementia and is angry, don’t attempt to convince them of anything or re-orient them to “reality” instead, try to divert their attention.

 

     Maybe sing to them or remind them of a special time. Only touch them if it does not agitate them more. Attempt to maintain control of the situation by keeping everyone safe and staying calm.  Don’t panic or use force—both will likely make matters worse. Give them space.  Don’t crowd them.

     Suppose your family member’s behavior continues to be agitated? In that case, it may not be easy to remain calm. Check yourself periodically to see if you are beginning to crowd them, argue, criticize, raise your voice, or fall into the trap of following their aggressive behavior. If so, if it’s safe, you may need to step away for a time to take a breather before you continue to deal with the situation.

     Do not ignore physical abuse. A diagnosis of dementia does not provide the right to “act out” or harm anyone else. If your family member is violent and physically aggressive, notify your doctor promptly about the behavior to begin a correction plan.

     If your family member cannot calm down and violence may be a concern, safety is your priority. Always call 9-1-1 in emergencies. Tell the dispatcher that you are dealing with dementia, they have become aggressive, and you need their assistance. In many areas, you can register the potential need for assistance with emergency services in advance. Doing so saves you time and provides them with the necessary information for the future should you need help but be unresponsive.

Wife attempting to convenience husband that his delusion isn't real. but getting nowhere.
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