When older adults are acting badly, that is a sign of
an unmet need. – Melissa Batchelor, PhD, RN,
FNP-BC, FGSA, FAAN
Older adults with Alzheimer’s disease can get angry or be aggressive. These types of behaviors, when associated with Alzheimer’s disease, can be a challenge for care providers and family members alike. These behaviors should not be overlooked and should be taken into consideration of the context in which the behaviors occur to try to find a solution.
Join me for this episode of This Is Getting Old: Moving Towards an Age-Friendly World, where we’ll talk about How To Manage Anger and Aggression in Alzheimer’s Disease.
Part One of ‘How To Manage Anger and Aggression in Alzheimer’s Disease.’
Anger and aggression generally happen in response to some underlying trigger, resulting in the behavior(s) observed. Below are some of the underlying causes of anger and aggression for an older adult living with Alzheimer’s disease and the best ways to respond as a caregiver.
Understanding The Underlying Cause(s) Or Trigger
Possible Cause 1: Brain Changes
As caregivers or family members, you need to understand what cognitive abilities remain intact versus what deteriorates. Alzheimer’s disease is essentially “brain failure” – meaning memory ability is lost over time, and thinking and problem-solving become much more difficult. At a certain point, the person also loses the ability to use and understand language. However, one part of the brain that remains intact is the basic responses of Fight, Fright, or Flight. The Fight, Flight or Fright response may be what’s coming out as angry or aggressive behavior in the person with Alzhiemer’s disease, so we need to be mindful of this when interacting with a person. To make sure that they hear us and see us, before we touch them.
Possible Cause 2: A General Health Problem or Physical Discomfort
Another trigger for angry and/or aggressive behaviors are a general health problem or physical discomfort. You need to understand that when a person with Alzheimer’s disease is experiencing pain or discomfort, they aren’t going to be able to tell you what’s hurting. They may hurt in their elbow or their hip, but they can’t tell you exactly where they’re hurting because they can’t localize pain (what this means is that when they feel pain all over – rather than in one specific spot).
To figure out if or where they are hurting, you will have to look at nonverbal behavior, such as facial grimaces or holding a specific part of their body. Look for any nonverbal behavior as the way the person will communicate with you – rather than just straight out telling you what’s wrong when they can no longer use or understand words.
Possible Cause 3: Environmental Factors
The environment does have an impact on someone with Alzheimer’s disease. If your home is generally quiet or you live by yourself when you have a little bit of cognitive impairment, if the whole family shows up and there are twenty-five people in the room, that is a totally different level of activity. The sudden change of environmental noise may be too much stimulation and this can create anxiety, which might drive angry and/ or aggressive behavior(s).
Possible Cause 4: Poor Communication
When a person living with Alzheimer’s disease loses the ability to use and understand words, their only option is to use behavior to communicate with you. When you see someone acting badly, that is usually a sign of an “unmet need” – so trying to figure out what they may need will be the better strategy for managing the behavior.
Part Two of ‘How To Manage Anger and Aggression in Alzheimer’s Disease.
Best Ways to Respond?
Response 1: Safety First
If you’re dealing with someone that’s very angry and they are being very aggressive, the first thing to do is to make sure to maintain their safety. Once you know they are safe, it would also be best if you back off and give them space to calm down. You may need to remove yourself from the room if the anger or aggression is directed towards you. Give them the time and the space they need to calm themselves down in a safe place.
Response 2: Become A Detective
After making sure the person is safe, the next best response is to become a detective. I usually teach what I call the 3CP Model. The 3C’s are: Change the person, Change the people, or Change the place. This is a simple way to think through identifying behavioral triggers and preventing or resolving problematic behaviors.
CHANGE THE PERSON:
When thinking about something that may need to Change the Person – this means the Person living with Alzheimer’s disease. As caregivers, when we look at the person, we need to think about what their behavior is trying to tell us. There is some “unmet need” driving the behavior: Are they hot? Are they cold? Are they hungry? Are they tired? Or are they in pain? Starting with seeing if there’s anything that needs to be addressed for the Person is the first place to start.
CHANGE THE PEOPLE:
The second level to think through that may need to Change is the People – this means us as caregivers. Think through if there may have been something that you did when interacting with the person that accidentally sets the behavior off. Always give people warnings that you’re coming, by making sure that they see you and hear you first. Startling someone can sometimes set off aggressive behaviors.
CHANGE THE PLACE:
The third thing to consider is Change the Place – this means the environment. Is there too much noise? Do you need to move the patient into a different environment with less distractions? Too much background activity can sometimes cause stress, which can trigger anger and aggressive behavior.
Response 3: Don’t Push Your Agenda.
Sometimes as caregivers or staff members, we have things that we need to get done – such as helping the person get dressed or get a bath – and we’re very focused on getting these things done within a certain time frame. In the well-meaning spirit of helping the person with Alzheimer’s disease, we try to push our agenda on the person. During our time frame, the person we are helping may or may not feel like doing the things.
When you first sense a change in behavior from cooperation to resistance, remember that resistance is met with resistance. If the person gets agitated and you get agitated back, it becomes a tug of war between the two of you – which doesn’t help either one of you.
When this happens, as the people with the “big brain”, you need to back off and wait for a different time. If the person you’re trying to help becomes aggressive, try to shift the focus to another activity – and come back to whatever it was that you’re trying to get them to do.
Response 4: Reflect and Regroup
If you get into the “resistance is met with resistance” dynamic, take time to think through that interaction, reflect on how the situation could have been handled differently, and regroup. There is a way to pick up on someone’s nonverbal cues earlier, as soon as they start to become agitated in order to prevent it from getting into a full-blown fight.
And if you’ve tried several times and you can’t figure out what’s going on, ask another person, someone you trust, to come in and watch. Let someone else observe the interaction(s) can help you see if there’s something that you may be missing – doing this can also be helpful.
Furthermore, getting into a support group of finding family/ friends you can share your experience with can also help. A person living with Alzheimer’s disease is doing the best they can, so try not to take it personally.
I earned my Bachelor of Science in Nursing (‘96) and Master of Science in Nursing (‘00) as a Family Nurse Practitioner (FNP) from the University of North Carolina Wilmington (UNCW) School of Nursing (SON). I truly enjoy working with the complex medical needs of older adults. I worked full-time for five years as FNP in geriatric primary care across many long-term care settings (skilled nursing homes, assisted living, home and office visits) then transitioned into academic nursing in 2005, joining the faculty at UNCW SON as a lecturer.
I obtained my PhD in Nursing and a post-Master’s Certificate in Nursing Education from the Medical University of South Carolina College of Nursing (2011) ) and then joined the faculty at Duke University School of Nursing as an Assistant Professor. My family moved to northern Virginia in 2015 and led to me joining the faculty at George Washington University (GW) School of Nursing in 2018 as a (tenured) Associate Professor where I am also the Director of the GW Center for Aging, Health and Humanities.
Find out more about her work HERE.