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DISCLAIMER ...
There is no hard and fast answer to addressing a problem behaviour.
The following information is provided as a tool to help the Caregiver find the solution that works for situation they are faced with.

Problem Behaviours - Angry

| Possible Causes | Coping Strategies | Other Considerations | Additional Information

At some point in the course of the disease, people with Alzheimer's may become physically aggressive, although this does not occur as often as people think. They may sometimes throw things, hit, kick, bite, or pinch the caregiver or others they come into contact with. They may not know why they are doing this, and they may not even realize that they are doing it. These displays of behavior can be very frightening. Try to remember that these behaviors are probably an indication that the person with AD is very upset about something.

Possible Causes

Physiological or Medical Causes

  • Fatigue at time of request, activity or event.
  • Disruption of sleep pattern causing sleep deprivation.
  • Physical discomfort, such as pain, fever, illness, constipation, fecal impaction.
  • Loss of control.
  • Adverse side affects of medication impaired vision or hearing.
  • Hallucinations

Environmental Causes

  • Sensory overload - too much noise, activity, or clutter, or too many people in the environment
  • Unfamiliar people, place, or sounds
  • Sudden movement or startling noises
  • Feeling insecure, lost, insecure, forgotten
  • Difficulty adjusting to environment light to dark
  • Inability to perform what was once a simple task

Other Causes

  • Being asked to respond to several questions or statements at once
  • Responding to arguments between other people
  • Response to caregiver's impatience, stress, irritability
  • Person scolded, confronted, contradicted
  • Surprised by unexpected physical contact
  • Inability to perform what was once a simple task - for example buttoning clothes
  • Instructions unclear or too complicated
  • Change in schedule or routine
  • Attention span too short for task
  • Task not broken down into manageable steps
  • Activity perceived as being childlike or insulting

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Coping Strategies

  • Begin with medical evaluation to rule out physical and/or medication problems.
    • Discuss possible adverse effects of current medications with physician.
    • Have vision and hearing checked
  • Alternate quiet times with more active periods ... Plan outings, activities when person is rested
  • Make sure person is comfortable - clothes not to tight, person is not too hot or too cold.
  • Simplify environment by reducing noise, number of people, and clutter.
  • Keep daily routine as consistent as possible.
    • Avoid changes and surprises.
    • For some people with dementia, the slightest change may lead to confusion and disorientation.
    • Try scheduling meals, bathing, and walks, for example, at the same time everyday.
    • Determine an appropriate amount of time to accept change in routine when rescheduling is necessary.
      • For example, if a new caregiver is to be introduced, or day care is being tried, accustom the person to the new place or caregiver as gradually as possible.
    • Keep furniture and objects in the same place at all times.
  • Orient person to time by using calendars and large numeral clocks, as the person may lose a sense of time because of the disease.
  • Make sure the person is protected from hurting him/herself.
    • Remove sharp utensils, tools, and objects from the environment.
    • Remove the person from stressful situation, person(s), or place.
    • Gently guide the person from environment while speaking in a calm and reassuring voice.
  • Distract the person with a favorite food or activity... This may reduce agitated feelings.
    • Distraction and avoidance are often the most useful approaches to handling agitated or angry behaviors.
  • Exercise regularly to help reduce stress... Try walking or dancing.
  • Try music, massage, quiet readings as way to calm person.
  • Use gentle physical touch to calm person.... Holding hands and hugging may be comforting to some dementia victims, but perceived as restraining by others.

Try these communication techniques:

  • Avoid asking questions that rely on memory.
  • Try not to reason with the person as he/she no longer has the ability to think logically... Reasoning or rationalizing with the person frequently leads to frustration and anger.
  • Try not to express your anger or impatience verbally or with physical movements such as shaking head, pointing finger, etc. these responses are easily sensed and likely to increase confusion and agitation.
  • Speak slowly and clearly... Use short simple sentences.
  • Approach the person slowly and from the front... Approaching from behind or side may startle the person.
  • Be sure you have the person's attention before speaking and touching.
  • Use repetition... Frequent, clearly stated reminders are needed to reassure the person with dementia.

For tasks or activities, try to:

  • Allow adequate time for person to respond to directions, request, or to perform activity.
    • Due to physical changes in the brain, more time is needed to absorb instructions.
  • Limit choices such as with food, activities or clothing.
    • Decision-making may be overwhelming to the person and result in an angry response.
  • Give clearly stated directions for each step.
    • Complete one step at a time.
    • The person no longer has the ability to think of several things at once and may be overwhelmed in trying to keep track of multiple events, statements, questions or directions.
  • Offer activities and events that the person is capable of doing.

In long term care settings:

  • Try to maintain consistent staffing... When possible have familiar staff person be responsible for person with dementia.
  • Try to involve families or volunteers in one-to-one activities, if large group activities are upsetting to person.
  • Identify stressful times of day for person and try to schedule baths, dressing, or other difficult activities at other times.
    • Discuss successful and unsuccessful approaches with other staff.
    • Be aware that shift changes are often stressful times and provoke anxiety because of increased noise and activity level.

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Other Considerations

  • It is important to recognize that angry or agitated behaviors are often symptoms of dementia and are not deliberate responses.
  • Sometimes keeping a log or journal can be helpful in identifying why the person becomes angry or agitated.
  • Try writing down everything that happened each time the person becomes agitated.
  • What time of day was it?
  • Who was present?
  • What immediately preceded the outburst?
  • Often a pattern emerges which can help the caregiver think about how to alter the situation.
  • The way in which caregivers approach people with dementia is a critical part of avoiding angry behaviors.
  • A gentle, supportive, simple approach will almost always be more successful than commands or rationalizing.
  • Dementia victims will often sense a caregiver's frustration or anger and become anxious or angry themselves.
  • Anger and rage are often signs that the person is feeling loss of control of his/her life.
  • Calmly acknowledge feelings even when you do not understand what is being said or why the person is angry.
  • Saying something like "I know you are angry (or upset) about what is happening to you," can be helpful in reducing agitation.

If you feel your physical safety is threatened:

  • Stand out of reach of person.
  • Leave the scene to prevent injury.
    • Call for help - call neighbors, family members, friends or physician.
    • Call police as a last resort. many times an unfamiliar, uniformed person can be threatening to dementia person.
  • After episode has passed, try not to remind person of incident ..... He/she will probably soon forget.
  • Caregivers should carefully consider what can be changed to avoid another reoccurrence.
  • In addition, caregivers should work out an emergency procedure for themselves in the event of physical danger.

Additional Information

Alzheimer's Association (ADRDA) chapter newsletters

Aronson, Miriam (ed) Understanding Alzheimer's Disease. New York: Charles Scribner's Sons, 1988.

Gwyther, Lisa. Care of Alzheimer's Patients: A Manual for Nursing Home Staff.

American Health Care Association and the Alzheimer's Association (ADRDA), 1985.

Mace, Nancy and Peter Rabins. The 36-Hour Day. Baltimore: The John Hopkins University Press, 1981

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