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Managing Physical Aggression

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Managing Physical Aggression

People with dementia may sometimes behave aggressively in one or more of the following ways:

  • Verbally abusive or threatening
  • Physically threatening, such as kicking or pinching
  • Lashing out violently at people or property
  • Over-reacting to a situation, or becoming very agitated as a result of what seems to be a very minor setback or criticism.

There are many reasons why a person with dementia may act aggressively, including:

  • Feelings of
    • Fright
    • Humiliation
    • Frustration
    • Lack of Control
    • Loss of Independence
    • Pressured by demands (may not understand or be able to implement simple tasks done before)
    • Being judged or criticized because they have made a mistake.
    • Nervous or threatened because they don’t recognize people or places.
  • Frustration with inability to communicate effectively or be understood.
  • Unable to understand what is being told to them or requested
  • Physical effects of dementia, which may have eroded their judgment and self-control  (memory loss, poor judgment, lack of self control, disorientation, and difficulty in communication–symptoms that can lead to fear, depression, anxiety, and panic.)
  • Loss of inhibitions and decreased awareness of rules about appropriate behavior
  • Medical condition, pain, physical discomfort (thirsty, constipated, hungry) or infection (urinary tract infection, upper respiratory infection)
  • Psychological problems can translate into aggressive behaviors, including, depression and a host of serious and persistent mental disorders.
  • Mental illnesses have been a persistent and lifelong struggle. These illnesses include schizophrenia, bipolar disorder (manic-depressive illness), some anxiety disorders, and post-traumatic stress disorder (PTSD).
  • Demands exceed abilities. This is often a major problem!
  • Privacy is threatened. Being forced to accept help with intimate functions such as washing, dressing or going to the toilet can be understandably stressful, as most of us have had privacy in these areas of life since childhood
  • Bewildered or anxious because there is too much noise, there are too many people around, or there has been a change in a familiar routine
  • Frightened by a sudden noise, sharp voices, abrupt movements or a person approaching them from behind without warning

Strategies to Try to Prevent Aggression

Active listening and effective verbal responding taking the time to really hear what a person is saying and then thinking about the response.

  • For example, an elderly gentleman was very upset and began angrily pacing the floor. As a CNA started to walk with him and listen to his concerns, he confided in her that his wife was late in coming to see him that day. When the CNA checked the day’s schedule, she was able to reassure him in a calm, caring voice that his wife would arrive in two hours. He was relieved by this and his pacing ceased.

Prepared approach – be kind, non-confrontational and address the client face to face.  Have distractions ready (chocolate, etc.  build the relationship at the beginning of the day or your shift before doing anything else.  i.e., bring a small present: flowers, coffee and breakfast in bed)

Simple communication – Clear, Concise and non-demeaning communication limited to one or two stage demands. Try to remember that the person may not understand what you are trying to do and why. Wherever possible, explain things calmly and in simple sentences, allowing the person more time to respond than they would have needed before the dementia.

Therapeutic lying – “little white lies.” They address the subject the person is dwelling on, provide some comfort, and allow the person to mentally move on to another subject.

  • At 4 p.m. a client became agitated because “her factory shift was up and she had to catch the bus home.” She paced the floor and wanted to get on the bus. Staff recognized her daily distress, and each afternoon at 3:55 p.m. would give her a ticket for her bus and tell her to wait for it. The “ticket” was a fiblet that redirected her. After a few minutes she became interested in supper and forgot about her bus.

Don’t jump to conclusions – Listen to what the resident is really concerned about and respond to it rather than assuming the obvious.

  • For example, one day a resident began yelling. Staff assumed she was annoyed that her son had not visited that day. When her CNA asked what she was shouting about, the resident told the aide about pain she was experiencing in her right shoulder.
  • Information from other members of the treatment team.

Preserve Dignity – Find tactful ways to offer help without seeming to take over. Guide or prompt the person, and break tasks down into easily manageable steps, so that they can do as much as possible for themselves.

Keep Positive and Set Person up for Success – Try not to criticize, and do your best to hide any irritation that you feel. Avoid situations where the person is set up to fail. Praise any achievements, and focus on the things that the person can still do, rather than what is no longer possible.

Be Aware of Warning Signs and Identify Triggers — Watch out for warning signs, such as anxious or agitated behavior or restlessness, and take action immediately to help the person feel more calm and reassured.

Activities – Find activities to stimulate the person’s interest, and make sure that they take enough physical exercise. Activities should be matched with the patient’s primary needs for social contact and meaningful and challenging activity. Information regarding preferred activities can be obtained from close relatives. It is also important for patients to maintain the sense of identity they may have found through work and family roles. Current sensory and cognitive abilities, as well as the person’s ability to comprehend, respond to, and process information, should also be considered.

Communicate with Multiple Modes – If the person has auditory or visual processing issues use a combination of verbal and visual cues to communicate.

Identify Soothers and Likes – Identify things that calm the person so that you can use them when the person starts to get agitated.

Quiet Periods – provide quiet times and alone time for person as long as they are safe and monitored.

No Caffeine

Structure the Environment – Because people with dementia cannot cope with change, it is important to follow a predictable routine each day. Establish a consistent schedule for sleeping, eating and activities.  Each morning review that days schedule and continue to review as needed. Holidays such as Christmas can be particularly stressful because of the overabundance of novel stimuli: decorations, parties, singing groups, visiting children. The solution is to “avoid overdoing it.”

Reasonable Demands – There is a tendency to want to “exercise the brain” of people with dementia by asking numerous questions and trying to assess the person’s cognitive skill level. Caregivers and families need to accept that the person is doing his or her best at all times, provide unconditional encouragement, and offer assistance when the patient cannot perform a task. If the person with dementia does not seem to be coping well, reduce any demands and make sure they have an unrushed and stress-free routine.

Understand Losses – No one wants to talk to the patient about the disease, but many patients do want to know what is wrong with them and need to talk about their functional losses, even if they become angry and deny that anything is the matter. Cherished lost activities should be replaced with safer activities that engage attention and interest. If the patient has clinical depression, it should be treated.

Music Therapy – Music helps decrease aggressive behaviors in people with dementia, it relieves anxiety and agitation, promotes relaxation, and provides opportunity for reality orientation and access to memory, provides cognitive stimulation, increases attention span, increases socialization (even in withdrawn patients) and social skills, and improves quality of life in dementia patients. Consider use of soothing music at meal times and patients’ preferred music at bath time. Individualized music (music that has been integrated into the individual’s life and is based on personal preference) may decrease agitation in dementia patients.

Exercise  – Activities that provide exercise can improve overall feeling of well-being and decrease agitation and aggressiveness.

 Pet Therapy – If the person loves animals focus on their pet or bring a pet to visit.  This can be very calming.

Strategies to Manage Verbal Aggression

Care should be taken to diffuse verbal aggression before the situation escalates. Remember, the goal is to get on the same side of the table as the patient and regain emotional support. You have to suspend your previous notions about right and wrong, and just go with making peace:

Agreeing – It is impossible to argue with someone who agrees with you. You can agree by seeing someone’s point. You don’t have to give in, but you can acknowledge their feelings and put yourself in the same position. You can see the patient’s point of view. It isn’t fair.

  • For example:
    • Patient: “I want to drive and you won’t let me. The doctor says I can’t drive. What does he know? Give me the car keys NOW!
    • Caregiver: “We can’t have you drive with your memory loss, but that is so awful. I can see why you are angry. It is unfair this should happen to you”

Apologizing – Now I know you haven’t done anything wrong and you shouldn’t have to apologize, but again, we are diffusing an argument here. You can not argue when a person is being contrite.

Playing dumb – “I don’t know anything about this. Tell me more? How could this have happened? I don’t understand?” These buy a lot of calmness

Avoid trying to reason and explain –  The person’s “reasoner” is broken. Back off and let time heal the wound.

Strategies to Manage Physical Aggression

When you have a loved one who is aggressive towards you, this is a crisis. Suspend everything until the episode passes. This is not the time to get someone dressed for bed or in the morning. This is not the time to insist on a shower. When a crisis presents, you want to back off and stay back until help arrives — whether it be medication, a hospitalization, an ER visit or whatever.

It is sort of the idea that when the house is on fire, you don’t want to finish breakfast and get dressed before you call the fire department.

 Stay Calm –  Before you react, take a deep breath, step back to give the person space, and count to ten. You may need to leave the room until you have both calmed down. Try to stay calm and don’t enter into an argument. A heated response will probably make the situation worse.

Step back – Suspend cares until the crisis is over. Do only what absolutely HAS to be done, such as food and getting in any mood controlling medications. If you try to intervene with normal activities you are increasing the risk to you.

Stance and positioning – Attention to your stance and positioning in relation to an agitated person is very important. By standing with feet about 18 inches apart, you are able to work and move without losing balance. Also, if you position yourself to the side rather than directly in front of the person behaving aggressively, and maintain a distance of approximately six feet, you are less likely to be struck by person and she will feel less threatened by them, as well.

Provide reassurance– acknowledge you can see they are upset, try not to show any anxiety (may increase agitation)

Redirection – draw attention to another subject and take her mind off of whatever she is focusing on

Use care in body language – Make sure you always approach from the front. Do not turn your back. And make sure you give the person plenty of space. Turn OFF TV, radio, and stop any extraneous stimuli. Just for now take down family pictures and cover mirrors. This is a crisis and needs special care. Talk in a measured low soft voice. If you have to give directions, make sure they are simple declarative sentences. (“Give me the knife” or “Put the knife down.”)

Tincture” of time – allowing the person to have time and space to let his/her outburst settle down

Make environment safe – moving people out of harm’s way, remove objects that could be used by the person to hurt herself or others, and block routes by which she could leave but make sure the agitated person is not alone and is always kept in view.

Get help immediately Do not stay alone in the house with a violent person. The patient is in a panic mode and cannot be counted on to inhibit any impulses. Recognize the danger and call the doctor.

Teamwork – The team must cooperate on many levels. When the person is becoming agitated, several staff members working together can be very effective. It is important for each staff member to communicate with all members of the team about the resident’s status

If serious or unsafe, call 911 or press Lifeline Many times the police coming is reassuring to the patient as he/she is terribly frightened. The uniform can work wonders. Do not be embarrassed to call BUT if the police think the episode is over because the person calms for a few minutes, forget that thinking. As soon as they leave there is a good chance, an excellent chance, the fear will start again. Insist on an ER visit.

Act defensively – Plan an escape route. Lock yourself away from a violent patient and take the cordless phone. Never be without your cordless phone.

  • The caregiver in the closet phenomenon may seem absurd, but I’d rather have my caregiver in a closet with a cordless phone than out trying to fend off a person who is out of control.
  • If the person is violent it is far more likely to start at night. Move to another bedroom and make sure you can lock it in case the person comes after you. Two of my caregivers woke to find their loved one standing over them and beating them.

Remember, anything can be used as a weapon –  There should be no guns in the house at all, not even in a locked cabinet. Fireplace pokers and knives should be stored out of sight. Your loved one is panicked at this point and may use a book, alarm clock, letter opener, or even a small table to injure you. Minimize potential weapons in the house and make sure you watch for anything that might be used. Never turn your back on someone who is violent.

DO NOT BLAME YOURSELF –  This just happens some time. No one is going tothink it is you that caused this.

 Remember:  Never argue with a demented person. You will not win.

© Copyright Reserved, Eldercare Specialists, LLC, May 2009 Version 1.0