Monday, September 26, 2011

How to deal with Aggressive Behavior in Alzheimer’s Patients?

Understanding Alzheimer’s aggression

In order to understand the phenomenon known as “Alzheimer’s aggression” or “Elder Rage”, as author of the book with the same title Jacquelin Marcell calls it, takes a bit of background information. For one thing, it is not necessarily caused by a single factor. Yes, a patient may have been officially diagnosed with Alzheimer’s disease, but this does not mean that the damages done by the disease itself are what lead to aggression.

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Consider that of the 4.5 million people diagnosed with Alzheimer’s each year; at least half of these folks will manifest some sort of Alzheimer’s aggression. This can be something as simple as hostile or strange vocalizations to full-blown hitting, biting, and punching. Clearly, there will usually be a reason for this sort of behavior, but each person will be different.

Most medical professionals now understand that Alzheimer’s aggression can be indicative of physical discomfort that results from common medications (for example, many of the anti-anxiety medications often given to patients can cause headaches and nausea), it might be caused by delusions and/or neuropsychiatric symptoms, or it could be triggered by the return of memories or emotions that were from long before. In fact, Alzheimer’s aggression can be something as simple as frustration with an inability to communicate or remember something, and this leads to irritation and a “lashing out” at those around them. Often, this is particularly the case when an Alzheimer’s patient has lost the ability to communicate easily or clearly.

So, the first real step in understanding Alzheimer’s aggression is to identify the “trigger”. Interestingly enough, this often helps the caregivers to find a bit of peace and comfort because it helps to prove that the Alzheimer’s aggression is not directed at them “personally”.

So often, an adult child or primary caregiver experiences enormous emotional pain when they feel that a person is physically attacking them or directing anger and rage at them. Simply, working at identifying the trigger for Alzheimer’s aggression usually allows them to actually eliminate themselves from the proverbial equation. Unfortunately, the process by which triggers are identified can often take a substantial amount of time.

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Dealing with Alzheimer’s aggression

Dealing with aggressive behavior is not easy, and there are no simple solutions to it. However, it is possible to make it less of a problem through a gradual process of identifying what triggers the aggression, and finding some effective ways to deal with it. It is important to remember that all behavior is a form of communication. If we can establish quickly what the person is trying to communicate, it may prevent them from feeling frustrated and acting aggressively towards us.

The most important advice to caregiver is: Don’t take it personally. This is a hard thing to do, but you have to remember that you are dealing with a person who is manifesting the symptoms of a disease. It isn’t personal to them either.

Any form of aggression can be upsetting, but the most important thing to remember is that the person is not being aggressive deliberately. The behavior may appear to be targeted at you, but that is probably just because you are the one that is there at that particular moment. The fact that the person is aggressive towards you doesn’t mean that their feelings towards you have changed − just that their reactions have become different as the structure of their brain has changed.

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So, what can someone do to help a loved one suffering from the condition and also lashing out with Alzheimer’s aggression? There are currently some prescription medications given to patients with “dementia” but most are still in the testing phases or considered questionable. They come in a range of intensities and can reduce some incidents of Alzheimer’s aggression, but most physicians recommend that the “first line” of defense begins with individual patient-oriented strategies.

For example, if Alzheimer’s aggression is triggered by anything from hunger, fear or confusion, to actual anger or physical discomfort, it is necessary to find ways to address and/or eliminate all of the possible issues. This might be through actual, physical methods or it can be through thought and patience.

As you observe your loved one, you may need to look for signs of a pattern or of side effects from prescribed drugs. These observations will help the doctor to make a final diagnosis and plan a treatment routine. Your doctor may have questions or comments pertaining to your case. As you care for your loved one, try to observe him or her closely in order to answer the following questions:

  • Do you notice any pattern to the behavior?
    • Does the behavior occur at any set time of day?
    • Does it occur after your loved one takes a certain drug?
    • Does it occur when he or she is hungry or frustrated?
    • Does the behavior come out only when a certain person is present?
  • When you first noticed the problem, did you notice any other changes in the way your loved one was acting?
  • Were any big changes occurring in the home at that time?
    • Did you move?
    • Did anyone move in or out?
    • Did anyone in the family die or become ill?
    • Did you make any changes in care arrangements?
  • Has your loved one started any new drugs or changed drug dosage?
  • Has your loved one suffered a recent injury?

Be sure your doctor knows all the drugs that your loved one takes, even over-the-counter drugs.

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General advices for those dealing with family or friends showing bouts of Alzheimer’s aggression are to:
  • Learn diversionary tactics – if you suspect a “trigger”, such as a behavior (on your part) that seems to make them react, it is up to you as a caregiver to stop and step away from them in the most appropriate way possible. Never try to argue the point, just try to distract the patient from the issue and then get them into another or a new line of thought. For example, if the person seems to become upset when their clothing is removed, you cannot avoid bathing them, but you can speak the words such as “Here, let me get you ready for a warm bath,” and then move directly into the bathing process. Don’t quit at the first signs of trouble, but definitely bring the issue to a close if there is an escalation of aggression from them. Keep a written list of things he or she likes (such as going for a walk, listening to music, having a snack) and offer these as diversions.
  • Don’t forget signals – when your diversionary tactic is failing, it is a time to use the gentlest tones and the most reassuring touches you can. If you can put a sincere smile on your face, and try to convey that “all is well” through touches and expressions, it often calms a patient down at a remarkably hasty pace.
  • Consider communication – many Alzheimer’s patients lash out violently because they cannot remember something, they have forgotten where they are, or what a common item is for, or because they cannot communicate an idea clearly. If you make a point of putting labels and signs on everything with which they interact, you are going to greatly reduce the times when their lack of memory triggers a reaction. This can go so far as leaving lists of things “to do” in obvious places. For example, it is often a good idea to put a few words on a piece of paper tacked to the outside of the kitchen cabinets. These might be as simple as “Food and Snacks” that helps them to easily remember where they are and what they were doing.
  • Focus on the past – communicating with the patient, remember that Alzheimer’s strongly affects short-term memory. It’s often easier - and less stressful - for someone with Alzheimer’s disease to recall and talk about distant memories than it is for them to remember what they watched on TV the night before.
  • Stress factors - limit the amount of the generally recognized stress factors for the Alzheimer’s patients as loud noises, frenetic movement, and clutter. Remember that they may be easily frightened by a sudden noise, sharp voices, abrupt movements or a person approaching them from behind without warning.
  • Get into a routine – along with signs and notes, a solid routine is another fantastic way to help overcome moments of aggression. Not only does this reduce the opportunity for unexpected events, but it also ensures that hunger or bathroom related aggression is kept to a minimal level too.
  • Validation – when an Alzheimer’s patient is upset, angry, or severely frustrated, don’t argue with them about this. The last thing anyone wants to hear is “there’s no need to be so angry/sad/confused” when they don’t have any control over the issue or the environment. Instead, you MUST tell them that it is perfectly fine to feel as they do, and then work with them to get through the moment. Again, this is best done with reassuring words and gestures.
  • Try a bit of logic – if the patient has a relatively calm demeanor about a situation, you can actually ask them to think a bit about a situation to see if that helps resolve the issue. Try and stay calm, while also providing reassurance and support at all times. It is important the person understand you are not upset and you are there to help.
  • Safety - check the entire house and remove any object that your patient might use as a weapon. Stand out of range and, if you feel that your loved one may injure you, leave the room. Experts do not agree about physically restraining a person during a violent outburst. If you are strong enough to restrain your patient, you might try doing so. The danger is that you might frighten or further anger him or her, making the situation worse. If your patient struggles, there is the chance that one or both of you could be hurt.
  • Nothing is working? – the most common cures for the moments when a patient refuses to calm down include, ignoring them if they cannot do harm, trying to find a bit of humor in the moment, putting on a bit of soothing music, and making notes about the situation in order to help determine a better outcome for the next time that it occurs. If aggressive incidents are frequent or worrying, discuss them with a professional, such as a psychiatrist specializing in older people or a community psychiatric nurse. They may be able to offer support and suggest other ways of handling the situation.

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